An enabler or a barrier: implications of local government autonomy for effective primary health care (PHC) reforms in Nigeria.

INTRODUCTION

in July 2024, Nigeria´s Supreme Court granted autonomy, including financial, to local government, a decision with major implications for primary health care (PHC). Although local governments are constitutionally responsible for PHC, weak fiscal independence and administrative capacity have hindered performance. This study examines opportunities and challenges that LGA autonomy poses for PHC reforms, particularly within the Primary Health Care Under One Roof (PHCUOR) policy.

METHODS

a qualitative exploratory policy analysis was conducted using key informant interviews (n=288) and a desk review. Participants were purposively drawn from federal, State, and local levels, including policymakers, LGA officials, civil society, and development partners. Data were analyzed using a hybrid of framework and thematic analysis, guided by study objectives and allowing for emerging insights across governance, financing, accountability, coordination, and service delivery.

RESULTS

stakeholders largely viewed the ruling as a catalyst for grassroots health system strengthening. Nonetheless, concerns were raised about LGA capacity in financial management, service delivery, and alignment with governance structures such as PHCUOR. Key risks include fragmentation of coordination, fiscal mismanagement, and human resource inefficiencies. At the same time, autonomy could enhance responsiveness, accountability, and community engagement if supported with capacity development, oversight, and inclusive governance.

CONCLUSION

local government autonomy presents both transformative potential and systemic risks for PHC in Nigeria. Realizing its benefits requires institutional capacity building, effective intergovernmental coordination, digital financial systems, and political economy-informed planning. The ruling provides a critical opportunity to recalibrate PHC governance and advance health equity locally.