National burden of non-communicable diseases

Noncommunicable diseases (NCDs) are leading causes of death globally with associated large economic, social and health impacts [1]. The burden of NCDs is highest in low-income and middle-income countries (LMIC) [2]. Most populations with limited access to services and conditions, such as adequate education and routine screening, that will enhance the prevention, early detection and prompt treatment of NCDs experience a disproportionate share of the disease burden compared to those with adequate access to essential services [1].

The current (year 2020) NCD progress monitor report reveals a rising NCD burden in Nigeria with 617,300 NCD related deaths, accounting for 29% of total deaths, of which, 22% occurred among those aged between 30–70 years (referred to as premature deaths) [3]. Cardiovascular diseases account for 11% of these deaths, 4% are due to cancers, 2% are due to chronic respiratory diseases, 1% diabetes and other NCDs account for the remaining 11% [1]. The country’s NCD burden was generated using mortality estimated from 2016 WHO Global Health Estimates and the most recent United Nations Population Division World Population Prospects. The likelihood of dying between ages 30–70 years from the four main NCDs were calculated from age-specific death rates and proportional mortality for NCDs [1]. In addition to these four leading NCDs, sickle cell diseases (SCDs) are also significant NCDs in Nigeria. Nigeria is estimated to be the highest SCD burden globally [4] and contributes about 30% of the global burden of children born with sickle cell anaemia annually [5].

Nigeria’s health system and national policy response to NCDs

Nigeria has a three-tier government structure (federal, state, and local government), and consequently, the health system is decentralized. In practice, health system decentralization is “the transfer of authority and power from higher to lower levels of government or from national to subnational levels of government” [6]. This decentralized system places health on the concurrent legislative list [7, 8], and this implies that the health system operates with shared authority across each tier of government, [9] such that delivery, management, and financing of health services is the responsibility of all three tiers of government [10]. The constitution does not delineate the responsibilities of each tier of government with regards to health [8]. As each possesses a high level of autonomy, significant authority is exercised by each tier with regards to resource allocation and utilization [11]. The federal government is responsible for development of national health policies and issuing guidelines for their implementation at the state and local government level [11, 12]. Every state has an elected governor who is the head of the executive council, and a legislative body–the house of assembly. Local governments are managed by an elected executive chairperson along with legislative councillors from political wards. Each state has a Ministry of Health, and each local government has a department of health.

The private health sector plays a significant role in the health system. It constitutes about 30% of the country’s health facilities across all levels of healthcare system and (along with ‘informal’ healthcare providers such as traditional medicine providers, patent and proprietary medicine vendors, drug shops and complementary and alternative health practitioners) delivers about 60% of the country’s healthcare services [10].

Health system fragmentation in federalised countries with decentralised governance structures is a well-recognised risk to coherent national health policymaking [13]. Consequently, the NCD policy response in Nigeria requires strategic intent by all levels of government. Until 2020, the National Strategic Plan of Action on Prevention and Control of NCDs was the overarching policy document for NCDs prevention and control in Nigeria. First launched in 2013, it was updated in 2015 to span the period 2016–2020 [4]. It provided a framework for using a multisectoral approach to strengthen the health system for the prevention and control of NCDs. In 2019, the National Multi-Sectoral Action Plan for the Prevention and Control of Non-Communicable Diseases (2019–2025) was launched. This action plan supersedes the previous policy and is currently the main guiding document for a national, multi-sectoral response to NCDs [14].

Previous NCD policy analysis have evaluated the importance of a multisectoral approach and implementation of NCD ‘best buys’–well-evidenced interventions that are feasible, low-cost and appropriate to implement within the constraints of the local health system [15]. One such study analysed NCD policies across multiple stakeholder organizations in Nigeria. It generated evidence on the use of a multisectoral approach in formulating policies for NCD ‘best buys’ implementation as well as assessed its barriers and facilitators. Nigeria’s WHO membership, leading to government commitment to a series of resolutions, was found to be the most important facilitator, while over-dependence on donor funding, lower political priority and poor understanding of how to implement multisectoral plans were cited as barriers [16].

Studies that explored NCD risk factors found comprehensive tobacco related policies [17] and some alcohol-related policies [18]. However, both areas had weak multisectoral approaches, and some did not adhere to the principles of ‘best buys’. Multi-country studies that have analysed NCD prevention policies through a multisectoral lens found that the policies are influenced by several global and local factors such as political will, available resources and locally generated data. These studies established the existence of policy implementation gaps that require mechanisms to attain better policy outcomes with a particular focus on contextual factors such as political support and adequate resource allocation [19–22].

