Effective implementation processes are important for achieving the outcomes of complex health system interventions  and traditional linear approaches have not been effective in achieving the desired outcomes of such interventions. When evidence-based initiatives are introduced to new settings, they do not automatically get implemented as designed due to differences in context . It is therefore necessary not only to focus on executing the intervention but to also ensure fidelity and quality in implementation. Implementation here refers to “efforts designed to get evidence-based programs or practices of known dimensions into use via effective change strategies” . Given that investments in evidence-based interventions often fail to achieve expected results particularly 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 . Batalden’s observation that “every system is perfectly designed to get the results it gets”, has become associated with improving the implementation of health system strengthening initiatives . To ensure effective implementation, it is important to understand the systems in which interventions are implemented.
Generally, government systems are designed as multi-level structures . While in unitary systems, there is a clear chain of command between national and sub-national levels of government, federal (decentralized) systems are characterized by sharing of authority across the various tiers of government . However, the delineation between both systems is not clear cut, as “unitary” does not indicate that all decision making is done at the national level. Neither do politically decentralized systems confer all decisions-making powers to sub-national government structures. Rather, classification is with regards to the tier at which sovereignty lies . But policy making in unitary systems is largely central, thus implementation can be more efficient than in decentralized systems, given the reduction in bureaucratic bottlenecks (common in decentralized systems) between policymaking and execution . For example, a recent study found that African countries operating federal (decentralised) system of government consistently performed lower in vaccination coverage than the continent’s average . Notably, with the propagation of democracy (particularly in Africa), decentralization is increasingly adopted even in constitutionally centralized countries . Consequently, understanding how this system affects the health policy chain becomes important to ensure optimal benefits of decentralization while minimizing its untoward effects.
Administrative decentralization manifests in three forms: deconcentration, delegation and devolution, . Considered the weakest form of decentralization (and a characteristic of unitary systems), deconcentration redistributes decision-making power across different levels of the central governance authority, by moving its actors from the centre to act as sub-national representatives in regions and/or sub-regions. Delegation, transfers decision-making power from the central authority to semi-autonomous institutions accountable, but not fully subservient to it. Devolution occurs when central government transfers decision-making powers to autonomous sub-national (local) institutions which have independent administrative systems from the central administration. These local governments have legally defined geographical boundaries as well as independent financial management systems. Decentralized (federal) political governance is characterized by devolution of powers [5, 8, 9]. Abimbola et al. described decentralisation in relation to primary health care (PHC) as “a system of governance in which the power, authority, resources, and responsibility for PHC service delivery are transferred from a central government to actors and institutions at the periphery”.
In this paper, 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 nationally initiated health policies and programmes. Fidelity has been described in 5 dimensions: adherence, exposure, quality of delivery, participant responsiveness, and programme differentiation [3, 10–12]. We focus on the “adherence” dimension that reflect the extent to which policy components are implemented by lower levels of the health system as prescribed by policy guidelines [3, 13].
Since independence from British colonial rule in 1960, Nigeria has fluctuated between democratic federal systems, unitary military autocracies and hybrid (a mix of autocratic central government and pseudo-democratic sub-national governments) governance systems . Much of the principles underpinning the current structure of the health system were developed during military and hybrid eras; particularly the devolution of responsibility for health to the various tiers of government. While Nigeria regained democratic rule in 1999, these principles of decentralisation were retained in the 2004 national health policy . Nigeria operates a three-tier federal system of government comprising the federal government, 36 states and 1 territory (the Federal Capital Territory), which in turn consist of Local Government Areas (LGAs) totalling 774 nationally. The states are semi-formally clustered into six geopolitical zones, each with an average of 6 states having comparable sociocultural characteristics, without any administrative structure .
