This article attempts to elucidate the intricacies of primary health care delivery in Nigeria. Among myriad complexities, the central proposition made herein is that the absence of an effective regulatory and enforcement framework in developing countries results in a prominent informal decision space. The findings show that the prominence of an informal decision space compromises the objectives of an information-based public health system. The article concludes that decentralisation in developing countries must have a coordinated top-down and bottom-up development component for it to be effective in improving the performance of primary health systems. One of the implications of the study is that researching decentralised healthcare delivery requires analytical models which are able to illuminate the complexities of local accountability in developing countries. The study also reveals the need to further research the dynamics of democratic decentralisation in developing countries as this goes beyond administrative structures but involve socio-cultural institutions.
TopIntroduction
Health systems simply defined, are the foundational (i.e. institutional, political, legal, economic, technical and socio-cultural) arrangements through which health services are delivered to the population (Berman and Bossert 2000). There is a complex chain of interdependent factors which influence the performance of health systems. In developing countries where there are high mortality and morbidity rates, a multiplicity of stakeholders (i.e. rich nations, international donors, non-governmental organisations (NGOs), bilateral and multilateral agencies) employ different strategies to try and improve specific aspects of the health system (Okuonzi and Macrae 1995). These diverse and often uncoordinated interventions usually have a fragmentary effect on these systems (Buse and Watt 1996). In essence, the imperatives of international health policies and donor-aid practices have a tendency to weaken the capacity of national governments to independently formulate and implement policies which address the health needs of the population (Smith et al. 2008).
This article highlights the implications of decentralisation on the performance of health systems in Nigeria. By conceptualising decentralisation as a strategy for delivering health services through a primary health care system, the study is able to focus on the micro-level processes of the health system. The performance of a health system can therefore be investigated through the effectiveness of primary health care delivery. To study this phenomenon, decision space is adopted as an analytical tool (Bossert 1998). This framework conceptualises the multi-level dynamics of primary health decisions made by local government agents. Decision space illuminates the choices of local government actors and how these impact health system performance. It also frames the role of information in monitoring and evaluating the performance of health systems. There are three main reasons for adopting a local perspective of the decision space approach: firstly, primary health care services are the building blocks of general public health systems therefore we would expect a strong association between local and general public health systems performance; secondly, information systems are implemented with a view to aid planning and decision making at the local level. Consequently this focus provides an opportunity to go back one step to evaluate the intricacies of information practices (in a general sense) without reference to a particular health information systems project; lastly, local agents make health decisions out of a quagmire of often conflicting motivations and opposing evidence: this study will provide some insight into the possible factors that actually influence choices made regarding primary care delivery.
With decentralised health sectors, central governments through the Ministry of Health have a complex task of designing the framework through which local government agents can provide adequate health services (WHO 2000). Their challenges include developing the socio-economic, political, legal, administrative and institutional arrangements that will support the efficiency and effectiveness of primary care systems. The formal (and informal) authority afforded local government agents by the central government, combined with the discretions they exercise (both within and outside formal authority) make up their “decision space”. The relationship between central and local government actors contributes formally and informally to the decisions made at the local level with consequences for the performance of primary health care systems.
The Decision space framework conceives the relational dynamics between the local and the central government through a principal-agent theory (Griffith 1966 and Rhodes 1986 in Bossert 1998) the central (or State) government as the principal and local governments as agents. It analyses the capacity of the principal to influence decisions made by local government agents in order to align them to the principal’s objectives e.g. better performing health system. This being the case, the primary role of the Federal Ministry of Health for instance, would be to make adjustments to local agents’ decision space in a way that would align their interests with national public health objectives. The central government can accomplish this by adopting a scheme of rewards and sanctions.