The extent to which Nigeria’s decentralized health system governance may be an important driver of NCD policy implementation has been inadequately appraised to date. In this study, we aimed to understand the implementation of NCD policies in Nigeria, and the implications of decentralisation for achieving national NCD targets.

NCD policy analysis

We analyzed national NCD guidelines, policy and strategy documents by the Federal Ministry of Health over the period 2009–2019. This was supplemented by empirical studies and country reports on the implementation of NCD programmes to explore the context of the implementation of NCD policies and strategies in Nigeria. We retrieved publicly available NCDs policy documents developed by the ministry of health from government’s and World Health Organization’s websites. Key individuals were contacted through email or direct call and the Federal and State Ministries of Health were also visited to obtain other relevant documents that were not accessible online.

Using guidelines on decentralization [23], we examined how these policies aligned with the multiple dimensions of decentralization as it applies to both unitary and federal countries. The OECD guidelines on decentralization was developed multi-level governance studies series and applied to some countries. It outlines ten domains for decentralization that are necessary for local and regional development [23]. It also provides the rationale for each domain, suggested practical guidance, stated drawbacks to avoid, listed good practices and included a checklist for action. Five of the ten domains were chosen because they bear direct relevance to the aim of our study. The other five domains are beyond the scope of this study as they focus broadly on legislative and fiscal structures. The five domains considered were: (1) clear roles and responsibilities of different government levels; (2) sufficient funds for all responsibilities; (3) support subnational capacity building; (4) adequate coordination mechanisms among levels of government; and (5) accountability framework and performance monitoring system.

Stakeholder perspectives on implementation of NCD policies

To understand the structure and process of implementation of NCD policies across the various level of the health system, qualitative data were collected from August 2019 to September 2019 and guided by the consolidated criteria for reporting qualitative research guidelines for qualitative research [24]. Interviews with key informant NCD stakeholders were conducted by the lead author (WSA), a male public health researcher who has worked with the Nigerian government at various level of the country’s health system. He was supported by two other data collectors who were trained to become familiar with the aims of the study, interview questions and the use of field notes. All recruited participants were interviewed face-to-face except for one who provided a written response. All interviews were audio recorded, conducted in locations conducive and appropriate for the participants’ privacy such as personal office space with only the researchers and participants present. Interview duration ranged from 30–60 minutes.

At the national level, we interviewed staff in the Departments of Public Health (NCD Division) and Hospital Services (Cancer Control Unit) on the structure and process of implementation of the overarching NCD policies. At the sub-national level, we interviewed staff in four states, two in each of the Southern and Northern regions. This is because each region has varying health indices profiles [11]. These states were selected on the basis of varying socio-economic profiles, health indices and similarity in health intervention programmes being implemented. Purposive sampling was used to select the policy actors based on their roles, relevance, or expertise in the NCD prevention policies and strategies. This was to ensure a maximum variation across all relevant units. We also took a ‘snowballing’ approach to identify additional respondents during interviews with the initial key informants. Interviews focussed on the structure, resources and mechanisms through which the Nigeria National Policy and Strategy on NCDs 2015–2020 was delivered [25] (see S1 File for the interview guide).

Interviews were transcribed, coded, and analyzed thematically. Themes were both derived from the data and also guided by the five domains from the OECD guidelines on decentralization described above [23].

Altogether, eleven policies, guidelines, and strategic plans for NCDs in Nigeria were examined and twenty-two key informant interviews conducted.

Ethical considerations

Ethical approval was granted by the National Health Research Ethics Committee of Nigeria (Approval no: NHREC/01/01/2007) and the University of New South Wales Human Research Ethics Committee (HC: 190051). Informed written consent was obtained from all participants before conducting the interview. Anonymity and confidentiality of all respondents were maintained throughout the process. Participants names were also replaced with codes during data analysis (Table 1).

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Table 1. Participants of key informant interview (KII).

https://doi.org/10.1371/journal.pgph.0000050.t001

A. NCD policy documents and decentralization

Eleven national documents were reviewed—four on cancers, one on sickle cell disease, one on tobacco control, two on diet related NCDs, and two on multiple NCDs. There were no government-led national guidelines on the management of hypertension, diabetes, and respiratory diseases. (Table 2) Although there are some clinical guidelines developed by national health professional associations for diabetes and hypertension, these were not developed under the auspices of any national government body. The two key findings from the document analysis and interviews was that there was inadequate consideration for decentralisation and delayed implementation of the National Strategic Plan.

B. Themes from interviews

Evolving NCD policies with limited consideration for decentralization

All policy documents examined primarily originated from the national level of government, but sub-national governments are chiefly responsible for the implementation. Mapping these documents against domains of decentralization suggests they are insufficiently developed to support sub-national implementation.

