Improving Primary Health Care Delivery in Nigeria
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Improving Primary Health Care Delivery in Nigeria

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This paper, based on quantitative surveys at the level of primary health care facilities, health care personnel, and households in their vicinity, aims at understanding the performance of primary health care providers in four states in Nigeria. As possible ways to improve performance, the paper concludes that clearly defining lines of responsibility, implementing performance-based financing of local governments and providers, and collecting, analyzing, and sharing information are some options that can help realign incentives and improve accountability in the service delivery chain and service provision.
This working paper was produced as part of the World Bank's Africa Region Health Systems for Outcomes (HSO) Program. The Program, funded by the World Bank, the Government of Norway, the Government of the United Kingdom, and the Global Alliance for Vaccines and Immunization (GAVI), focuses on strengthening health systems in Africa to reach the poor and achieve tangible results related to Health, Nutrition, and Population. The main pillars and focus of the program center on knowledge and capacity building related to Human Resources for Health, Health Financing, Pharma-ceuticals, Governance and Service Delivery, and Infrastructure and ICT.

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Published 28 April 2010
Reads 38
EAN13 9780821383117
Language English

WORLD BANK WORKING PAPER

AFRICA HUMAN DEVELOP

Improving Primary Health

Care Delivery in Nigeria

Evidence from Four States

THE WORLD BANK

EMTN

NO. 187

ES

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I

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PW1_78w_be3_1--801p.WORLD BANK WORKING PAPER NO. 187

ImprovingPrimaryHealth
CareDeliveryinNigeria

EvidencefromFourStates
Africa Region Human Development Department

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ISBN:9780821383117
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ISSN:17265878DOI:10.1596/9780821383117
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PW1_78w_be3_1--801p.Contents

Foreword....................................................................................................................................
ix
Acknowledgments....................................................................................................................
x
AcronymsandAbbreviations................................................................................................
xi
ExecutiveSummary...............................................................................................................
xiii
PrimaryHealthCareDeliveryinFourStates..............................................................
xiii
UnderstandingthePerformanceofPrimaryHealthCareintheStates...................
xvii
DivisionofResponsibilityamongGovernmentLevels.............................................
xvii
Citizens/ClientsPolicyMakers....................................................................................
xviii
PolicyMakersProviders..................................................................................................
xx
ClientsProviders.............................................................................................................
xxi
PossibleWaysForward..................................................................................................
xxii
1.Introduction............................................................................................................................
1
Objectives.............................................................................................................................
2
ConceptualFramework......................................................................................................
3
Methodology.......................................................................................................................
5
2.Context....................................................................................................................................
7
HealthOutcomesandAccesstoHealthServicesinNigeria.........................................
7
ContextinStatesIncludedintheStudy...........................................................................
9
3.StatusofPrimaryHealthCareServices...........................................................................
11
OrganizationofthePrimaryHealthCareSystem........................................................
11
SurveyResults...................................................................................................................
12
InfrastructureandAmenities..........................................................................................
13
ServicesAvailable.............................................................................................................
14
EquipmentandMedicalSupplies...................................................................................
15
Pharmaceuticals................................................................................................................
16
HealthPersonnel...............................................................................................................
17
ExemptionandWaiverPrograms..................................................................................
20
EducationandPromotionActivitiesofPHCServices.................................................
30
ServiceCharges.................................................................................................................
31
4.DivisionofResponsibilitiesamongGovernmentLevels............................................
33
LawsandPoliciesInformingtheDivisionofResponsibilitiesfortheDeliveryof
PrimaryHealthCare.................................................................................................
33
DivisionofResponsibilitiesinPractice..........................................................................
34
PoliciesandGuidelines....................................................................................................
34

