BackgroundIn 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.ObjectiveThis 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.DesignThe 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.ResultsThe 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.ConclusionsIn 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.

Direct vaccine delivery to health facilities in Kano, through a streamlined architecture, has resulted in decreased stock-outs and improved stock adequacy. Concurrent operation of insourced and outsourced programs has enabled Kano build in-house logistics capabilities.

This study aimed to evaluate the impact of the COVID-19 pandemic on routine immunization (RI) programs in six Northern Nigerian states: Bauchi, Borno, Kaduna, Kano, Sokoto, and Yobe. This study compared the programmatic data of 2019 and 2020, as well as survey data collected during the pandemic. RI program variables included service delivery, leadership and governance, monitoring and evaluation/supportive supervision, community engagement, vaccine supply chain and logistics, and finance and financial management. Data were analyzed using SPSS (version 23, IBM), student t-test, and structural equation modelling. The results showed that RI programs were affected by the pandemic in terms of reduced meetings and low completion rates of action points in certain states. However, routine immunization support services increased owing to improved monitoring techniques and consistent vaccine deliveries, with fewer reports of stock-outs. The most significant impact of the pandemic was observed on activities coordinated at the healthcare facility level, whereas those at the state level were less impacted. The major challenges encountered during the pandemic included insufficient supplies and consumables, movement restrictions, shortage of human resources, and fear of infection.