Assessment of Organizational Capacity for Evidence-Based Health Systems Operations in Nigeria

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Assessment of Organizational Capacityfor Evidence-Based Health SystemsOperations in NigeriaChigozie J. Uneke a , Abel E. Ezeoha b , Chinwendu D. Ndukwe c ,Patrick G. Oyibo d , Friday Onwe e & Anayo Ogbonna fa Department of Medical Microbiology/Parasitology, Faculty ofClinical Medicine , Ebonyi State University , Abakaliki , Nigeriab Department of Banking and Finance, Faculty of ManagementSciences , Ebonyi State University , Abakaliki , Nigeriac Department of Community Medicine, Faculty of Clinical Medicine ,Ebonyi State University , Abakaliki , Nigeriad Department of Community Medicine , Delta State University ,Abraka , Nigeriae Department of Sociology/Anthropology, Faculty of Arts , EbonyiState University , Abakaliki , Nigeriaf Department of Pharmaceutical Services , Federal Medical Centre ,Abakaliki , NigeriaPublished online: 05 Mar 2013.

To cite this article: Chigozie J. Uneke , Abel E. Ezeoha , Chinwendu D. Ndukwe , Patrick G.Oyibo , Friday Onwe & Anayo Ogbonna (2013) Assessment of Organizational Capacity for Evidence-Based Health Systems Operations in Nigeria, Social Work in Public Health, 28:2, 97-108, DOI:10.1080/19371918.2011.555639

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Social Work in Public Health, 28:97–108, 2013

Copyright © Taylor & Francis Group, LLC

ISSN: 1937-1918 print/1937-190X online

DOI: 10.1080/19371918.2011.555639

Assessment of Organizational Capacity for

Evidence-Based Health Systems Operations in Nigeria

Chigozie J. Uneke

Department of Medical Microbiology/Parasitology, Faculty of Clinical Medicine,

Ebonyi State University, Abakaliki, Nigeria

Abel E. Ezeoha

Department of Banking and Finance, Faculty of Management Sciences,


Chinwendu D. Ndukwe

Department of Community Medicine, Faculty of Clinical Medicine,


Patrick G. Oyibo

Department of Community Medicine, Delta State University, Abraka, Nigeria

Friday Onwe

Department of Sociology/Anthropology, Faculty of Arts, Ebonyi State University,

Abakaliki, Nigeria

Anayo Ogbonna

Department of Pharmaceutical Services, Federal Medical Centre, Abakaliki, Nigeria

In Nigeria, health outcomes are unacceptably low largely due to the inability of the health system to

function optimally. As part of a strategy to strengthen the health system, an assessment of institutional

capacity for use of evidence for health system operations was conducted. The health system operations

in terms of stewardship, health administration, service delivery, and access to essential medical

products/technologies were fairly adequate. In terms of generation/strategic use of information, health

financing, and health workforce, the operations were generally inadequate. There is need to evolve

strategies that will guarantee equitable and sustained improvements across health services and health

outcomes.

Keywords: Evidence-based, health systems, capacity, organization, policymaking

The authors are grateful to World Health Organization for the provision of financial support for this investigation

through the Alliance for Health Policy and Systems Research (Research Grant No. 2009/25025-0; PO-No. 2 00072059).

Authors are also grateful to all organizations, policymakers, researchers and other stakeholders for their participation in

this research.

Address correspondence to Chigozie J. Uneke, Department of Medical Microbiology/Parasitology, Faculty of Clinical

Medicine, Ebonyi State University, K3, Abakaliki-Enugu Express Way PMB 053 Abakaliki, Nigeria. E-mail: unekecj@

yahoo.com

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98 C. J. UNEKE ET AL.