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Contents

PersonnelTraining............................................................................................................
36
HealthCarePersonnelManagement.............................................................................
36
Infrastructure:ConstructionandMaintenance.............................................................
37
ProcurementandDistributionofPharmaceuticalProducts.......................................
39
Supervision........................................................................................................................
41
PossibleWaysForward....................................................................................................
41
5.ClientsPolicyMakers........................................................................................................
43
LocalGovernmentRevenuesandResponsibilities......................................................
43
PublicFinancialManagement.........................................................................................
46
LocalGovernmentCivilService.....................................................................................
49
LocalGovernmentHealthExpenditure.........................................................................
50
LocalGovernmentAccountabilityforServiceDelivery..............................................
54
PossibleWaysForward....................................................................................................
55
6.PolicyMakersProviders....................................................................................................
61
CharacteristicsofHealthPersonnel...............................................................................
62
EducationLevel.................................................................................................................
63
IncentivestoProviders.....................................................................................................
64
MechanismstoRewardandDisciplinePHCPersonnel..............................................
67
OtherNegativeIncentivesFacedbyPHCPersonnel...................................................
68
HealthPersonnelCopingMechanisms..........................................................................
70
PossibleWaysForward....................................................................................................
71
7.ClientsProviders.................................................................................................................
74
IncreasingClients’Power................................................................................................
74
SurveyResults...................................................................................................................
75
PossibleWaysForward....................................................................................................
77
References.................................................................................................................................
81
Appendixes...............................................................................................................................
85
AppendixA:SampleSize................................................................................................
85
AppendixB:HouseholdSurveySampleCharacteristics............................................
88
Tables
Table1.PrimaryHealthCareFacilitiesInfrastructureacrossStatesandFacility
Ownership(in%)............................................................................................................
xiii
Table1.1.AnalysisofSurveyQuestionnaires.......................................................................
6
Table2.1.HealthOutcomesandHealthCareUtilizationacrossGeopolitical
Zones,Nigeria2003...........................................................................................................
8
Table2.2.Population,Poverty,andInequalityIndicators,Nigeria2004.........................
10
Table3.1.HealthFacilityTypebyLGAType.....................................................................
12
Table3.2.BasicInformationfromAllStates(in%)............................................................
13

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Table3.3.PrimaryHealthCareFacilities,Infrastructure,andAmenitiesacross
States(in%)......................................................................................................................
14
Table3.4.PercentageofFacilitiesOfferingBasicServicesacrossStates..........................
15
Table3.5.PercentageofFacilitieswithEquipmentandMedicalSuppliesacross
States..................................................................................................................................
15
Table3.6.PercentageofFacilitiesHavingBasicPharmaceuticalsandVaccinesin
StockacrossStates............................................................................................................
17
Table3.7.AverageStaffingofPHCFacilitiesacrossStatesandAcrossTypeof
Ownership........................................................................................................................
18
Table3.8.AverageStaffingofPublicHealthFacilitiesacrossFacilityType...................
19
Table3.9.AverageStaffingofPHCFacilitiesacrossLGAType.......................................
19
Table3.10AverageStaffinBasicHealthCentersacrossTypeofLGA............................
20
Table3.11.PercentageofFacilitiesOfferingExemptionandWaiversacrossStates.........
21
Table3.12.OpeningHoursacrossFacilityTypeandLGAType(in%)..........................
21
Table3.13.PercentageofFacilitiesOfferingBasicServicesacrossTypeofFacility
andacrossTypeofLGAs................................................................................................
22
Table3.14.PercentageofFacilitieswithBasicEquipmentacrossTypeofFacility
andTypeofLGA.............................................................................................................
23
Table3.15.PercentageofFacilitieswithBasicDrugsandVaccinesinStockacross
TypeofFacilityandTypeofLGA.................................................................................
23
Table3.16.BasicInformationonPHCFacilitiesacrossPublicandPrivate
Ownership(in%).............................................................................................................
25
Table3.17.PercentageofFacilitieswithBasicEquipmentacrossPublicand
PrivateOwnership...........................................................................................................
26
Table3.18.AvailabilityofBasicHealthServicesinNearestFacilityacrossStates
(in%)..................................................................................................................................
28
Table3.19.HouseholdSatisfactionwithNearestPHCFacilityacrossStates(in%)......
28
Table3.20.HouseholdSatisfactionwithNearestPHCFacilityacrossFacility
OwnershipandacrossTypeofLGA(in%)..................................................................
29
Table3.21.DifferenceinSatisfactionwithNearestPHCFacilitybetweenMaleand
FemaleHeadsofHouseholds(in%).............................................................................
29
Table3.22.PercentageofHouseholdsnearaPHCFacilityVisitedbyFacility
HealthPersonnelacrossStates,TypeofOwnership,andTypeofLGA..................
30
Table3.23.ReasonforHealthFacilityWorkerVisitacrossStates(in%).........................
31
Table3.24.PercentageofServiceswithaChargeacrossStates........................................
31
Table3.25.HouseholdUtilizationofNearestHealthFacilityacrossTypeofLGA
(in%)..................................................................................................................................
32
Table4.1.LevelofGovernmentorAgencythatProvidedtheHealthFacility
Building(in%).................................................................................................................
37
Table4.2.MainAgencyResponsibilityfortheMaintenanceofEquipmentand
BuildingsacrossStates....................................................................................................
38
Table4.3.MainSupplierofMedicalConsumables,Drugs,andEquipmenttoPHC
FacilitiesacrossStates......................................................................................................
40
Table5.1.ChangesintheActualDistributionofFederationAccountRevenues
acrossThreeGovernmentLevels(in%).......................................................................
44

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Contents

Table5.2.

