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



Having 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.



Contrary 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.



Our 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.
Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa. ejemai.eboreime@wits.ac.za.|Department of Planning, Research and Statistics, National Primary Healthcare Development Agency, Abuja, Nigeria. ejemai.eboreime@wits.ac.za.
Ejemai Amaize
EA
Eboreime
Department of Planning, Research and Statistics, National Primary Healthcare Development Agency, Abuja, Nigeria.|University of Sydney, School of Public Health, Edward Ford Building A27, Sydney, NSW, 2006, Australia.
Seye
S
Abimbola
Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.
Felix Abrahams
FA
Obi
Direct Consulting and Logistics, Abuja, Nigeria.
Obinna
O
Ebirim
Department of Planning, Research and Statistics, National Primary Healthcare Development Agency, Abuja, Nigeria.
Olalekan
O
Olubajo
Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.|School of Geography and Earth Sciences, McMaster University, Hamilton, Canada.
John
J
Eyles
Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
Nonhlanhla Lynette
NL
Nxumalo
Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
Faith Nankasa
FN
Mambulu
D000288:Administrative Personnel; D054976:Clinical Governance; D035082:Federal Government; D006076:Government; D006078:Government Programs / Q000458:organization & administration*; D006291:Health Policy; D006801:Humans; D008483:Medical Assistance; D009549:Nigeria; D011050:Policy Making; D011057:Politics; D011320:Primary Health Care / Q000592:standards*; D013219:State Government
Decentralization; Health policy; Implementation fidelity; Nigeria; Primary healthcare