Table 3 Governance practices in FMCHP in Enugu State

Strategic vision

Autonomy of purchaser and providers

Dysfunctional inter-organisational relationships

Lack of purchaser-provider split

Selection of health facilities

Absence of selective contracting/ accreditation of providers

Financial oversight

Existence of financial monitoring committee

Participation and consensus orientation

Participation in benefit package design

Weak stakeholder participation in formulation and implementation of evidence of tax payment

Participation in provider monitoring

Lack of clarity about position of Local Health Authority Secretaries

Participation in reimbursement process

Disengagement of Local Health Authority Secretaries in reimbursement process.

Rule of law

Enforcement of reimbursement standards

Delays in reporting claims, vetting claims and approval and transfer of funds to providers

Revised reimbursement process to reduce delays

Quality assurance visit to health facilities by vetting team

Transparency

Transparency of benefit package design

Misinterpretation of evidence of income tax payment by providers and district-level policymakers

Transparency in reimbursement process

Inflation of claims by providers, district officials and vetting officers

Resistance to financial monitoring committee from State Health Board officials

Responsiveness

Need-based resource allocation

Service delivery gaps because resources for free care allocated to providers are not need-based

Effective return of user fees/ informal payments

Equity and inclusiveness

Equity in access to free care

Rural-urban health workforce imbalances favoured urban areas

Lower use of free care in rural areas than urban areas due to evidence of tax payment and service delivery gaps

Effectiveness and efficiency

Functioning of FMCHP institutional structures.

Dysfunctional Steering and Implementation Committees of FMCHP

Ministry of Health and State Health Board usurped functions of Steering and Implementation Committees

Use of FMCHP funds for other purposes

Non-existent district implementation committees

Accountability

Citizen-driven accountability

Purchaser and providers weakly accountable to users

Civil society organisations champion delinking of entitlements from evidence of income tax payment

Intelligence and information

Generation and use of data

Transition of state tertiary hospital from primary care provider to referral centre evidence-driven

Policy change in reimbursement of providers informed by evidence

Lack of information technology-driven provider payment system.

Ethics

Ethical standards of care

Preference for fee-paying users by providers

State tertiary hospital refuses referrals from lower facilities

Rationing of free services even in emergencies