While it has led to a considerably decentralized governance system, Nigeria’s constitution is silent on the functions and responsibilities of each tier of government in the provision and oversight of health services . Nevertheless, the National Health Policy prescribes a system in which PHC is under the purview of local governments while the state and federal governments are responsible for the management (administrative and financial) of secondary and tertiary health care services respectively . One of the consequences of PHC being the least resourced (technically and financially) level of government in Nigeria (i.e. Local Governments) is that other levels of government have had to assume a level of responsibility for PHC as well. This system in which functions, structures and human resources for PHC are managed by different tiers and organs of government is poorly coordinated and lacks defined accountability mechanisms. Many services are organised along vertical lines with poor integration and limited co-ordination. Referrals across levels of care are dysfunctional. Diverse management structures co-exist with duplicated or poorly defined roles and responsibilities within and between the three tiers of government [18–20].
One strategy Nigeria adopted for central coordination of the health sector within its decentralized system is the National Council on Health (NCH). The NCH is recognized as the highest policy making body for health in Nigeria, tasked with the responsibility of setting national visions and goals for health to be implemented across the various levels of government. The NCH consists of all state ministries of health, represented by their commissioners, and is chaired by the national minister for health [15, 21]. This composition assumes that decisions taken by the NCH should find easy implementation at sub-national levels, given that the commissioners for health are the highest authority figures for health at the state government level. Another strategy to improve coordination within the health system is the Integrated Primary Health Care Governance initiative, also called “Primary Health Care Under One Roof (PHCUOR)” – the focus of this study. The aim is to improve uniformity in access and quality of care for the majority of the population [22, 23]. This policy was introduced in 2010 by the Federal Ministry of Health through the National Primary Health Care Development Agency (NPHCDA), in response to the challenge of weak governance at the lower levels of the health system . The NCH approved PHCUOR as a national policy in its 54th session, May 2011.
The PHCUOR policy prescribes that a state level management agency, commonly referred to as the State PHC Development Agency (SPHCDA) should be established by each state government to govern all aspects of PHC thus eliminating the problem of fragmented governance. The PHCUOR reforms are hinged on the core principles of “One Management, One Plan, One Monitoring and Evaluation System” thus integrating PHC governance at the state level within an organizational system administered by the SPHCDA. To stimulate compliance to the policy by sub-national governments, the national government included a provision in the 2014 National Health Act known as the Basic Health Care Provision Fund . This fund comprises of not less than 1% of the Consolidated Revenue of the Federation as well as grants from international donors and funds from other sources. States can only access the funds through their respective SPHCDAs after fulfilling requirements stipulated in guidelines developed by the NPHCDA . Many donors now require states to have set up SPHCDAs as a part of requirements for receiving grants for PHC development.
In its ideal form, the SPHCDA is expected to absorb all PHC staff who were hitherto employees of the other ministries, departments, and agencies of both state governments and LGAs. The deconcentrated LGA arm of the SPHCDAs is to be known as the Local Government Health Authorities (LGHAs) and should report to the Chief Executive of the SPHCDA (Fig. 1). This is a radical transition from the existing system in which the LGA department of health answers to the LGA Chairman (an elective political position in government). Expected to be autonomous of the State Ministries of Health and to only report to the State Governors through the State Commissioners for Health , the SPHCDAs are to be the sole employers of all human resources for PHC, and managers of all PHC-related financial resources, programmes and facilities in a state [18, 19]. The policy is an adaptation of World Health Organization’s District Health System [19, 24].
The government of Nigeria currently reports that 28 out of 37 states “now have State Primary Health Care Development Agencies or equivalent institutions with 26 of them having a legal basis for establishment” , thus implying that over 70% of states have complied with the national policy. This assumption, however, does not consider the degree of implementation or operationality of these SPHCDAs as defined by national guidelines. In this study, we evaluate the implementation fidelity of PHCUOR in Nigeria to understand how the intervention was executed and adapted at the sub-national level. While there are many studies on implementation fidelity at the micro (clinical) and meso (organizational) levels of the health system, little has work has been done in evaluating implementation fidelity at the macro level of health systems, particularly as relates to translation of national policies to lower levels.