An Application of the RTM Framework to Understand Primary Health Care in Nigeria

The following sections are included:This framework provides a conceptually coherent approach to understanding how well (or poorly) resources are being generated and converted into medical and public health services, ideally with a strong emphasis on serving the poor.Applying this framework to the overall picture of health care financing in Nigeria suggests considerable challenges and room for improvement.Resource mobilization: Government health spending as a share of total government spending is only 5% and government health spending as a share of total health spending is 13%. As a consequence, private out-of-pocket spending constitutes 75% of total health expenditure (THE).Resource allocation: Hospitals and health administration capture a very large share of government health expenditure, 48% for hospitals and 44% for health system administration and financing, which leaves little for ambulatory and preventive care. Local governments are largely responsible for paying for PHC.Resource utilization: As in many countries, capital budgets are chronically underutilized. Recurrent budgets are generally spent since most recurrent costs are consumed by salaries and, in fact, a large part of government health spending is consumed by salary costs.Resource productivity: Resource productivity is quite low in Nigeria as evidenced by the low rate of consultation at PHC levels. What is notable is that overall levels of human resources in Nigeria are close to WHO norms. The picture is one where low levels of government financing force PHC facilities to impose user fees on clients, lowering consultations. Providers at the PHC level end up seeing very few patients. The low level of public financing also impacts resource productivity in other ways, through absenteeism, drug and equipment shortages, and low levels of provider knowledge.Resource targeting: Resource targeting is poor for several reasons. First, government health spending is focused on hospitals and administration, which predominantly benefit the urban and wealthy. Second, the de facto policy of allowing user fees at the primary level means that poor and rural populations have to pay for care, which few do as they choose instead to not seek care or to seek care in the private sector. In either case, public spending does not benefit the poor.The analysis from an application of the RTM framework suggests some promising reforms such as greater demand-side financing, strengthening fiscal policy, health financing pilots that reward results, and induce shifts in financing across tertiary, secondary, and primary care levels.