The Primary Health Care (PHC) approach is promoted and supported by the Federal and State Ministries of Health and implemented by the local government area: Nigeria was among 134 countries which endorsed the concept of PHC in1978 as a tool to achieving health care for all by the year 2000 (WHO 1978). It offers the basis for successful integration of nutrition activities into the health care system. PHC was considered a vehicle for effective implementation of the health sector’s nutrition policy, which fed into the development of the National Food and Nutrition Policy. This had a number of objectives related to improving nutritional status in a number of areas, which have since been modified.

Health care in Nigeria has been judged to be in a poor state (Akinyele 2009), especially in rural areas. Although the number of primary health centers across the country suggests reasonable availability, higher level primary health centers (PHC) are concentrated in the South while the North experiences lower level services. In 2005, 80% of households in urban areas were within 5 kilometers of a PHC, compared to 66% in rural areas (World Bank /FMOH 2005). The challenges of inadequate staffing and low capacity, equipment, and essential drugs, were consistent among the PHCs. In a study to determine how well six essential nutrition actions were being implemented in the PHCs, it was found that these services were haphazardly implemented and the challenges inherent in the PHC system made it impossible for these services to have any impact on nutrition (Akinyele 2009).

PHC covered less than 20% of the potential patients (Gupta et al., 2004) about ten years ago and it is unlikely that this spread has improved. Capacity building and empowerment of communities is called for through orientation, mobilization and community organization in the form of training, information sharing and continuous dialogue. Having identified the many problems against effective and efficient implementation and achievement of the objectives of primary health care services delivery at the local government, Abdulraheem et al (2011) make the following suggested recommendations as a way forward:

• Local government and other tiers of government need to increase allocations to the health sector; local governments should generate more revenue to reduce the dependence on the federal funds;
• Priority should be given to effective health education to help eliminate such diseases as malaria, typhoid and other infectious diseases;
• Poor leadership and political instability have been the basis for unsuccessful implementation of most government policies and programmes on health care delivery.
• LGAs are given unnecessary responsibilities by the state governments e.g. purchase of nonfunctioning generators and fridges and imposition of sponsored programmes;
• Priority should be given to the training of more rural health workers, to prevent the drift of health workers from rural communities to urban centres. 
• Financial and other incentives should be provided to prevent the high staff turn-over of health workers.

The PHC system has been recently upgraded by the MCH Programme (MCH) which is part of the National Health Insurance Scheme (NHIS) and started in 2008 to accelerate achievement of MDGs 4 and 5. It provides free PHC for children under five and primary and secondary care (including for birth complications and caesarean sections) for pregnant women up to six weeks after childbirth.

The programme is being implemented in the country in phases. In 2006, one state from each zone and six LGAs in each of these states were chosen for Phase 1. Phase 1 started in September 2008 and included Bayelsa, Gombe, Niger, Imo, Oyo and Sokoto states. In 2008, national health data were published, disaggregated by state. Phase 2, which started in September 2009, added six states, this time on the basis of need: Bauchi, Cross River, Jigawa, Katsina, Ondo and Yobe.

Reports from the NHIS (2010) show that Phase 1 was to cover 621,400 people (100,000 enrollees per state). By December 2009, only a total of 69,000 pregnant women and 175,000 children had been provided with services – well below the targeted enrolment rate (Gavrilovic et al., 2011), but by June 2010 a total of 615,100 (98.9%) had reportedly been covered (NHIS, 2010). For Phase 2, out of 452,300 people targeted, a total of 236,100 (52%) had been covered as of June 2010. There are plans to scale the programme up to cover additional states and LGAs, and funding has been secured to cover an additional 12 states.

Only public health facilities can be accredited for the scheme (except in Oyo state, where private facilities may also be accredited but had not been by January 2010). Health management organizations enroll participants and receive fixed capitation payments of N622 per enrollee per month, of which N36 is retained as an administration fee, and a further N36 retained as a capitation payment for secondary care (whether it is a child or pregnant woman). N550 is passed on to the health provider (Gavrilovic et al., 2011). The budget for Phase 1 was N5.0 billion (as a grant) and for Phase 2 it was N4.25 billion (NHIS, 2010). By the end of 2009, it was estimated that around N2 billion of Phase 1 funding had been disbursed (Gavrilovic et al., 2011). Each state must now provide matching funds of 50% of the amount disbursed; funding has now finished and states have not provided counterpart funding for the scheme so far, although some states have implemented their own fee waiver systems.