Primary Health Centre Performance And Universal Health Coverage In Nigeria: A Governance And Accountability Approach To BHCPF Reform

BACKGROUND 

Primary Health Centres (PHCs) are the foundation of Nigeria’s health system and central to achieving Universal Health Coverage (UHC). They serve as the first point of care for communities and provide essential, affordable services, especially for vulnerable populations.

However, PHC performance remains uneven across the country. They are often afflicted with persistent challenges such as poor infrastructure, workforce shortages, irregular drug supply and weak service delivery systems, particularly affecting rural and low-income populations. The scale of this underperformance is documented. 

The 2023 BudgIT State of States report found that BHCPF disbursements to states were consistently irregular, with several states receiving funds months behind schedule and others reporting utilisation rates below 40%. NPHCDA facility assessments indicate that more than half of Nigeria's roughly 30,000 PHCs are either non-functional or operating below minimum service standards.

In response, the Jonathan government introduced the Basic Healthcare Provision Fund (BHCPF) in 2014 to strengthen PHC service delivery. While this represents a key policy effort, its success largely depends on effective governance, implementation and accountability, as increased funding alone is insufficient to drive meaningful improvements in health outcomes or progress toward UHC. Subsequent governments, under Buhari and Tinubu, have continued the project to varying degrees of success.

This policy brief examines why PHC performance in Nigeria has remained weak despite the introduction of the BHCPF, arguing that the root cause is not insufficient funding but the absence of robust governance and accountability mechanisms to ensure that resources translate into improved health outcomes. It proposes two concrete policy instruments: a BHCPF Transparency Dashboard and a PHC Performance Accountability Framework designed to strengthen institutional accountability, improve data-driven decision-making, and align financing with measurable performance across all levels of the health system.

BHCPF GOVERNANCE ANALYSIS

The fund was established under the National Health Act of 2014 and designed to provide a sustainable financing mechanism for primary healthcare in Nigeria. Funded through at least 1% of the Consolidated Revenue Fund, alongside contributions from development partners, it is intended to support essential service delivery, strengthen health system infrastructure, and expand access to basic health services.

The BHCPF is structured across multiple implementing gateways, including the National Primary Health Care Development Agency (NPHCDA), which oversees facility-level service delivery; the National Health Insurance Authority (NHIA), which is responsible for financial risk protection; and other designated entities that support emergency medical treatment and system strengthening. Funds are expected to flow from the federal level to states and subsequently to accredited PHC facilities.

Despite its well-structured design, it has been undermined by weak governance and accountability systems, limiting its impact on PHC performance. Key challenges include delays in fund disbursement due to bureaucratic and coordination inefficiencies, as well as limited transparency in how funds are allocated and utilised, creating risks of mismanagement and weak oversight. The 2020 BHCPF Guidelines mandate quarterly disbursements and financial reporting by states as conditions for access to funds, obligations that exist in law but lack a public enforcement mechanism.

Accountability for performance is also inadequate, with funding rarely tied to measurable service delivery outcomes, allowing inefficiencies to persist without consequences. In addition, institutional responsibilities are fragmented across multiple agencies, with weak coordination and unclear lines of accountability.

At the state level, variations in political commitment and governance quality further influence PHC outcomes, yet there are no standardised mechanisms for comparing performance. The BHCPF seeks to address these by introducing several standardised governance requirements that states must meet before they can access funds. These include establishing state PHC governance structures, creating dedicated financial management and treasury arrangements and also abiding by nationally defined operational guidelines for fund management. 

Yet, the Fund can only do so much in managing party and governance transitions and varying levels of leadership and administrative capacity. Overall, these challenges highlight that improving PHC outcomes requires strengthening governance and accountability systems, not just increasing funding.

THE PERFORMANCE ACCOUNTABILITY GAP

Nearly a decade after its enactment, the gap between policy intent and on-the-ground performance remains wide. The commitment to improve PHC performance has been constrained by persistent governance deficits, weak accountability structures, fragmented data systems and misaligned incentives across federal, state, and local government levels.

The 2023 Nigeria National Health Facility Survey documents that immunisation coverage has stagnated below 60% nationally, with skilled birth attendance at PHC facilities remaining below 40% in several northern states, outcomes that years of BHCPF investment have failed to change.

Disbursements have been irregular, and monitoring and evaluation systems and mechanisms to track how funds translate into service delivery outcomes have remained underdeveloped. At the facility level, PHCs continue to grapple with staff absenteeism, stock-outs of essential medicines, and infrastructure decay, conditions that persist not merely because of insufficient funding, but the absence of real-time, publicly accessible data to assess PHC performance and track funding.

At the subnational level, variations in governance capacity and political commitment further affect PHC performance, and there are no standardised mechanisms to compare or publicly assess state-level outcomes. Addressing these accountability gaps is therefore critical to improving BHCPF effectiveness and advancing progress toward Universal Health Coverage.

COMPARATIVE LESSONS: WHAT ACCOUNTABILITY SYSTEMS HAVE ACHIEVED ELSEWHERE

Nigeria is not the first country to confront the problem of health funds that cannot be tracked and performance that carries no political consequence. Two cases from Asia and East Africa offer instructive precedents, not models to replicate wholesale, but evidence that targeted accountability architecture can produce measurable improvements even within constrained fiscal environments.

Kenya: District Health Scorecards

Kenya introduced facility and district-level health scorecards under its Kenya Health Policy 2014–2030, with quarterly public reporting of performance against standardised indicators. A 2019 evaluation found that counties with higher scorecard compliance showed measurably better maternal and child health outcomes than those with lower compliance, even after controlling for resource levels. The mechanism was not the data itself but the public nature of the rankings, county health executives faced reputational pressure to act on poor performance in ways that internal reporting had never produced. Kenya's devolved county system is structurally analogous to Nigeria's state-level PHC governance, making the scorecard model a credible template for adaptation.

India: Performance-Linked Health Financing

India's National Health Mission introduced performance-based financing for state health systems, tying a portion of central government transfers to verifiable service delivery outcomes. States that improved on institutional delivery rates, immunisation coverage, and PHC utilisation received additional allocations; persistent underperformers faced scrutiny and had their transfers reduced. The lesson for Nigeria is specific: performance-linked financing only works when the underlying data systems are reliable and public. India's early implementation failures were concentrated in states where health information system reporting was incomplete, making verification impossible. Nigeria's proposed Transparency Dashboard directly addresses this prerequisite, it is the data infrastructure that enables meaningful performance financing.

Both Kenya and India operate with stronger baseline state capacity than many Nigerian states. The lesson is that public data, combined with political accountability, produces better outcomes than funding increases alone. Implementation must be adapted to Nigeria's federal structure, existing institutional mandates, and the significant variation in state capacity documented in the analysis below.

PROPOSED PHC PERFORMANCE ACCOUNTABILITY FRAMEWORK

Nigeria’s primary health care system is failing not because of insufficient funds, but because those funds cannot be reliably tracked, verified, or linked to results. BHCPF allocations move through multiple government tiers with minimal public visibility. When money is released, there is no mechanism to confirm whether it reached the facilities, and no consequences for state governments when it does not. This brief proposes a two-instrument solution to close that governance gap directly: The BHCPF Transparency Dashboard and National PHC Performance Ranking Framework

While the Dashboard produces evidence, the Ranking Framework makes that evidence consequential. Visibility without consequences changes nothing, and consequences without reliable data are arbitrary

BHCPF Transparency Dashboard (Visibility Tool)

This would serve as a real-time, publicly accessible digital platform that would track BHCPF funds from federal allocation down to facility-level expenditure. It will answer the primary question of whether money is reaching facilities and being used judiciously. 

