Implementing National Policies in Decentralized Health Systems: a case study of an Integrated Primary Healthcare Planning and performance improvement initiative in Nigeria

Eboreime, Ejamai Amaize
Journal Title
Journal ISSN
Volume Title
Implementing policies in decentralized health systems is complex as numerous actors attempt to influence policy formulation, deployment and execution across tiers of multi-level governance systems. Consequently, policy processes commonly suffer misalignment between design and real-world implementation. Thus, examining policy processes across the designdeployment-implementation continuum is important to identify and address implementation bottlenecks and improve health system performance and outcomes. This research tested the use of multiple frameworks, drawn from implementation science and health policy and systems research, to assess implementation of a complex intervention in Nigeria. The intervention to improve local primary healthcare planning used a quality improvement model known as Diagnose-Intervene-Verify-Adjust (DIVA) developed nationally and deployed to subnational levels. Uptake of DIVA has been poor, and implementation not sustained. Data on implementation were collected through key informant interviews, document and routine data as well as structured questionnaires. Overall, 242 respondents were interviewed from each layer of the health system as well as from the various spectrum of actors involved in the interventions (government and non-government). Further, 39 policy documents were analyzed. Both deductive and inductive analytic approaches were employed. Meyer’s Quality Implementation Framework was used to identify gaps between the national design of DIVA and its local deployment. Contextual factors affecting deployment were identified using Kaplan’s Model for Understanding Success in Quality. Interpretation of results was conducted through an inductive synthesis that categorized emergent themes across four elements (what, why, who and how) informed by Walt and Gilson’s health policy triangle. The results are presented in 4 published papers. Papers 1 and 2 examined the formulation processes and translation of national policy initiatives to subnational implementers. Papers 3 and 4 mostly examined implementation quality and effectiveness at subnational levels (state and LGA) as well as their determinants. Potentially effective interventions were found to be commonly constrained by poor implementation fidelity, occasioned by political and administrative bottlenecks. Sub-national leadership and management have the most significant impact on implementation outcomes. Rather than implementing to improve health outcomes, findings suggest that national financial/political incentives were better motivators of subnational adherence to national guidelines. Sub-national governments’ exercise of discretionary power compromised implementation quality of PHC strengthening initiatives in Nigeria. Understanding and engaging the various interests across the governance spectrum is key to improving quality and sustainability
A thesis completed by published work, submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Doctor of Philosophy, Johannesburg 2019