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.
Highlights
Policy making, translation and implementation in politically and administratively decentralized systems can be challenging
Following the criteria spelt out in the policy guidelines, we found 25 (68%) states had met the criteria for having established State Primary Health Care Development Agencies (SPHCDAs) or equivalent structures
None of the SPHCDAs adhered completely to the core principles of “One Management, One Plan, One Monitoring and Evaluation System” as the management of primary health care (PHC) was still fragmented across various government agencies
Summary
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, in low and middle-income countries. When evidence-based initiatives are introduced to new settings, they do not automatically get implemented as designed due to differences in context [2]. Implementation here refers to “efforts designed to get evidence-based programs or practices of known dimensions into use via effective change strategies” [2]. Given that investments in evidence-based interventions often fail to achieve expected results in low- and middle-income countries (LMICs), there are ongoing debates and discussions on how to evaluate health system interventions to understand the mechanisms and elements that influence their execution and outcomes [3]. It is important to understand the systems in which interventions are implemented
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