A qualitative study of health worker experiences navigating dual financing streams of statutory and project-based funding in Nigerian primary health centres

Nigeria’s Basic Health Care Provision Fund (BHCPF) and project-based Direct Facility Financing (DFF) often operate concurrently in primary health care facilities. Understanding how frontline workers navigate these overlapping funding streams can inform primary health care financing reforms that could strengthen routine immunisation and other essential services. We conducted a qualitative study nested within a large Cluster Randomised Controlled Trial (cRCT) of Demand-Side Incentives (DSI) project in Oyo and Kwara States, Nigeria. Using purposive sampling, we interviewed 37 primary health care facility Officers-in-Charge (OIC) across urban, semi-urban and rural settings. Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR), with the framework matrices used to chart barriers and enablers and thematic synthesis to generate cross-cutting lessons. Sixteen CFIR constructs emerged as most salient. Health workers described BHCPF as the statutory backbone providing system-wide accountability, broader service coverage, and structured stewardship, but noted bureaucratic delays, rigid business plans, and reporting burdens. In contrast, DSI-DFF was valued for flexibility, rapid access to cash via prepaid cards, and simplified reporting, enabling timely micro-procurement, outreach, and caregiver-facing interventions that generated demand. The two mechanisms were perceived as complementary: BHCPF ensured structural stability, while DSI-DFF enhanced responsiveness and operational agility. Reported limitations of DSI-DFF included modest grant size, duplicated reporting, equity concerns, and sustainability risks if donor support ceased. The study highlights the BHCPF as the essential statutory backbone for primary health care, securing system-wide accountability and stewardship. However, responsiveness is often constrained by bureaucratic delays and rigid guidelines. In contrast, DSI-DFF demonstrates that flexible, facility-controlled financing enhances operational readiness and demand generation. To build a resilient system, this study recommends integrating DSI-DFF’s adaptive features—specifically rapid digital disbursement and autonomy—into the BHCPF framework. This harmonisation balances structural stability with the operational agility required to advance Universal Health Coverage in Nigeria.