Lack of clearly assigned roles for each of the levels of government is known to be associated with inefficient service provision and may result into failure to effectively address critical needs [23] such as the rising burden of NCDs. Findings from this study is similar to the report of the National Health Policy which revealed that the national constitution and the 2014 National Health Act has failed to address the clear roles and responsibilities of each tier of government towards health [8, 12]. Greater role clarity and articulation of shared responsibilities for NCD prevention and control could ensure that duplication is avoided, and accountability for implementation is enhanced. It is therefore important that more attention be paid, in these policies, to adoption, scale up, and quality implementation at subnational levels.

This needs to be accompanied by adequate funding for the activities and roles assigned to the various level of governments accompanied by effective coordination mechanisms (discussed below). Well designed and implemented decentralization policies could deliver multiple benefits including enhanced frontline service delivery for NCD programmes, efficient resource allocation and ultimately a positive impact on health indices [23].

Limited political will and inadequate financial resources for NCD programmes and policy implementation

Successful implementation of policies and programmes requires strong political will. For translation of intent to action, political will must be also be accompanied by political capacity [26]. This implies the creation of an enabling governance environment and structure to drive the process. Such enabling socio-political and bureaucratic environments can lead to increased availability and accessibility to necessary human and financial resources [26]. The lack of recent, reliable state-wide and national data on the burden of NCDs could reflect the lack of such political will and capacity. While there are regular surveys on infectious diseases such as HIV/AIDS and tuberculosis, the most recent national NCD survey is almost three decades old [14]. It is therefore important that contemporary and robust data are generated to advocate for increased political commitment to support NCD policy implementation.

Nigeria can draw lessons from the role that enhanced political will and capacity played in the elimination of poliomyelitis. During the era of polio scourge in Nigeria, all Presidents were outspoken in their commitment to elimination of the virus. A presidential taskforce was formed to directly supervise and coordinate national campaigns, and to monitor progress of each states to ensure accountability, including sanctions for poor performances [27]. National level campaigns were launched alongside community level engagement that included religious leaders, community leaders, opinion leaders and local government chairmen [28]. State Governors were also required to sign a commitment to polio eradication, provide additional funding for the implementation and report regularly to federal government. The presidential task force also tracked progress at local government levels and made all data publicly accessible [27]. This high level of political will and capacity across all governance levels was a major factor in polio eradication and the approaches taken to optimise Nigeria’s decentralized health system are prescient for addressing NCDs.

Though political commitment is a necessary condition for adapting and implementing policies and strategies, it is not sufficient in itself [29]. It needs to be accompanied by other factors including robust governance structures and adequate resource allocation. Currently, the national government provides minimal financial support to sub-national level governments (especially for NCD programmes). This combined with inadequate locally generated revenues, inevitably leads to NCDs being placed lower on the policy agenda at the subnational level [30]. There is a pressing need for financing reforms to foster the appropriate environment for effective NCD policy implementation. First, the main revenue source currently for NCD programmes is via the annual budget appropriation. While this is commendable, the bureaucracy involved results in a minority of the appropriated budget being disbursed downstream to those responsible for implementing these policies. This complex bureaucratic process associated with NCD budgets also reflected Botswana’s experience even in the face of political commitment [31]. Second, although multisectoral approaches to improve NCD programme implementation are essential, there needs to be a less bureaucratic processes for leveraging resource contributions and allocations from different government departments. Third, there is limited consideration given to NCDs in the National Health Insurance Schemes (NHIS) and the Basic Health Care Provision Funds (BHCPF) [14]. Fifty per cent of the BHCPF is disbursed through NHIS for a basic minimum package of health services (BMPHS). Of the nine BMHPS interventions, only one relates to NCDs (urinalysis and blood pressure check to screen for diabetes and hypertension) with the remaining interventions dedicated to infectious diseases, maternal and child health [32]. Fourth, NCD programmes attract little international donor support relative to infectious diseases and maternal and child health programmes. This places further constraints on the fiscal space needed to expand NCD policy implementation, especially at the sub-national level [33]. The persistence of vertical program funding and the lack of a health system strengthening approach from international donors are major barriers to addressing NCD prevention and care. [34, 35].

In order to reduce the burden of NCDs, make progress in achieving national targets as well as reduced out-of-pocket spending associated with NCDs care, Nigeria needs to increase and prioritize funding for NCDs through multiple sources and at all levels of care [36]. Increasing the current national budget allocation to health from 3% to 15% according to the Abuja Declaration [10] could generate increased funding of NCD programme. Like Uganda, Nigeria can also develop a costed NCD strategy using locally generated data to determine the country’s scope of NCD services. Uganda has quarantined funds to NCDs programmes annually and this is increased proportionally when there is a need for implementation of special programmes [37].