MainFiscalTrendsfortheConsolidatedGovernment,1999–2005,
(billionsofnaira)..............................................................................................................
45
Table5.3.BudgetExecutionRateacrossLGinKadunaandCrossRiver(in%)............
46
Table5.4.CapitalBudgetExecutionRateacrossLGinKadunaandCrossRiver
(in%)..................................................................................................................................
48
Table5.5.WageBillinDifferentSubSaharanAfricaCountries,2005.............................
49
Table5.6.PercentageofCivilServantsoutofTotalPopulationinSubSaharan
AfricanCountries.............................................................................................................
50
Table5.7.RealGrowthRateofKadunaLGExpendituresin2003–04and2004–05
(in%)..................................................................................................................................
53
Table5.8.RealGrowthRateofCrossRiver’sLGExpendituresin2005–06(in%).........
54
Table5.9.CrossRiverLocalGovernmentsExpenditure2005...........................................
59
Table5.10.KadunaLocalGovernmentExpenditure2005.................................................
60
Table6.1.HealthCarePersonnelSampledacrossStates...................................................
61
Table6.2.HealthCarePersonnelSampledbyGenderacrossStates................................
62
Table6.3.CharacteristicsofPHCPersonnelacrossStatesandacrossTypeof
FacilityOwnership..........................................................................................................
63
Table6.4.CharacteristicsofPHCPersonnelacrossTypeofPersonnel...........................
63
Table6.5.HighestLevelofEducationCompletedbyPHCStaffInterviewed(State
Comparison).....................................................................................................................
64
Table6.6.AverageSalaryofPHCPersonnelacrossTypeofFacilityOwnership..........
65
Table6.7.SalaryofDoctorsandNursesinRelationtoGDPperCapitainDifferent
SubSaharanAfricanCountries(in%)..........................................................................
65
Table6.8.SalariesandFringeBenefits(StateComparison)(in%)...................................
66
Table6.9.AverageSalaryofPublicPHCPersonnelacrossTypeofLGA.......................
67
Table6.10.CriteriaforPromotionofStaff(in%)................................................................
68
Table6.11.NegativeincentivesFacedbyPHCPersonnelacrossStates(in%)...............
68
Table6.12.ObstaclesinDoingJobacrossRuralandUrbanAreas(in%).......................
69
Table6.13.ObstaclesinDoingJobacrossTypeofFacilityOwnership(in%)................
69
Table6.14.PercentageofPersonnelWhoAreFulltimeEmployeesand
SupplementTheirSalary................................................................................................
70
Table6.15.ActivitiestoSupplementSalariesofHealthStaffacrossStates(in%).........
71
Table7.1.PercentageofHealthFacilitieswithaFunctioningHealth
Management/DevelopmentCommitteeandGenderofCommitteeMembers
acrossStates,andacrossFacilityOwnership...............................................................
75
Table7.2.FrequencyofMeetingsofHealthCommitteesacrossStates...........................
76
Table7.3.ActionsofCommunityHealthManagement/DevelopmentCommittees
acrossStatesandFacilityOwnership(in%)................................................................
76
Table7.4.FinalDecisiononHealthFacilityManagerialIssues(in%).............................
77
TableB.1.EmploymentandOccupationofHouseholdSurveyRespondents................
88
TableB.2.HousingCharacteristicsofHouseholdSurveyRespondents..........................
89
TableB.3.HouseholdSurveyRespondents’ProximitytoNearestHealthFacility........
90

