The formal structures in a health system, characterized by the enforcement of rules and regulations, effective human resource management, and adequate funding, are critical contributors to effective governance and optimal health service delivery. Conversely, shortcomings in these domains could lead to poor accountability and corruption within the system. Therefore, this study assesses the state of Nigeria's subnational governance structures that are conventionally and increasingly responsible for primary healthcare (PHC) delivery. In this qualitative phenomenological study, we conducted and analyzed interviews with senior managers within the PHC system. We found significant informalities and deficiencies in four areas: (a) absence of local interest in strengthening PHC, (b) weak documentation and enforcement of written rules, (c) poor practices and processes of human resource management, and (d) erratic financing of PHC. These deficiencies are seen to encourage the continuation of corruption and weaken institutional capacity to provide effective PHC. We argue that investing in PHC without first addressing these deficiencies as key aspects of subnational governance may result in wasted resources. Based on our findings, we present critical areas to consider for a well-governed PHC system to enhance accountability and address corruption at the healthcare level. The findings of this study are now more important than ever, particularly in light of a Supreme Court ruling on the autonomy of Local Government Areas (LGAs) in Nigeria and the push for state governments to ensure effective PHC services. The study demonstrates critical areas for strengthening the subnational administration of primary healthcare institutions across low- and middle-income countries (LMICs).
Agwu et al. (Thu,) studied this question.