Weak regional structures and defective coordination mechanisms

The setting and structure in which a policy is delivered influences both implementation and outcomes [25]. The presence of many actors at different governing levels of the system make coordination very challenging as some of these structures may have intersecting or competing roles in the delivery of NCD services [34]. Improved coordination mechanisms have potential to harmonize the engagement and activities of all relevant stakeholders [38].

The findings from the study are not unique to Nigeria. Previous studies show that in sub-Saharan Africa, the implementation of NCD prevention and control programmes is poorly coordinated [39] and often relies on non-governmental organizations to compensate for weak governance structures [21]. In Ghana, the coordination of NCD programmes between the policy (national) and service delivery (subnational) arms of the health sector was described as poor [40]. Achieving a successful sub-national implementation plan and efficient use of available resources in Nigeria will therefore depends largely on improved coordination between national and subnational levels [41]. Additionally, enforceable and practical accountability frameworks such as sanctioning of non-performance states and rewarding performance should characterise policy design and implementation [30].

For effective implementation of disease programmes such as NCDs, where ‘last mile’ connectivity for service delivery is required within the community, these coordination mechanisms needs to include the lowest level governance units [42]. Leveraging existing coordination structures is one of the most expedient way to achieve this, reducing the time, effort and costs needed to establish new structures and processes. Thailand implemented an effective coordination structure for coordinating alcohol and tobacco programmes and this has since been expanded to accommodate other NCDs [43]. Cambodia [44] and Kenya [45] also leveraged on existing HIV platform for care and coordination of NCD care delivery on a pilot scale and achieved a successful outcome. While the task of scaling this up on a larger scale may be complex, there are no doubts about its potential benefits.

Integrated PHC service delivery and the way forward

The primary health facility, the lowest and most important level of the formal health care system for health programme implementation, is worst hit by the effect of the poor political will and inadequate resources for NCD programmes [10]. Despite constrained human resources, infectious disease and maternal and child health services are far better supported than NCD services. These programmes are better coordinated, augmented by task shifting policies (e.g. the midwives service schemes [46]), attract numerous donors supports for community outreach [10]. This starkly contrasts with the situation for NCDs. PHC facilities have limited management guidelines and minimal accountability frameworks for NCDs.

There is need to build the capacity of PHC staff, most of which have not received any form of in-service training for NCD management and prevention but are currently providing various forms of NCD services. In sub-Saharan Africa, only around one third of countries reported having trained PHC health workers for NCD management or have a national strategy with such plan [47]. It is therefore important that regular in-service training for PHC staff should be prioritized for successful integration of NCD care into routine service delivery. This will also ensure achievement of the planned task-shifting between the primary health care team [48] and equip them for effective service delivery [49]. Nigeria can learn from models such as those implemented by eSwatini to support health workers to achieve long term goals of NCD care implementation in decentralized health systems [50]. More so, all NCD services, including data management of the DHIS2 and IDSR, need to be done in a coordinated and integrated approach along with other essential services at the PHCs.

PHC capacity to integrate NCD services into frontline care delivery is a challenge in most countries in the African region. A recent study found that no African country met all the recommended indicators for integrating NCDs services into PHC [47]. To effectively align NCD prevention and control strategies with the country’s decentralized system, similar service delivery strategies deployed for chronic infectious diseases such as HIV and poliomyelitis should be considered for NCD integration. This may include pooling human resources, technical and financial support in conjunction with sub-national advocacy efforts to drive NCD programme implementation with a focus on achieving national targets. NCD-HIV service integration in rural Malawi has demonstrated high patient retention rates and statistically significant improvements in clinical outcomes for patients with NCDs [51].

Study limitations

The current study was conducted at the national level, four states and a few selected local government areas. The findings for these states and local governments are therefore not generalizable as each sub-national entity has varying socio-economic and political profiles. However, the findings are transferable, when contextualised to the local circumstances in each state and local government area. More so, issues such as budgetary allocation and accessible funds for NCDs were self-reported and was not verified by the research teams as they were not publicly available. Other limitations of our study are that, the study focused mainly on the public sector of the health system and did not also include the non-health sector stakeholders. To address some of these potential limitations, we selected two states each from the Northern and Southern parts of the country and recruited relevant key participants to ensure robust data collection. However, future studies should not only explore the structures and processes within which policy implementation occurs (the focus of our study) but also conduct a detailed evaluation of the actual implementation of these strategies. This should be extended to the private sector of the health system as it plays a central role in the delivery of PHC services in the country. It is important that future research explore how the non-health ministries, departments and public agencies approach decentralization and its impact on multisectoral collaboration with the health sector for NCDs prevention and control.