INTRODUCTION

The World Health Organization (WHO) in its World Health Report of 2000 defined the health

systems as comprising all the organizations, institutions, and resources that are devoted to pro-

ducing health actions, whose primary purpose is to improve health. A framework was developed

by WHO to promote common understanding of what a health system constitutes. This frameworkprovides definition of a discrete number of “building blocks” that make up the system based

on the functions defined in World Health Report 2000. The building blocks are service delivery,

health workforce, information, medical products and technologies, financing, and leadership andgovernance (stewardship) (WHO, 2007). It has been argued that though stronger health systems

appear to be a prerequisite to achieving the health Millennium Development Goals (MDGs),

there is currently little direct focus on systems strengthening (Travis et al., 2004). This is the

situation in most developing countries including Nigeria, where emphasis is placed more on theimplementation of specific interventions in disease priority but with gross neglect of the health

systems on which such interventions operate. The WHO (2007) noted that health outcomes are

unacceptably low across much of the developing world, and the persistence of deep inequities in

health status is a problem from which no developing country in the world is exempt and at thecenter of this human crisis is a failure of health systems.

A major factor that has been identified to be responsible for health systems failure in the

developing world is institutional capacity constraint especially in the use of evidence for health

system operations (Alliance for Health Policy and Systems Research [AHPSR], 2007). Accordingto WHO (2007), one of the greatest challenges facing the member-states is how to ensure access

to safe and effective health services for those population groups most in need, and strengthening

individual and organizational capacities for a more functional health systems is a core part of this

challenge. The United Nations Development Programme (UNDP; 2006) defined capacity as theability of individuals, institutions, and societies to perform functions, solve problems, and set and

achieve objectives in a sustainable manner. Bowen and Zwi (2005) noted that a key challenge to

public health in most developing countries is to better contextualize evidence for more effectivepolicy making and practice. Hence health system operations (whether policy or practice) that

are based on systematic evidence are likely to produce better outcomes. This is largely because

in evidence-based health system operations, there is a shift away from opinion-based policies

and practices to a more rigorous, rational approach that gathers, critically appraises, and useshigh-quality research evidence to inform health policy making, professional practice, and systems

operations (Salchev, Hristov, & Georgeieva, 2008).

There is increasing recognition that strong and effective health systems that are evidence

based in their operations are necessary to achieve continued improvement in health outcomesin an efficient and equitable manner (Travis et al., 2004; WHO, 2008). This is because without

stronger health systems new technological developments and innovations, as well as many of

those already in existence, are likely to remain inaccessible to poorer people (AHPSR, 2007).

However, more specific evidence is needed in each country/region about what works in termsof health system strengthening, and under what conditions. In Nigeria, as in most developing

countries, there is a dearth of information on the status of organizational capacity for evidence-

based health systems operation. The scarcity of such baseline information hampers effective

health system-strengthening interventions. The major objective of this study therefore is to as-sess the institutional capacity for health systems operations in Nigeria health-based ministries,

organizations, and associations. This is with the view to providing scientific information that

can be used to direct policy development and intervention program implementation on health

system strengthening and also provide baseline measurement for monitoring and evaluating inter-ventions.

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CAPACITY FOR EVIDENCE-BASED HEALTH SYSTEMS OPERATIONS 99

METHOD

Study Participants

This research was a subnational study, and participants consisted of individuals whose geographical

area of operation is the southeastern Nigeria with emphasis on Ebonyi State. The participantsincluded the following: health professionals in charge of the health systems; regional, state, and

local government directors of the health ministry; health professionals working with specific

programs in the health ministry involving policy making; staff and consultants involved in public

health issues within the health ministry; program/project managers under the health ministry; chiefexecutive officers of civil society groups including nongovernmental organizations, leaders of

national health-based associations, for example, medical, nurses, and pharmaceutical associations;

health directors/managers in uniform services, for example, police, prisons, and military; and

executive officers of print and electronic media.

Definition of Participant Category

All the participants in this project are involved in the health policy-making process in Nigeria and

are therefore referred to as policy makers. In this project the participants were categorized into

two broad groups based on how their job specifications influence the policy-making process: those

who have direct influence on the policy-making process and those who have indirect influence onthe policy-making process. The definitions are provided below.

