1. Local Governance and Accountability for Health Services in Nigeria International Conference on Governance and Accountability in Social Sector Decentralization February 19, 2004 Stuti Khemani Development Research Group, The World Bank

2. Institutions of Local Governance Locally elected governments (LGAs) with responsibility for primary health services since late 1980s LGAs constitutionally entitled to about 20% of federal revenues—since 1999, LGA revenues over 10% of GDP Community participation institutionalized through Village and District Development Committees Yet, constitutional ambiguity in the relative responsibilities of state and local governments

3. Objectives & Methodology Study designed to address very basic (but unanswered) questions about the functioning of a significantly decentralized service delivery system, not to evaluate the causal impact of decentralization: -- Is there variation in local government autonomy? -- Is there correlation between variation in autonomy and variation in service delivery outcomes? Survey of LGAs, health facilities, and health personnel in Lagos and Kogi states in 2002 15 LGAs in each state,100 facilities in Lagos, 152 in Kogi, 700+ health workers

4. Striking Results No variation in local government autonomy—almost all LGA and facility-level respondents cited the local government as primarily responsible for health services Focus on Kogi: -- LGAs report owning 90% of all primary health facilities -- Facilities tend to be single-staffed, one-room health posts/dispensaries– so-called “Type 1” facilities -- Evidence of significant community participation in service delivery

5. Results cont. -- Pervasive non-payment of salaries of health workers -- Non-payment of staff salaries cannot be explained by lack of resources available to local governments -- Even when local government spending on staff salaries are estimated to be sufficient to cover actual staff costs, survey of staff revealed extensive non-payment of salaries -- Facilities with greater non-payment of staff salaries are more likely to provide health services privately -- Greater community participation is associated with greater staff productivity, but lower public health record-keeping

8. Pervasive non-payment of salaries of primary health workers in Kogi

9. Explaining variation across local governments in average number of months of non-payment of staff salaries: (OLS with robust standard errors, t-statistic in parentheses, * Significant at 1% level) Local Government Revenues (per capita)0.0001 * (2.60) Local Government Spending on Staff Salaries (per facility)0.0000001 (1.42) Total Number of Facilities Owned by Local Government0.05 * (2.68) Indicator Variable for Kogi State2.58 * (3.13) Number of observations26 R-sq0.88 Non-payment of staff salaries cannot be explained by lack of resources available to local governments

11. Facilities with greater non-payment of staff salaries are more likely to provide health services privately Average Number of Months of Non-payment of Staff Salaries Number of Home Visits by Facility Staff2.27 * Cleanliness of Health Facility (1=Clean; 0=Not clean) -0.02 ** Chloroquine Privately Provided (1=privately provided by staff; 0=facility owned) 0.02 ** Paracetamol Privately Provided (1=privately provided by staff; 0=facility owned) 0.03 *** Antibiotics Privately Provided (1=privately provided by staff; 0=facility owned) 0.03 *** Coefficients reported from a robust OLS regression for over 100 facilities in Kogi state; * Significant at 10% level; ** Significant at 5% level; *** Significant at 1% level

14. Main Conclusions Non-payment of provider salaries appears to be an endemic problem of decentralized service delivery in Nigeria—similar issue with teacher salaries for primary education Evidence suggests general problem of local accountability in the use of public resources transferred from higher tiers of government, about which local citizens may not be well informed since they are not the tax payers Evidence of significant local discretion in combating problems of service delivery, when public services are likely to be the only services available

15. Policy Lessons Study cannot answer the question of whether outcomes would be better with more or less decentralization…. ….But can suggest policy lessons for how institutions of decentralization could be designed for better outcomes

16. Policy Lesson 1 Specific purpose transfers for salaries? -- No! --Compromises LGA accountability for services-- Eg: primary education and “deductions at source” of teacher salaries --Political economy: general problem of accountability of political representatives for broad social services, which centralization of salary payments is unlikely to solve

17. Policy Lesson 2 Conditional transfers? -- Not really… --Usually designed to give incentives to communities to internalize spillover effects of local spending; assumes local government accountability to local electorate -- Not likely to be large enough to undo the underlying political economy problem

18. Policy Lesson 3 Information Campaigns? -- Great potential…but no evidence -- Centralization of resource control facilitates “finger- pointing” and evasion of responsibility by local governments -- Addresses the political economy problem by empowering citizens with information about the responsibilities of and resources available to local governments --However, no real evidence on what works—need innovative interventions and rigorous impact evaluation studies