The Dashboard will aggregate data from all 36 states and the FCT into a single platform, and should be structured around four data domains:

1. Disbursement tracking: allocation by state, dates of fund release, delays, and proportion received versus expected.

2. Facility-level utilisation: expenditure breakdowns, unspent balances, and financial reporting compliance.

3. Service delivery and commodity availability: medicines, patient volumes, staffing levels, and facility functionality status.

4. Accreditation and performance status: NHIA accreditation, compliance with national PHC minimum standards, and inclusion in performance-based financing schemes.

The platform will be accessible on web and mobile, allow state-by-state comparison, and use plain visualisations legible to citizens, media, and legislators alike. Its role is not to judge but to make financial flows and facility performance visible.

National PHC Performance Ranking Framework (Accountability Tool)

This would serve as a quarterly governance scorecard that converts Dashboard data into public state-level rankings across all 36 states and the FCT. It answers the second question of which governors are delivering PHC results and which are not. 

Rankings are published publicly, tying health outcomes directly to political accountability. Unlike previous monitoring approaches that relied on internal government reporting, this framework is designed as a public instrument, one that makes poor PHC performance politically and institutionally costly for state governments.

Ahead of future elections, these rankings can serve as a concrete record of governance, enabling voters, the media, and civil society to hold leaders accountable for measurable results in primary health care.

What the Rankings Can Measure

Each state would receive a composite score across four standardised domains:

a. Service Delivery Outcomes: outpatient utilisation rates, skilled birth attendance, immunisation coverage, and treatment coverage for malaria, diarrhoea, and acute respiratory infections.

b. Facility Readiness and Inputs: essential medicines availability, skilled health worker ratios, facility functionality status, and equipment adequacy.

c. Financial Management and BHCPF Utilisation: timeliness of disbursement, fund utilisation rates, financial reporting compliance, and evidence of leakage or mismanagement.

d. Governance and Accountability: data reporting completeness, NHIA accreditation coverage, integration of performance-based financing, and public availability of PHC data.

These two instruments are only complete when they operate together. Separately, each is limited. Together, they create a closed accountability loop:

• Every naira of BHCPF funding becomes traceable.

• Every state’s PHC performance becomes publicly comparable.

• Every governor becomes accountable for measurable results in primary health care.

This is not a new data collection exercise. It is a governance architecture, one that converts existing health system data into political and institutional consequences, and gives Nigerians the tools to demand better.

Policy Recommendations

Governance and Institutional Responsibilities

To operationalise governance and accountability reforms within the Basic Healthcare Provision Fund (BHCPF), responsibilities must be clearly assigned across key institutions. The following recommendations specify who is responsible for what, ensuring that implementation is coordinated, measurable, and enforceable.

The National Primary Health Care Development Agency (NPHCDA) should serve as the lead technical agency for strengthening transparency and performance monitoring within PHC systems. At the centre of this mandate is the development and management of a BHCPF Transparency Dashboard, enabling real-time tracking of fund disbursement, facility-level expenditures and service delivery indicators. Beyond the dashboard itself, the Agency should define and standardize the PHC performance metrics that underpin the national ranking framework, and aggregate and publish state-level performance rankings on a quarterly or annual basis. To ensure that these rankings rest on credible foundations, the NPHCDA should integrate data from national health information systems for consistency and reliability, while providing technical support to states as they build their capacity for data reporting and performance improvement.

Where the NPHCDA designs the system, State Primary Health Care Development Agencies (SPHCDAs) must operationalise it. As the actors closest to service delivery, SPHCDAs carry responsibility for ensuring timely and accurate data collection and reporting from all PHC facilities, and for monitoring how BHCPF funds are utilised at the facility level, from expenditures through to service delivery outputs. This monitoring role extends to routine supervision of PHCs to ensure compliance with staffing, service delivery and reporting standards. Critically, SPHCDAs should not merely observe performance but act on it: identifying underperforming facilities, implementing corrective actions, and supporting the deployment and retention of health workers in underserved areas where gaps are most acute.