Participants who have direct influence of policymaking process (DIPP): This refers to indi-

viduals who receive processed information, data, reports, and submissions on health-relatedissues and synthesize/translate them into items required for policy drafting. They rarely

take part in data generation/collection activities. They participate in fora/meetings where

various types of policy documents are produced including policy briefs, policy drafts, and

principally the main/final policy documents.Participants who have indirect influence of policymaking process (IIPP): This refers to indi-

viduals who are mainly involved in the generation, collection, and assembling of relevant

information, and processing of data and reports on health-related issues from the differentsectors of the health system and preparing them into forms that can be used for the drafting

of policy documents. They may make inputs during the production of policy briefs and

policy drafts but are not signatories to the main/final policy documents.

Data Collection

Data collection instrument. The data collection instruments consisted of a structured

pretested questionnaire, consisting of questions that centered on the key health-related activ-ities/objectives of the organization, in terms of use of evidence in health system operations.

The questionnaire that was produced was adapted from the self-evaluation tool developed by

Canadian Health Services Research Foundation (http://www.chsrf.ca/other_documents/working_e.

php), but with some modifications to accommodate the objectives of the project and peculiaritiesof the Nigeria health system. The health system operational components assessed are health

administration, service delivery, use of information and evidence, medical products/technologies,

health workforce, health financing, and leadership and governance (stewardship). The measurement

strategies include the use of the Likert-type scale rating of four options (1 [grossly inadequate],2 [inadequate]. 3 [fairly adequate], 4 [very adequate]).

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Strategies for the administration of data collection instruments. An Evidence-PolicyWorkshop was organized by the research team in July 2009, and during this forum, the data

collection questionnaire was administered to 73 participants who attended. The data collection

instrument accompanied with a letter of invitation for participation was sent to organizations who

could not attend the workshop, and a total of 31 completed questionnaires were returned. At theend of the data collection exercise, a total of 104 completed questionnaires were obtained.

Data Analysis

The data collected via the questionnaire were analyzed using the methods developed at McMasterUniversity Canada by Johnson and Lavis (2009). The analysis was based on mean rating (MR),

median value, and range.

RESULTS

The outcome of the various operational components of the health system assessed in this studyis summarized in Table 1. In the area of health administration; the MRs for the use of evidence

in planning activities were relatively high, ranging from 2.42 to 2.89 points and median values

at 3 points. The MRs for performance measurement and bench marking/best practice were also

relatively high with the median values at 3 points among all categories of respondents. Theoutcome of the assessment of organization’s service delivery showed that the MRs for capacity for

evidence use in service management, access to health services, and quality of health services/safety

were relatively high among DIPP and IIPP categories of the respondents, ranging from 2.53 to

3.02 points with median values generally at 3 points.The outcome of the assessment of generation/strategic use of information and evidence indicated

that the MRs among DIPP (range: 2.53–2.62 points) were higher than those of the IIPP (2.39)

with median values at 3 points and 2 points, respectively. In the assessment of organization’saccess to essential medical products/technologies result showed that the MRs ranged from 2.53 to

2.62 points and median values were mostly at 3 points. The organization’s health workforce was

assessed, and the outcome indicated that in terms of the effectiveness of the personnel management

structure, the MRs in all categories of respondents were relatively high ranging from 2.54 to 2.72points, with the median values generally at 3 points. However in the assessment of availability of

qualified health workers in the organization, the MRs were generally low in both categories of

respondents ranging from 2.32 to 2.41 points with median values at 2 points. In the assessment of

organization’s policy on training, remuneration, and performance of health workers, the medianvalues were generally at 2 in both categories of respondents. The MRs for DIPP (range: 2.40

points) were higher than the MRs for IIPP (2.17 points).

