Aligning policymaking in decentralized health systems: Evaluation of strategies to prevent and control non-communicable diseases in Nigeria.

Whenayon Simeon Ajisegiri,Rohina Joshi,David Peiris,Seye Abimbola,Azeb Gebresilassie Tesema,Dike B Ojji,Olumuyiwa O Odusanya,Yodi Mahendradhata

doi:10.1371/journal.pgph.0000050

Abstract

Noncommunicable diseases (NCDs) are leading causes of death globally and in Nigeria they account for 29% of total deaths. Nigeria's health system is decentralized. Fragmentation in governance in federalised countries with decentralised health systems is a well-recognised challenge to coherent national health policymaking. The policy response to the rising NCD burden therefore requires strategic intent by national and sub-national governments. This study aimed to understand the implementation of NCD policies in Nigeria, the role of decentralisation of those policies, and to consider the implications for achieving national NCD targets. We conducted a policy analysis combined with key informant interviews to determine to what extent NCD policies and strategies align with Nigeria's decentralised health system; and the structure and process within which implementation occurs across the various tiers of government. Four inter-related findings emerged: NCD national policies are 'top down' in focus and lack attention to decentralisation to subnational and frontline care delivery levels of the health system; there are defective coordination mechanisms for NCD programmes which are underpinned by weak regional organisational structures; financing for NCDs are administratively burdensome and fragmented; and frontline NCD service delivery for NCDs are not effectively being integrated with other essential PHC services. Despite considerable progress being made with development of national NCD policies, greater attention on their implementation at subnational levels is needed to achieve more effective service delivery and progress against national NCD targets. We recommend strengthening subnational coordination mechanisms, greater accountability frameworks, increased and more efficient funding, and greater attention to integrated PHC service delivery models. The use of an effective bottom-up approach, with consideration for decentralization, should also be engaged at all stages of policy formulation.

Highlights

National burden of non-communicable diseasesNoncommunicable diseases (NCDs) are leading causes of death globally with associated large economic, social and health impacts [1]
Cardiovascular diseases account for 11% of these deaths, 4% are due to cancers, 2% are due to chronic respiratory diseases, 1% diabetes and other NCDs account for the remaining 11% [1]
We analyzed national NCD guidelines, policy and strategy documents by the Federal Ministry of Health over the period 2009–2019. This was supplemented by empirical studies and country reports on the implementation of NCD programmes to explore the context of the implementation of NCD policies and strategies in Nigeria

Summary

Introduction

Noncommunicable diseases (NCDs) are leading causes of death globally with associated large economic, social and health impacts [1]. The likelihood of dying between ages 30–70 years from the four main NCDs were calculated from age-specific death rates and proportional mortality for NCDs [1]. In addition to these four leading NCDs, sickle cell diseases (SCDs) are significant NCDs in Nigeria. Nigeria is estimated to be the highest SCD burden globally [4] and contributes about 30% of the global burden of children born with sickle cell anaemia annually [5]

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Conclusion