Institutional Analysis of Primary Health Care Governance: Insights from Nigeria on governance where governments under-govern

This thesis sought to explore how primary health care systems are governed where governments under-govern; taking the institutional approach to governance, with governance defined in terms of “the rules that distribute roles and responsibilities among societal actors and shape the interaction among them.” This was done in a series of studies conducted on the primary health care system in Nigeria. Chapter One defined three levels at which the rules (or institutions) governing primary health care can be made, changed, monitored and enforced: constitutional (governments and large NGOs), collective (community groups and health committees), and operational level (demand and supply decisions by individuals). Weakness at one level can be assuaged by governance at another level. Chapter One also explored quantitatively the impact of weak governance on the transaction costs of navigating health care markets for patients with tuberculosis. Chapter Two explored qualitatively how decentralisation (constitutional governance) and community engagement (collective governance) influence the retention of primary health care workers in rural communities and their posting and transfer to/from communities (operational governance). Chapter Three explored, qualitatively, how and under what circumstances community engagement (collective governance) compensates for government weakness (constitutional governance). These studies highlight that interventions to strengthen primary health care governance should be informed by an understanding of context: i.e. socio-economic (influence of social cohesion, opportunities to meet, and the participation of high- and low-income community members on collective action); geographical (influence of size, remoteness, and proximity to alternative health providers on collective action) and institutional (influence of transaction costs and laws supporting the property and co-management rights of community members on collective action) context in a community