The outcome of the assessment of health financing showed that in terms of the affordability

of the health services rendered by organization, the MRs in both categories of respondents werehigh ranging from 2.71 to �2.79 points with the median values at 3 points. In the assessment of

the adequacy of organization’s access to key sources of health funding, the median values were

generally at 2 points, with the MRs ranging from 2.11 to 2.43 points. In the assessment of the

effectiveness of the budgetary, procurement, accounting and auditing practice in organization, themedian values were at 3 points according to DIPP and IIPP but the MRs was higher in the DIPP

(2.67 points) than the IIPP (2.53 points). In terms of the influence of external funding on organiza-

tion’s policy on resource allocation and utilization, the MRs was higher in the DIPP (2.60 points)

with median at 3 points, compared to the MRs of the IIPP (2.16 points) with median at 2 points.In the assessment of leadership and governance, in terms of effective oversight and control,

the median values were at 3 points for extent organizations adhere to international and national

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TA

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103

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regulations and control mechanisms. However, in terms of the extent activities of regulatoryagencies and legislators influence leadership and governance; and level of organization’s effort to

initiate and update health system framework, the median values among the IIPP were at 2 points.

In terms of how global practice influence the process of development and adoption of health

system framework in the organization, the median value in all categories of respondents were at3 points, with the MRs ranging from 2.50 to 2.85 points.

DISCUSSION

The assessment of the capacity to use evidence in the various key areas of activities of participating

institutions provided some insights on the policy-making process at organizational level. It is

interesting to note that in the area of health administration, specific activities such as planning,performance measurement, and benchmarking/best practice involved the use or evidence to some

reasonable extent as the median ratings were at 3 points (i.e., fairly adequate). This finding is

not a surprise because the administrative activities considered in this study cannot be carried out

without the use of one form of evidence or the other. Jewell and Bero (2008) noted in theirreport that administrators often are career officials who are well trained and have a lot of work

experience with particular health policy issues and so the “technical” nature of their responsibilities

in carrying out policy development and implementation requires collecting and assessing data as

a core part of their work.In terms of the use of evidence in service delivery, the MRs for service management, access

to health services, and quality of health services/safety were relatively high among the respon-

dents, with median values generally at 3 points (i.e., fairly adequate). This is expected because

health service delivery in Nigeria, in general is usually anchored on well-proven and validatedmodels, and there exist various health ministry policy documents to this effect (FMHN, 2003,

2005a, 2005b, 2005c, 2005d, 2006). Although this may not be functioning at optimal levels

in all circumstances, there is still a high level of effort to carry out health service delivery inaccordance with international and national guidelines or well-established requirements. These

guidelines and requirements are principally based on some research evidence. However, the fact

that the observed MRs in the study are just relatively high implies that there is still need for

improvement in the existing health services delivery platforms in Nigeria until what works bestis identified. This observation is essentially in line with the position of the WHO (2007) report

on strengthening health system, which had noted that what service delivery models work best in

resource-constrained environments, are still poorly understood.

In the assessment of the generation/strategic use of information and evidence, most of the policymakers rated their organization’s information technology (IT) capacity to source and generate

relevant evidence as inadequate. As revealed by further investigation, this is largely as a result

of unavailability of functional IT system in most health-based organizations in Nigeria. Although

individuals of the DIPP category recorded a median rating of 3 points, which may indicate theavailability of some forms of IT capacity, which in practice may be very far from optimal.

The WHO (2007) described a well-functioning health information system as one that ensures

the production, analysis, dissemination, and use of reliable and timely health information by

decision makers at different levels of the health system, on a regular basis and in emergencies.The unavailability of functional IT system in most health-related organizations in Nigeria is a

major constraint in the policy-making process. Although the Internet and various online resources

were mentioned as useful in improving access to research, most of the policy makers in this

study noted that their organizations are not connected and those who are have limited access topaid sites. This appears to be a common trend in many developing countries as reported by a

number of investigators (Albert, Fretheim, & Maïga, 2007; Gonzalez Block & Mills, 2003). In

