How decentralisation influences the retention of primary health care workers in rural Nigeria.
BACKGROUND
In Nigeria, the shortage of health workers is worst at the primary health care (PHC) level, especially in rural communities. And the responsibility for PHC - usually the only form of formal health service available in rural communities - is shared among the three tiers of government (federal, state, and local governments). In addition, the responsibility for community engagement in PHC is delegated to community health committees.


OBJECTIVE
This study examines how the decentralisation of health system governance influences retention of health workers in rural communities in Nigeria from the perspective of health managers, health workers, and people living in rural communities.


METHODS
The study adopted a qualitative approach, and data were collected using semi-structured in-depth interviews and focus group discussions. The multi-stakeholder data were analysed for themes related to health system decentralisation.


RESULTS
The results showed that decentralisation influences the retention of rural health workers in two ways: 1) The salary of PHC workers is often delayed and irregular as a result of delays in transfer of funds from the national to sub-national governments and because one tier of government can blame failure on another tier of government. Further, the primary responsibility for PHC is often left to the weakest tier of government (local governments). And the result is that rural PHC workers are attracted to working at levels of care where salaries are higher and more regular - in secondary care (run by state governments) and tertiary care (run by the federal government), which are also usually in urban areas. 2) Through community health committees, rural communities influence the retention of health workers by working to increase the uptake of PHC services. Community efforts to retain health workers also include providing social, financial, and accommodation support to health workers. To encourage health workers to stay, communities also take the initiative to co-finance and co-manage PHC services in order to ensure that PHC facilities are functional.


CONCLUSIONS
In Nigeria and other low- and middle-income countries with decentralised health systems, intervention to increase the retention of health workers in rural communities should seek to reform and strengthen governance mechanisms, using both top-down and bottom-up strategies to improve the remuneration and support for health workers in rural communities.
National Primary Health Care Development Agency, Abuja, Nigeria.|School of Public Health, University of Sydney, Sydney, Australia.|The George Institute for Global Health, Sydney, Australia; seyeabimbola@hotmail.com.
Seye
S
Abimbola
Solina Health, Abuja, Nigeria.
Titilope
T
Olanipekun
Solina Health, Abuja, Nigeria.
Uchenna
U
Igbokwe
School of Public Health, University of Sydney, Sydney, Australia.
Joel
J
Negin
School of Public Health, University of Sydney, Sydney, Australia.|The George Institute for Global Health, Sydney, Australia.
Stephen
S
Jan
School of Public Health, University of Sydney, Sydney, Australia.|The George Institute for Global Health, Sydney, Australia.|Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
Alexandra
A
Martiniuk
National Primary Health Care Development Agency, Abuja, Nigeria.
Nnenna
N
Ihebuzor
Solina Health, Abuja, Nigeria.
Muyi
M
Aina
D003153:Community Health Services / Q000458:organization & administration*; D035082:Federal Government; D017144:Focus Groups; D006801:Humans; D009111:Local Government; D009549:Nigeria; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D011057:Politics; D011320:Primary Health Care / Q000331:legislation & jurisprudence*; D019035:Rural Health Services / Q000458:organization & administration*; D012424:Rural Population; D013219:State Government; D000078329:Workforce
Nigeria; community health committees; decentralisation; governance; human resources for health; primary health care; retention; rural