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Background Primary Health Centers (PHCs) in Nigeria often have inconsistent and deficient supplies of resources (drugs, medical supplies and equipment), funds and staff, a situation which is underpinned by lack of investment, governance fragmentation and political inference. Rent-seeking remains a major, albeit unexplored, problem. This study explored whether accountability mechanisms in PHCs could be adapted to the local socio-political context in order to reduce rent-seeking among staff, improve the supply of commodities and ensure better delivery of essential services. Method We employed a qualitative approach, conducting 8 weeks of participant observation in 6 PHCs and 2 Local Government Health departments (n=2). We followed this up with in-depth interviews (N = 40) with facility health managers, policy makers and Health Facility Committee Chairmen in Enugu, south east, Nigeria. Data were analyzed thematically. Results Staff at PHCs have multiple intersecting and conflicting relationships with actors at different levels of the political and health ecosystems. The relationships underpinning funding flows, salaries, supervision, reporting, implementation, security arrangements, capacity building, infrastructure development and supply of medical equipment and drugs are complex. The intertwining of the informal relationships with the formal rules disrupts existing accountability mechanisms. We identified how conflict of interests, and political interferences are managed – often leading to inefficient formal complaint and feedback mechanisms, affecting provider-patient relationships and trust in the system. Conclusion Examining the intricate web of accountability mechanisms, identifying the role of the formal vis-à-vis informal mechanisms and building on these, can help to improve access to primary healthcare in Nigeria through addressing rent-seeking and enabling effective responses to the ongoing crisis.
Ogbozor et al. (Fri,) studied this question.