The National Health Insurance Authority (NHIA) provides the financial lever that gives this monitoring architecture real force. By tying PHC accreditation status to clearly defined performance indicators and integrating performance-based financing mechanisms into BHCPF implementation, the NHIA can ensure that funding follows results rather than routine. Performance data should directly inform which facilities are eligible for funding and enrolment expansion, creating a continuous incentive for improvement. To make this system coherent, the NHIA must collaborate with the NPHCDA to align performance metrics with financing criteria, and should publish accreditation and performance data as a further contribution to transparency. By mid-2027, accreditation criteria should be revised to incorporate Dashboard performance indicators, with performance-linked financing conditionality activated starting with the 2028 budget cycle. The legal basis for this already exists in the conditionality provisions of the 2020 BHCPF Guidelines.

Overarching these operational and financing functions, the Federal Ministry of Health (FMoH) should provide strategic leadership and regulatory oversight. Its role is to establish and enforce national governance standards for BHCPF implementation, and to clarify and formalise the respective roles and responsibilities of federal and state actors so that accountability does not fall through institutional gaps. The Ministry should also ensure that BHCPF reforms remain aligned with broader health sector policies and universal health coverage goals, monitor compliance with transparency and accountability requirements across the system, and facilitate the intergovernmental coordination needed for policy coherence. A ministerial directive under Section 11 of the National Health Act, issued by Q1 2027, would formalise existing BHCPF reporting obligations and establish the Dashboard as the mandatory compliance platform.

However, the performance of primary health care rests on political will, and it is at this point that state governments become decisive. Governors and their executive leadership must guarantee the timely release and proper utilisation of state-level health funds and counterpart financing, and provide the political leadership required to strengthen PHC systems, particularly in workforce distribution and infrastructure support. State leaders should treat PHC performance data and rankings not as external judgement but as a management tool, using them to guide policy decisions and resource allocation. In turn, they must accept accountability for PHC outcomes as reflected in the national performance ranking framework, and engage citizens and stakeholders in ways that build transparency and trust in the health system.

Crucially, the proposed PHC performance-ranking framework holds governors directly accountable for measurable health outcomes, enabling citizens to assess and compare state performance, particularly in the lead-up to national and state elections. By aligning technical roles with political responsibility in this way, these recommendations move beyond general policy guidance to create a coherent governance system that drives performance.

Institutional Ownership and Political Accountability

Effective implementation of the PHC Performance Accountability Framework depends not only on strong technical design but on clear institutional ownership and political will. The proposed framework positions governors as directly accountable for measurable health outcomes, enabling citizens to assess and compare state performance, particularly ahead of national and state elections. Aligning technical roles with political responsibility across institutions moves beyond general policy guidance to create a coherent, outcome-driven governance system. 

The NPHCDA leads in designing indicators and publishing annual rankings; the NHIA integrates performance-linked financing criteria; SPHCDAs ensure timely and accurate facility-level data submission; and the FMoH provides overarching policy oversight. Independent verification by civil society organisations and development partners reinforces the credibility and integrity of the rankings. Together, these institutional arrangements ensure that the framework is both technically robust and politically accountable across all tiers of Nigeria's health system.

Accountability and Incentive Mechanisms

The effectiveness of the ranking framework depends on its ability to drive behavioural and political change, not just measure performance. This is achieved through three mechanisms:

i. Public Transparency and Citizen Oversight
Ranking results should be published annually and made accessible through digital platforms, enabling citizens, media and civil society to compare PHC performance across states. This transforms technical health data into information for public accountability.

ii. Political Accountability (Governorship Focus)
Given that PHC performance varies significantly across states, the ranking framework directly links outcomes to state-level governance. Ahead of electoral cycles, including the 2027 general elections, these rankings can function as a governance scorecard, enabling voters to assess how effectively their governors manage primary healthcare systems. This creates political incentives for improved performance.

iii. Performance-Linked Financing and Recognition
Federal allocations and incentives can be partially tied to ranking outcomes, rewarding high-performing states and encouraging underperforming states to improve. In addition, public recognition of top-performing states can reinforce positive competition.

