Aspirations and realities of intergovernmental collaboration in national- level interventions: insights from maternal, neonatal and child health policy processes in Nigeria, 2009–2019

Abstract

In Nigeria’s federal government system, national policies assign concurrent healthcare responsibilities across constitutionally arranged government levels. Hence, national policies, formulated for adoption by states for implementation, require collaboration. This study examines collaboration across government levels, tracing implementation of three maternal, neonatal and child health (MNCH) programmes, developed from a parent integrated MNCH strategy, with intergovernmental collaborative designs, to identify transferable principles to other multilevel governance contexts, especially low-income countries.National-level setting was Abuja, where policymaking is domiciled, while two subnational implementation settings (Anambra and Ebonyi states) were selected based on their MNCH contexts. A qualitative case study triangulated information from 69 documents and 44 in-depth interviews with national and subnational policymakers, technocrats, academics and implementers. Emerson’s integrated collaborative governance framework was applied thematically to examine how governance arrangements across the national and subnational levels impacted policy processes.The results showed that misaligned governance structures constrained implementation. Specific governance characteristics (subnational executive powers, fiscal centralisation, nationally designed policies, among others) did not adequately generate collaboration dynamics for collaborative actions. Collaborative signing of memoranda of understanding happened passively, but the contents were not implemented. Neither state adhered to programme goals, despite contextual variations, because of an underlying disconnect in the national governance structure.Collaboration across government levels could be better facilitated via full devolution of responsibilities by national authorities to subnational governments, with the national level providing independent evaluation and guidance only. Given the existing fiscal structure, innovative reforms which hold government levels accountable should be linked to fiscal transfers. Sustained advocacy and context-specific models of achieving distributed leadership across government levels are required across similar resource-limited countries. Stakeholders should be aware of what drivers are available to them for collaboration and what needs to be built within the system context.

Politics–evidence conflict in national health policy making in Africa: a scoping review

“…We found a persistent poor government commitment in most public health policy initiations, formulations and implementations [ 24 , 26 , 29 , 31 – 38 ]. Again, most public policies were formulated and implemented based on the motivation of policy-makers’ financial incentives as well as government and foreign policy conditionalities [ 27 , 30 , 36 , 37 , 39 ].…”

“…We found that fragmented stakeholder interest, institutional responsibility and accountability, inadequate understanding and interpretation of context by stakeholders divided perspectives of actors on the policy context, and lack of understanding among actors about how policy should be financed limits national public health policy formulation [ 27 , 30 , 41 , 51 – 53 ]. Moreover, incomplete and inaccurate data, poor management of resources, improper coordination and communication between actors, inadequate consultation with relevant stakeholders and inconsistency among actors during policy dialogue and formulation processes are also critical limitations to policy formulation [ 26 , 40 , 41 , 52 – 55 ].…”

“…The main barriers affecting an effective public health policy-making process in Africa include poor consultation, orientation and decentralization [ 26 , 29 , 36 ]. Typically, political policies are expected to promote stakeholder consultation, orientation and proper decentralization of health interventions.…”

“…Typically, political policies are expected to promote stakeholder consultation, orientation and proper decentralization of health interventions. However, we found that political policies and activities are rather undermining stakeholder consultation, orientation and proper decentralization of health interventions [ 26 , 29 , 36 ]. This strongly upholds findings from previous studies [ 3 , 5 , 15 , 16 ] that political interests undermined successful implementation of national policies.…”

National and subnational governance and decision-making processes during the COVID-19 pandemic in Nigeria: an empirical analysis

“…In Indonesia, for instance, the lack of effective action by the national government during the initial phase of the response resulted in conflicting responses from subnational governments, hampering overall effective response to the pandemic 45. Additionally, previous studies have assessed the impact of Nigeria’s decentralised governance system on the implementation of health programmes 46. Etiaba et al noted that governance characteristics such as fiscal centralisation, nationally designed polices and subnational powers did not allow for sufficient collaboration across government levels when it came to the implementation of maternal, neonatal and child health programmes 46.…”