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the assessment of the extent the organizations in this study have access to key sources of health-related information particularly, media, research findings, and educational materials, most of the

respondents rated their organizational capacity as fairly adequate. This is expected because most

of the organizations involved in this study have access to media reports (electronic and print) and

educational materials.In this study, most of the respondents rated their organization’s capacity to access essen-

tial medical products/technologies as fairly adequate. The reason for this may be connected to

the existence of Nigeria national policies that stipulate mandatory adherence by health-related

organizations to guidelines for the acquisition and usage of essential medical products andtechnologies in all its ramifications (FMHN, 2005b). Furthermore there exist regulatory agencies

empowered by law to enforce compliance by all and sundry; a good example is the National

Agency for Food and Drug Administration and Control (NAFDAC), which has operational base

in all the States of Nigeria. Furthermore the government of Nigeria at all levels encouragesevery health-based organization to adhere to internationally established standards that ensure

equitable access to essential medical products, vaccines and technologies of assured quality,

safety, efficacy, and cost-effectiveness, and their scientifically sound and cost-effective use (FMHN,

2005b).In the assessment of organization’s health workforce most of the respondents rated the effec-

tiveness of their organization’s personnel management structure as fairly adequate. The reason for

this was not far-fetched as all the organizations, particularly the government-owned ones, have

a very functional personnel management structure in place. However in terms of availability ofqualified health workers, and existence of organization’s policy on training, remuneration, and

performance of health workers, the ratings were generally noted as inadequate. This outcome is

not unexpected because among the many challenges facing the health system in Nigeria is theacute shortage of competent health workers, largely due to brain drain (Uneke et al., 2008). As

a matter of fact, Nigeria is a major health-staff-exporting nation (Nnamuchi, 2007). As a result

of inadequate infrastructure and poor compensation packages, a sizeable number of physicians,

nurses, and other health professionals are lured away to developed countries in search of fulfillingand lucrative positions (Awofeso, 2008; Raufu, 2002; Uneke et al., 2008). The efflux has resulted

to acute shortages in local health facilities and at primary health care levels and has also drastically

impacted access. The WHO (2007) described a “well-performing” health workforce as one that is

available, competent, responsive, and productive. Therefore in line with WHO recommendations,strengthening the human resource aspect of the health system must incorporate strategies that

would encourage organizations to devise mechanisms that would enhance actions needed to

manage dynamic labor markets, and that would address entry into and exits from the health

workforce, as well as improve the retention, distribution, and performance of existing healthworkers.

The outcome of the assessment of health financing indicated a general median rating of 3 points

(fairly adequate) for the effectiveness of the budgetary, procurement, accounting, and auditing

practice as well as affordability of the health services rendered by the organizations. In Nigeriamost organizations have functional budgetary, procurement, accounting, and auditing mechanism,

although there is still room for improvement. In terms of affordability of health services, it is

pertinent to state that health care services are quite affordable to low-income earners particularlyin most government health care settings in Nigeria. In fact some State governments have even

abolished user fees for certain categories of health care services in government health facilities,

for example, for the aged, pregnant women, and children, and this is known to have had a positive

impact on the Nigeria health system (Uneke et al., 2009). The WHO (2007) described a goodhealth financing system as one that raises adequate funds for health, in ways that ensure people can

use needed services, and are protected from financial catastrophe or impoverishment associated

with having to pay for them.

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However a major challenge of the health financing system in Nigeria is the unavailability ofsufficient and sustained funds. This explains why in the assessment of the adequacy of organization

access to key sources of health funding, the median values were generally at 2 points (inadequate).

The WHO (2000) report on improving health system performance noted that the purpose of health

financing is to make funding available, as well as to set the right financial incentives for providers,to ensure that all individuals have access to effective public health and personal health care. It is

therefore important to incorporate strategies that would encourage organizations to put in place

the necessary technical, organizational, and institutional arrangements that will enable them attract

more funding, while protecting people financially the fairest way possible, and to set incentivesfor providers that will motivate them to increase health and improve the responsiveness of the

system. This is in line with the WHO (2000) recommendation.

