Evaluating the sub-national fidelity of national Initiatives in decentralized health systems: Integrated Primary Health Care Governance in Nigeria

Abstract

BackgroundPolicy making, translation and implementation in politically and administratively decentralized systems can be challenging. Beyond the mere sub-national acceptance of national initiatives, adherence to policy implementation processes is often poor, particularly in low and middle-income countries. In this study, we explore the implementation fidelity of integrated PHC governance policy in Nigeria’s decentralized governance system and its implications on closing implementation gaps with respect to other top-down health policies and initiatives.MethodsHaving engaged policy makers, we identified 9 core components of the policy (Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Structure, and Office Establishment). We evaluated the level and pattern of implementation at state level as compared to the national guidelines using a scorecard approach.ResultsContrary to national government’s assessment of level of compliance, we found that sub-national governments exercised significant discretion with respect to the implementation of core components of the policy. Whereas 35 and 32% of states fully met national criteria for the structural domains of “Office Establishment” and Legislation” respectively, no state was fully compliant to “Human Resource Management” and “Funding” requirements, which are more indicative of functionality. The pattern of implementation suggests that, rather than implementing to improve outcomes, state governments may be more interested in executing low hanging fruits in order to access national incentives.ConclusionsOur study highlights the importance of evaluating implementation fidelity in providing evidence of implementation gaps towards improving policy execution, particularly in decentralized health systems. This approach will help national policy makers identify more effective ways of supporting lower tiers of governance towards improvement of health systems and outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2179-2) contains supplementary material, which is available to authorized users.

Effectiveness of the Diagnose-Intervene- Verify-Adjust (DIVA) model for integrated primary healthcare planning and performance improvement: an embedded mixed methods evaluation in Kaduna state, Nigeria

“…The LG teams are then supported to identify bottlenecks inhibiting optimal effective coverage with respect to each tracer intervention. This training and technical support was embedded into the DIVA process to ensure optimal implementation fidelity by mitigating lower-level discretion commonly observed in multi-level governance contexts 7 27–29…”

“…This is typical of complex health systems characterised by many actors and interest groups (governmental and non-governmental) operating at different levels 5 6. Lower levels of decentralised health systems are known to pose implementation challenges in low- and middle-income countries (LMICs) largely due to weak capacity for governance as well as political constraints 6–8. Several methods have been implemented to improve PHC performance in LMICs.…”

“…Most common of these approaches include supportive supervision, mentoring, tools and aids, quality improvement methods and coaching 9. These approaches have largely focused on health facilities and are mostly vertical (focusing on one intervention) 7 9. A systematic review of quality improvement strategies for improving maternal and child health in LMICs revealed a limited number of studies involved integrated approach to PHC 10.…”

Process Evaluation of Implementation Fidelity of the Integrated Chronic Disease Management Model in Two Districts, South Africa

“…Since the ICDM model development was an adaptation of the ICCC for the South African health context [7], it would be expected that it would be implemented with minimal adaptations and high fidelity, but this has not been evaluated. Moreover, in a decentralized health system, like South Africa, sub-national levels (provinces and districts) may further adapt innovations for a better fit with their contexts [31].…”

The Nigerian health information system policy review of 2014 : the need, content, expectations and progress

“…Nigeria's large disease and disability burden is associated with a weak health system (National Population Commission, Federal Republic of Nigeria & ICF International, Maryland USA, ). Governance of the health system in general has been a main problem, especially in a decentralised system as practiced in Nigeria (Eboreime et al., ; Uneke, Ezeoha, Ndukwe, Oyibo, & Onwe, ; Uneke et al., ). The recent drive to ensure Universal Health Coverage needs to be backed by evidence to show areas of progress or gaps in order to redirect investments (Tilley‐Gyado, Filani, Morhason‐Bello, & Adewole, ).…”