Creating the Foundation for Health System Resilience in Northern Nigeria

Abstract

The experience of a donor-supported Reproductive, Maternal, Newborn, and Child Health (RMNCH) program in four states of Northern Nigeria illustrates how a Complex Adaptive System (CAS) approach to health system strengthening can lead to health systems becoming more resilient. The program worked with the array of political, cultural and social determinants which interact to shape the health system and its functionality. It worked in an environment marked by weak governance with little public accountability and by very limited management capability in inadequately regulated markets. To these conditions of fragility was added the shock from the rapidly deteriorating security situation caused in 2011 by the Boko Haram insurgency and the government's ensuing response. A CAS theory of change provided the basis for the multi-faceted approach that identified critical points of leverage among institutions in social as well as professional systems and helped achieve significant improvements in health service delivery in the RMNCH continuum of care. It also established the foundation for Primary Health Care Under One Roof, which has emerged as a central national strategy in Nigeria for strengthening health sector governance and services under the 2014 Health Act. This article draws on the experience of work undertaken in Northern Nigeria over the course of the last 10 years. A team largely of Nigerian professionals from an array of disciplines worked widely across the health system, addressing issues of governance, finance, institutional management, community systems support, access and accountability, and service delivery-frequently at the same time. This experience provides lessons for efforts elsewhere on how to strengthen health systems during and after emergencies (such as Ebola in West Africa) and in situations affected by conflict. Renewed interest in health systems strengthening (HSS) for building health system resilience came with the outbreak of Ebola in West Africa in 2014. 1 When institutional and systems failure-the absence of health system resilienceaggravated the crisis, there was limited capacity, particularly

Health insurance coverage and antenatal care services utilization in West Africa

“…West African countries will face several barriers to setting up a public health insurance system that is equitable. The experience of Ghana and Nigeria suggest that poor institutional capacity due to limited financial resources and mismanagement will be among those barriers [ 18 , 19 ]. Building capacity in these areas will be crucial in building the health systems that will provide meaningful access to services for the most vulnerable women in the region.…”

“…Unfortunately, these systems are often weakened by a lack of institutional capacity and small tax bases, therefore limiting the possibility of attaining full coverage [ 17 ]. For example, Nigeria’s system has been hurt by poor financial management, including insufficient funding and a weak financial safety net for the poor [ 18 ]. Ghana’s system has a premium cost setting system that has excluded many low-income families [ 19 ].…”

A literature review exploring how health systems respond to acute shocks in fragile and conflict-affected countries

“…During acute shocks, countries need strong, robust health systems to respond to increasing demand and deliver essential health services [21]. The ability of health systems -which has been defined in relation to resilience as the ability to absorb or adapt, or transform -to provide essential health care [1,11,14,[22][23][24] varies significantly in the face of shocks [1,25]. While stronger health systems more successfully limited transmission and deaths from COVID-19, fragmented and weak health systems have struggled to cope with the accelerating number of cases [1].…”

Nonadherence to tuberculosis treatment and associated factors among patients using directly observed treatment short-course in north-west Nigeria: A cross-sectional study

“…Besides, the northern part of the country has significantly worse health indicators than the national averages. 29 For instance, the Nigerian health system is weakened and fragile due to underinvestment and poor financial management, poor budgeting, and a limited supply of essential medicines and equipment. 30 Researchers have employed theories and models to explain factors that might affect and change people's behaviors.…”