The findings from the assessment of leadership and governance (also known as stewardship)

indicated a somewhat complex pattern. Although the median ratings for effective oversight/controland attention to health design issues were generally at 3 points (fairly adequate) for the DIPP,

median ratings for some activities among the IIPP category were at 2 points (inadequate).

Although the organizations participating in this project have some form of operational oversight

and regulatory framework in place which they make effort to adhere to, but the extent to whichthese activities affect stewardship is difficult to measure. The WHO (2007) report on strengthening

health system noted that the leadership and governance of health systems is arguably the most

complex but critical building block of any health system because it is about the role of the

government in health and its relation to other actors whose activities impact on health.

Policy Implications

Directing policy development and intervention program implementation on health systems strength-

ening are very critical factors toward improving the health status of the populace in any resource-

constrained setting. Effective health policy development however is strongly anchored on the

availability of scientific research evidence. Hence health system operations (whether policy orpractice) that are based on systematic evidence are likely to produce better outcomes and are

more likely to deliver interventions to achieve the health-related MDGs of reducing maternal and

child mortality, and combating HIV, malaria, and other diseases. Thus the outcome of a study

such as the present one has policy implication in that it provides the needed scientific informationthat identifies and explains well where the gaps are in terms of organizational capacity for

health interventions/operations. Another crucial policy implication is that it provides the baseline

measurement for monitoring and evaluating interventions particularly those associated with healthsystems strengthening. The findings of this study clearly demonstrate the need to consider the

health systems as a comprehensive package, where all interventions and the evaluation of their

effects are influencing the health system, and where the health system is on its turn influencing

the implementation of all health interventions.

Study Limitation

One of the drawbacks of this study is that the data collected was from a subnational regionof Nigeria and thus may not adequately represent the actual country status of organizational

capacity for evidence-based health systems operations in Nigeria. Another limitation of this study

was our inability to attract the participation of very high-ranking policy makers such as the

commissioner and the permanent secretary of the health ministry. The limited number of thehealth-based organizations that participated in this exercise could also be described as a limitation.

The scaling up of this research to cover the entire regions of the country is advocated as well as

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the devising of a strategy that will ensure active participation of high-ranking policy makers andmore health-based organizations in future research effort.

CONCLUSION

This study has revealed the problem areas as well as the success factors, in terms of institutional

capacity for evidence use in health systems operations in Nigeria. Findings have shown thatmuch success factors are noticeable in terms of health administration, performance measurement,

benchmarking/best practice, use of evidence in service delivery, capacity to access essential

medical products/technologies, accountability, and affordability of health services on acquisition.

One of the key factors responsible for such success as revealed in this study is the existence ofnational policies on mandatory adherence to guidelines on the acquisition and use of essential

medical products/technologies, as well as the use of effective regulatory agencies to ensure

compliance. On the other hand, this study shows that major problem areas in organizationalcapacity for evidence use in health systems operations include generation/strategic use of infor-

mation and evidence (especially with regards to modern health-related IT facilities), availability

of qualified health workers, unavailability of funds and lack of sustainability of funding sources,

and leadership/governance challenges. Although there is need to sustain the progress so far madein some of the key areas of health system operational capacity in Nigeria, there is also urgent

need to resolve these critical areas of challenge.

One of the most pragmatic approaches to enhance evidence-based health systems operations is

through strengthening stewardship. Strengthening leadership and governance in the health systemsrequires strategies that would encourage the leadership of organizations to provide vision and

direction for the whole health system and oversee implementation of agreed health policies.

Emphasis should be placed on reconciling competing demands for resources; working across

government to promote health outcomes; managing growing private sector provision; tacklingcorruption, responding to decentralization; engaging with an increasingly vocal civil society, and

a growing array of international health agencies. There is therefore the need to improve the health

system building blocks and managing their interactions in ways that achieve more equitable and

sustained improvements across health services and health outcomes.

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Documents

Assessment of Organizational Capacity for Evidence-Based Health Systems Operations in Nigeria