Submission ID 131924
| Issue/Objective | In Nigeria, increased investment in Primary Health Care (PHC) has not consistently translated into improved service delivery. PHC facilities receive funding from multiple sources, including government allocations, insurance schemes, donor programs, and internally generated revenue. However, there is limited empirical evidence on how these resources are utilized at the facility level. This gap constrains understanding of financial accountability and governance, which are critical for translating financing into equitable health outcomes. This study examines how facility-level financial management practices influence the effectiveness of PHC financing. |
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| Methodology/Approach | A mixed-methods facility-level expenditure tracking and financial governance assessment was conducted across 23 purposively selected PHCs (one per LGA) in Kaduna State, Nigeria, covering January-December 2025. Quantitative analysis assessed financial inflows, expenditures, and service utilization rates, while qualitative assessment evaluated governance practices across five domains: record keeping, internal controls, planning and budgeting, reporting, and staffing. Data sources included cashbooks, bank statements, vouchers, and facility records, complemented by staff interviews and reconciliation exercises, which enhanced data validity and reliability. |
| Results | Significant variation in financial performance and service delivery was observed across facilities. Service utilization rates ranged from 47.7% to 99%, indicating uneven execution capacity. In several cases, expenditures exceeded recorded inflows by over 300%, reflecting weak financial traceability, poor fund categorization, and reliance on untracked or accumulated balances. Clinical spending accounted for 20%-69% of total expenditure, indicating prioritization of service delivery inputs but also variability in resource allocation. Internally generated revenue remained low at 3%-13%, highlighting weak service-to-revenue conversion and limited cost recovery. Although insurance capitation improved liquidity in some facilities, cost recovery remained inconsistent, suggesting that increased funding alone does not ensure efficient financial management. Governance gaps included reliance on ad-hoc staffing (13%-37%), large unclassified expenditures, and concentration of over 70% of funding in a few sources, indicating weak expenditure controls and vulnerability to funding shocks. These inefficiencies were associated with inconsistent service delivery patterns, including variability in patient volumes and potential gaps in essential inputs such as drugs and staffing. |
| Discussion/Conclusion | Discussion Findings reveal a systemic disconnect between financial flows, planning, and execution at the facility level. Weak financial controls, poor expenditure classification, and limited linkage between funding and service delivery constrain efficient resource allocation. Reliance on opening balances obscures real-time financial performance, delaying corrective action and contributing to uneven service delivery, including risks of stock-outs, staffing gaps, and infrastructure constraints. While insurance mechanisms improve financial inflows, their impact is limited by broader governance and accountability weaknesses. Conclusion Facility-level evidence shows that strengthening financial accountability is central to improving PHC performance and advancing health equity. Enforcing budget discipline, digitizing financial tracking, and standardizing financial systems through evidence-based routine reconciliation and transparent reporting can improve alignment between resources and service delivery for system-level policy recommendations, and enhancing governance and capacity. These reforms offer a critical and under-addressed, practical pathway for translating health financing into improved service delivery, efficiency, and sustainability in resource-constrained settings. |
| Presenters and Affiliations | Uchechukwu Ezenwa Ezeh Health Strategy and Delivery Foundation (HSDF) Dr Yewande Ogundeji Health Strategy and Delivery Foundation (HSDF) Abolade Oyelere Health Strategy and Delivery Foundation (HSDF) Kayode Samuel Alabi Health Strategy and Delivery Foundation (HSDF) Ibrahim Ibrahim Health Strategy and Delivery Foundation (HSDF) Hajara Nakkudu Health Strategy and Delivery Foundation (HSDF) Peace Olawepo Health Strategy and Delivery Foundation (HSDF) Ruth Musa Sunama Health Strategy and Delivery Foundation (HSDF) Dorcas Asuku Health Strategy and Delivery Foundation (HSDF) Muhammad Awwal Waziri Health Strategy and Delivery Foundation (HSDF) |