Monitoring and Evaluation Systems

Previous monitoring and evaluation systems in the health sector have tended to be internal, fragmented and weakly enforced, and their influence on performance has been limited as a result. The proposed ranking framework departs from this pattern in four fundamental ways. It is standardised, enabling meaningful comparison across all states rather than isolated, incompatible assessments. It is public-facing, enhancing transparency and inviting citizens into the conversation about how their health system performs. It is performance-linked, connecting outcomes directly to funding and incentives so that measurement carries real consequences. And it is politically relevant, tying PHC performance directly to governors and, through them, to electoral accountability.

It is this combination of technical measurement with public and political accountability that allows the framework to move beyond traditional health system monitoring and function as a genuine governance tool capable of driving real change. The National PHC Performance Ranking Framework transforms PHC performance from a largely administrative concern into a measurable, comparable and politically salient issue. Making governance outcomes visible and actionable strengthens accountability across all levels of the health system and creates sustained incentives to improve service delivery.

Incentivising Rural Workforce Redistribution (Governance-Linked Approach)

The uneven distribution of health workers, particularly the shortage in rural areas, continues to undermine PHC performance in Nigeria. Previous interventions, such as rural posting mandates and financial incentives, have had limited impact because they were not integrated into broader governance and accountability systems.

This brief proposes a governance-linked approach that embeds workforce redistribution within the BHCPF framework. It recommends integrating staffing levels into performance metrics, tying financial incentives to verified service delivery outcomes rather than mere postings, and holding state governments publicly accountable through PHC performance rankings.

By linking workforce distribution to measurable outcomes and political accountability, this approach shifts from isolated staffing policies to a transparent, performance-driven system that strengthens incentives, improves rural coverage and enhances overall PHC performance.

CONCLUSION

This policy brief demonstrates that the primary constraint to PHC performance in Nigeria is not the lack of funding, but the weakness of governance and accountability systems that determine how resources are utilised. By focusing on the governance of the BHCPF, particularly fund disbursement, institutional responsibility, and performance monitoring, this study makes a distinct contribution to the policy discourse.

Importantly, the proposed PHC performance ranking framework elevates governance from a technical issue to a matter of political accountability. By enabling citizens to compare how state governments deliver primary healthcare services, this approach positions PHC outcomes as a measurable criterion for evaluating leadership ahead of elections.

Strengthening transparency, linking financing to performance and holding state governments accountable are essential steps toward improving PHC outcomes. Without these reforms, increased investment will continue to yield limited results and progress toward Universal Health Coverage will remain slow and uneven. The time to act is now: the NPHCDA, NHIA, and Federal Ministry of Health should prioritise operationalising the BHCPF Transparency Dashboard and the National PHC Performance Ranking Framework as an immediate governance priority, with full implementation ahead of the 2027 electoral cycle.

Further Reading

Abimbola, S., Negin, J., Jan, S., & Martiniuk, A. (2014). Towards people-centred health systems: A multi-level framework for analysing primary health care governance in low- and middle-income countries. Health Policy and Planning,. 

Federal Ministry of Health. (2018). National guidelines for the basic health care provision fund. Abuja.

Uzochukwu, B., Ughasoro, M., Etiaba, E., Okwuosa, C., Envuladu, E., & Onwujekwe, O. (2015). Health care financing in Nigeria. Nigerian Journal of Clinical Practice, 18(4), 437–444.

World Bank. (2010). Improving primary health care delivery in Nigeria: Evidence from four states. Washington, DC: World Bank.

World Health Organization. (2021). Primary health care measurement framework and indicators. Geneva.