How (not) to promote sub-national ownership of national initiatives in decentralised health systems: The free maternal and child health programme in Nigeria, 2008-2015

Background Promoting the sub-national ownership of national health initiatives is essential for efforts to achieve national health goals in federal systems where sub-national governments are semi-autonomous. Between 2008 and 2015, Nigerian government implemented a pilot free maternal and child health (MCH) programme in selected states to improve MCH by reducing physical and financial barriers of access to services. This study was conducted to better understand why the programme was neither adopted nor scaled-up by sub-national governments after pilot phase. Methods We conducted a qualitative evaluation of the programme in Imo and Niger States, with data from programme documents, in-depth interviews (45) and focus group discussions (16) at State and community levels. Data was analysed using manual thematic coding approach. Result Our analysis indicates that the programme design had two mutually dependent goals, which were also in tension with one another: 1. To ensure programme performance, the designers sought to shield its implementation from sub-national government politics and bureaucracy; and 2. To gain the buy-in of the same sub-national government politicians and bureaucrats, the designers sought to demonstrate programme performance. The potential for community advocacy for sub-national adoption and scale-up was not considered in the design. Therefore, limited involvement of sub-national governments in the programme design limited sub-national ownership during implementation. And limited oversight of implementation by sub-national government policymakers limited programme performance. Conclusion Efforts to promote sub-national ownership of national initiatives in decentralised health systems should prioritise inclusiveness in design, implementation, and oversight, and well-resourced community advocacy to sub-national governments for adoption and scale-up.

Automated summary

This study examines the reasons why a pilot maternal and child health program in Nigeria was not adopted or scaled up by sub-national governments. Through qualitative evaluation and analysis, the researchers found that limited involvement of sub-national governments and lack of community advocacy were the main factors contributing to the lack of program ownership and poor implementation.