Putting Institutions at the Center of Primary Health Care Reforms: Experience from Implementation in Three States in Nigeria

Abstract

Within the last two decades, the Nigerian government has committed to strengthening its primary health care system, through reforms addressing institutional restructuring, deepening decentralized governance, and the incorporation of an alternative health care financing strategy. One of these reforms prescribed the establishment of state primary health care agencies/boards (SPHCDBs) as an integral part of the national health system, with the principal responsibility "for the coordination of planning, budgeting, provision and monitoring of all primary health care services that affect residents of the state." Central to this reform is the integration of primary health care (PHC) governance and management, popularly called primary health care under one roof. Another reform, piloting results-based financing, has been implemented since 2011 in three states under the Nigeria State Health Investment Project. This study assesses the implementation of the Primary Health Care Under One Roof (PHCUOR) policy as part of the broader PHC reforms, with a specific focus on how this policy has been strengthened through the Nigeria State Health Investment Project (NSHIP) in Adamawa, Nasarawa, and Ondo states, documenting the evolution of SPHCDB and PHC service delivery, with a focus on management, accountability, and incentives. The study shows that, in the abovementioned states, significant milestones were achieved in the establishment of the SPHCDB, the strengthening of PHC systems, the improvement of accountability linkages, and an increase in service utilization. The authors therefore argue that integrated PHC systems through SPHCDBs, as enshrined in the PHCUOR guidelines, are a panacea for effective provision of primary health care and a potential game changer for health outcomes, especially when reinforced with a results-based financing approach.

From Scheme to System (Part 2): Findings from Ten Countries on the Policy Evolution of Results-Based Financing in Health Systems

“…However, we caution against viewing these reforms as secondary or spillover effects of RBF interventions implemented as vertical programs. In line with Soucat et al, 15 we argue that RBF design and implementation should focus their attention on how they can contribute to the broader goal of health systems strengthening. We hope that the articles in this special issue bring home to the reader the importance of dynamic, everevolving intersections of RBF interventions with underlying health systems.…”

Does a pay-for-performance health service model improve overall and rural–urban inequity in vaccination rates? A difference-in-differences analysis from the Gambia

“…The pay for performance approach is increasingly becoming popular due to its potential to improve health systems [23] and promote equity in health service utilization [24] . A recent review reported that pay for performance schemes had been implemented in at least 23 African countries [25] .…”

Appraising and addressing design and implementation failure in global health: A pragmatic framework

“…Case study 1: Primary health care governance reform -Nigeria Nigeria recently initiated an integrated primary health care (PHC) governance policy commonly known as PHC under one roof (PHCUOR). The policy aims to integrate all primary health care services, structures and subsystems under a single governance body at the subnational level (Odutolu et al, 2016). PHCUOR is premised on a theory of change derived largely from brainstorming by subject matter experts in the national capital city, funded by international donors.…”

“…PHCUOR is premised on a theory of change derived largely from brainstorming by subject matter experts in the national capital city, funded by international donors. Although endorsed by the national council on health for nationwide implementation (National Council for Health, 2011; Odutolu et al, 2016), a recent evaluation revealed that subnational governments not only exercised discretion as to how they implemented the policy, in some cases the policy was redesigned at the subnational level without recourse to the theory of change (Eboreime et al, 2017). This may have untoward implications on the anticipated impact of the policy reform.…”