This study analyzes public service delivery in primary health care in two states in Nigeria, Lagos and Kogi, to understand how budgeted allocations translate into actual service delivery, and to begin a process of exploring innovative institutional solutions to improving public accountability in the country. It focuses on three broad issues:
The flow of resources allocated in public budgets to the front-line service delivery agency, primary health care facilities
Analysis of provider behavior and provider incentives in shaping outcomes at the health facility level
The role of local governments and community participation in determining outcomes in public primary health care service delivery.
Contact: Stuti Khemani Email: firstname.lastname@example.org.
This report contains valuable new evidence on the functioning of decentralized service delivery institutions, which is highly relevant for policies to promote public accountability for basic services. This paper presents findings from a survey of 252 primary health facilities and 30 local governments carried out in the states of Kogi and Lagos in Nigeria in the latter part of 2002. Nigeria is one of the few countries in the developing world to systematically decentralize the delivery of basic health and education services to locally elected governments. Its health policy has also been guided by the Bamako Initiative to encourage and sustain community participation in primary health care services.
The survey data provide systematic evidence on how these institutions of decentralization are functioning at the level local—governments and community based organizations—to deliver primary health service. The evidence shows that locally elected governments indeed do assume responsibility for services provided in primary health care facilities. However, the service delivery environments between the two states are strikingly different. In largely urban Lagos, public delivery by local governments is influenced by the availability of private facilities and proximity to referral centers in the state. In largely rural Kogi, primary health services are predominantly provided in public facilities, but with extensive community participation in the maintenance of service delivery. The non-payment of health staff salaries in Kogi—which is suggestive of problems with local accountability when local governments are heavily dependent on fiscal transfers from higher tiers of government—is highly relevant for decentralization policies.