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Figures
Figure1.PercentageofFacilitiesHavingEquipmentandConsumablesacross
States.................................................................................................................................
xiv
Figure2.PercentageofFacilitiesHavingBasicPharmaceuticalsandVaccineson
StockacrossStates............................................................................................................
xv
Figure3.HouseholdSatisfactionwithNearestPrimaryHealthCareFacility...............
xvi
Figure4.AccountabilityRelationshipsbetweenPoliticians/PolicyMakers,
Providers,andCitizens/Clients...................................................................................
xvii
Figure5.Clients/CitizenPolicyMakersRelationship.....................................................
xviii
Figure6.RelationshipbetweenLocalGovernmentsandProviders................................
xx
Figure7.AccountabilityRelationshipbetweenClientsandProviders..........................
xxi
Figure1.1.AccountabilityRelationshipsbetweenPoliticians/PolicyMakers,
Providers,andCitizens/Clients.......................................................................................
4
Figure2.1.SocioeconomicDisparitiesinHealthOutcomesandBasicService
Utilization,Nigeria,2003..................................................................................................
8
Figure2.2.UtilizationofOutpatientCareacrossPopulationConsumption
QuintilesandTypeofProviderorTypeofProviderOwnership...............................
9
Figure3.1.PercentageofPHCFacilitiesOfferingBasicServicesacrossPublicand
PrivateOwnership...........................................................................................................
25
Figure3.2.PercentageofFacilitiesHavingBasicPharmaceuticalsandVaccineson
StockacrossPublicandPrivateOwnership.................................................................
27
Figure4.1.GovernmentAgencieswithResponsibilitiesinPHCinCrossRiver............
35
Figure4.2.GovernmentAgencieswithPHCDeliveryResponsibilitiesinKaduna.......
35
Figure5.1.AverageRatiobetweenActualandProjectedInternallyGenerated
RevenuesinBauchi’sLocalGovernments....................................................................
47
Figure5.2.ShareofTotalLGExpenditureAllocatedtoHealthinKadunaLG,2005....
52
Figure5.3.TotalperCapitaPublicExpenditureacrossLocalGovernmentsin
KadunaandCrossRiver,2005.......................................................................................
52
Figure6.1.ProcesstoDisciplinePHCPersonnel................................................................
67
FigureB.1.HouseholdSurveyRespondents’LiteracyLevel............................................
88
FigureB.2.HouseholdSurveyRespondents’EducationStatus........................................
88

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Contents

Boxes

Box1.1.DeclarationofAlmaAta:InternationalConferenceonPrimaryHealth
Care,AlmaAta,(presentlyAlmaty,Kazakhstan)1978................................................
3
Box3.1.ProposedHealthManpowerforaPHCCentertoProvidetheMinimum
HealthCarePackage.......................................................................................................
18
Box5.1.ExtractfromReportoftheAuditorGeneralforLocalGovernmentsonthe
Accountsofthe23LocalGovernmentCouncilsofKadunaState.FortheYear
tsEnded31December,2004.............................................................................................
49
Box5.2.CitizenReportCards:TheBangaloreExperience................................................
57
Box5.3.ParticipativeApproachesintheManagementofEducation:Literacy
EnhancementAssistanceProject(LEAP)......................................................................
57
Box7.1.Kaduna:ExampleofFacilityHealthCommitteeRoleinImprovingthe
ConditionofPHCFacilities............................................................................................
78
Box7.2.ExperiencewithVouchersforHealthServices.....................................................
79

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PW1_78w_be3_1--801p.Foreword

acdihseyaesaers,mpaanrtyicluilvaersl,yespmealcaiarilla,ycphnielduremno’nsi,a,areanlodstdiinarrNheiga,erioaf.teCnomlimnkuendicabwiltehEmalnutrition,causedmostoftheseprematuredeaths.Mostinterventionsprovento
preventortreattheseillnessesareprimaryhealthcareinterventions;someofthemcan
beprovidedbythehouseholdsthemselvesaftersomeorientationfromahealth
provider,eitherinsidehealthfacilitiesorthroughcommunityoutreach.
Maternalmortalityisalsohighinthecountry.Someofthesedeathscanalsobe
prevented.Althoughaccesstoreferralcareisessentialtoimprovematernalsurvival;
primaryhealthcareinterventionscanpreventsomeoftheindirectcausesofmaternal
deathssuchasanemia,malaria,STIaswellasthemajorfactorsunderlyingmedical
causes.
Giventheimportanceofprimaryhealthcareservicesforthecountrytoachievethe
MillenniumDevelopmentGoals,itisimportanttogenerateknowledgeonthe
challengesfacedindeliveringPHCservicesthatwouldallowauthoritiestodesignand
implementprogramstorespondtothesechallenges.Thisreportthenaimspreciselyat
understandingtheperformanceofprimaryhealthcare(PHC)providersinfour
Nigerianstates,Bauchi,CrossRivers,Kaduna,andLagosandthevariablesdrivingthis
performance.Thereportalsoaimsatofferingpolicyoptionstoimprovethedeliveryof
PHCservicesinthesestates.
ThisreportwaspreparedbytheWorldBankinpartnershipwiththeNational
PrimaryHealthCareDevelopmentAgency,theFederalMinistryofHealth,andthe
CanadianInternationalDevelopmentAgency.Thereportwasmadepossiblethanksto
thesupportreceivedfromtheStatesMinistriesofHealthofBauchi,CrossRiver,
Kaduna,andLagosandthefinancialsupportoftheCanadianInternational
DevelopmentAgency.Finally,thestudyalsobenefitedfromsomefinancialsupport
fromtheBankNetherlandsPartnershipProgram(BNPP).
AgnesSoucat
Advisor,HealthNutritionPopulationforAfrica,
AfricaRegionHumanDevelopment
TheWorldBank

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