Health services in Nigeria mirror political organisation. The federal government is responsible for tertiary care, state governments are responsible for secondary care, and local government runs primary care. The financing of (but not the responsibility for) public health is tied to the flow of funds from the federation account. Funds are shared between levels of government according to an allocation formula that keeps about half at the federal level, allocates a quarter to the 36 states, and gives the other quarter to 774 local governments.

These resources are not sectorally earmarked and the states and local governments are not required by law to provide budget and expenditure reports to the federal government. Nigeria thus leaves the most important and consequential level of health care—primary health care—to the weakest tier of government. This results in poor coordination and integration between levels of care, giving rise to a weak and disorganised health system, in which widely varying patterns of outcomes depend on local situations.

The decentralisation policy that makes local governments run primary health care in Nigeria rests on the notion that services are most efficient when governance is close to the people, an assumption premised on the existence of a well-functioning participatory democracy with a sophisticated electorate. Most of the rural people our primary health care facilities serve have not been exposed to high quality health services so they accept what they get as the norm or, without complaints even when they imagine it not to be the norm. When they cannot put up with low quality services they ignore the primary health care facilities by staying at home, and they consult quacks, only to present in the health facility in emergency, often too late for life-saving interventions.

This is not a new problem, and Nigeria has responded in two ways to the disjunction between finances and responsibility on the one hand, and between communities and the political administration of primary health care on the other.

The national primary health care developing agency (NPHCDA) is one such Nigerian innovation. NPHCDA is a federal government agency with policy and oversight roles on PHC implementation at the state and local government levels in Nigeria. However, NPHCDA is not constitutionally empowered to implement programmes or policies at the state and local government levels. The governments must be willing to cooperate or nothing happens, and cooperation often has to come with financial commitment, itself a disincentive. The midwives service scheme in Nigeria illustrates the potential extent and limits of the success of an intervention implemented by NPHCDA.

The second innovation is the creation of ward or village development committees (WDCs or VDCs) which are designed to strengthen local communities in the hope that they can advocate for themselves. The committees are made up of influential community members who can help to enhance community participation and ownership, and promote demand for quality services. However, people can only demand what they are really passionate about. People may be empowered by knowledge, but it takes a deeper level of knowledge that can translate into passion and commitment to get people to act and change their behaviour.

It is much easier to ignore community participation when the issue is improving input—infrastructure and personnel. But for quality, it is clear that we either find a way to get communities actively engaged in the health system that serves them, or we establish structures and processes that will allow us to temporarily bypass community participation on the road to improving the quality of services. In a situation where people are not empowered to detect poor quality, speak up and fight, there is need for the health system to fill that role on behalf of the people.

We must therefore think of structures, both government and civil society led, to act on behalf of communities in the hope that by so doing, members of the community can learn to make demands in their own voices. This may happen through continuous supportive supervision, the use of standardised checklists, while discouraging a culture of blame and fault finding in quality assurance.

Local goverments in Nigeria currently lack the technical, financial, managerial, and political capacity for a complete decentralisation of health services. It may thus be necessary to bring primary health care under the state (where state governments have the capacity) or federal roof and cede tertiary care to state governments. The role of supportive supervision can then be left to local governments, with verification of their activities by independent civil society. Implementing this will be difficult, as there are great political hurdles to reorganising a system which involves huge financial commitment by the different tiers of government; but reorganise we must.

Seye Abimbola, a former BMJ Clegg Scholar, is a research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria.