THE DISTRICT HEALTH SYSTEM IN ENUGU STATE, NIGERIA: AN ANALYSIS OF POLICY DEVELOPMENT AND IMPLEMENTATION

Abstract

The District Health System (DHS) is a form of decentralised provision of health care where health facilities, health care workers, management and administrative structures are organised to serve a specific geographic region or population. The system was introduced in Enugu state following the election of a new government. However, experiences suggest that implementation of this policy is particularly complex and can be hindered by several factors. This study therefore investigated the development and implementation of the DHS in Enugu State in order to reveal the underlying factors that affected the implementation of the policy. The study involved case studies of two communities from different district health authorities in Enugu state Nigeria that had varying levels of success in implementing DHS. In-depth interviews were conducted with 21 policymakers and 12 focus group discussions were conducted with health workers and community members at the 2 study sites. In addition, document reviews of relevant documents and observation of health facilities and infrastructure were carried out. The implementation of DHS in Enugu State has led to significant improvements in health facilities and has stimulated demand for health services. However, challenges to successful implementation persist including a lack of government funding for heath, a ban on the recruitment of health workers, lack of 24 hour services, uncertainty about the sustainability of the DHS, irregular monitoring and evaluation of staff, a lack of trust between State and local government officials and no accountability of local government health workers to the State government. Additional health workers should be employed to maintain provision of services, Mistrust between local and state government actors has led to resistance at the local level to policy implementation and, in some instances, the withdrawal of funds for DHS. When planning and implementing new policies, efforts should be made to consult with and engage all actors, especially those who are responsible for implementation at the local level. Without dedicated funding and support from the State government, local level actors will have limited ability to support effective policy implementation