C Uneke, A Ogbonna, A Ezeoha, P Oyibo, F Onwe, B Ngwu, Innovative Health Research Group
C Uneke, A Ogbonna, A Ezeoha, P Oyibo, F Onwe, B Ngwu, Innovative Health Research Group. Health System Research and Policy Development in Nigeria: the challenges and way forward.. The Internet Journal of World Health and Societal Politics. 2008 Volume 6 Number 2.
In the vast majority of developing countries particularly in Africa, health systems face a number of challenges including under-investment, lack of human capacity, lack of public demand, inadequate utilization, and poor dissemination of results. One of the major ways of addressing the challenges of health system and improve human development is through health research with the findings translated into policy. Policymaking context has become highly political and rapidly changing, and depends on a variety of factors, inputs, and relationships. The complex nature of policymaking suggests several key challenges and needs for health policy and systems research. The policy processes should therefore involve understanding not only the mechanics of decision-making and implementation, but also more complex underlying practices of policy framing. It is thus pertinent to recognize policy development as political and complex process that proceeds through a set of stages from understanding agenda-setting, to exploring possible problem resolution options, weighing up costs and benefits, decision-making, and finally implementation, possibly followed by evaluation. When analyzing health sector policy it is vital to engage key stakeholders such as the government, health providers, scientists, and the community as well as establishing the mechanism that would enhance accountability at all levels.
In the vast majority of developing countries particularly in Africa, health systems face a number of challenges including under-investment, lack of human capacity, lack of public demand, inadequate utilization, and poor dissemination of results . One of the major ways of addressing the challenges of health system and improve human development is through health research. There is therefore a need for research capacity strengthening in the health sector and the promotion of health system research. At the same time, the search for strategies to get research findings into policy and practice has gained momentum and the global literature has called for further exploration in the area of research to policy . In particular, engaging decision makers in specific areas of health research, and promoting the use of surveys of decision makers has been advocated . Consequently, there has been increasing international interest currently in the transfer and uptake of research into policy and practice . Initially, this interest centered on clinical decision-making (evidence-based medicine), but more recently it has come to include health service managers and policymakers (evidence-based health service management, and evidence-based policy making) . Some of the problem is attributed to the “cultural” differences between those who do research, and those who may be in a position to use it .
Knowledge relevant to health system organization is not just about diseases and technologies (e.g. disease epidemiology, drug or vaccine efficacy), or about nature-society interactions (e.g. social influences on disease pathways). Understanding which knowledge and perspectives come to influence policy, and which are excluded, requires understanding the policy process as non-linear – shaped through politicized negotiations amongst multiple actors . Furthermore, there is often a process of mutual construction of research and policy, in which policy negotiations shape what kinds of research are funded and carried out, and which are not made by previous work done in this field, and contribute to both methods and results that are useful for understanding the nexus of research and policy and how that can positively impact the poor .
The reasons the failure to achieve optimal health outcomes, despite the existence of good technologies, lies in chronic problems in health systems, including (but not limited to) weak governance and management; political and financial pressures that pull public resources into higher-level curative care; and financial and organization barriers to access for those most in need. Just as targeted research is recognized as the cornerstone of future technologies, it has been argued that a well oriented policy research can lead the way toward solving some of these critical systemic problems. In this report a critical view of the challenges of health system research in Nigeria is considered as well as the implication for policy development.
Overview of health system in Nigeria
With disability adjusted life expectancy (DALE) of 38.3 years and the rank of 187 in the World Health Report 2000, the performance of the Nigerian health system is worse than many sub-Saharan countries . There is thus an urgent need to support the health system with adequately trained personnel in order to improve provision of the health services. The poor state of Nigeria’s health system is traceable to several factors: organization, stewardship, financing and provision of health services. These have been compounded by other socioeconomic and political factors in the environment. The overall availability, accessibility, quality and utilization of health services decreased significantly or stagnated in the past decade. The proportion of households residing within 10 kilometres of a health centre, clinic or hospital is 88% in the southwest, 87% in the southeast, 82% in the central, 73% in the northeast and 67% in the northwest regions . However, the fact that health facilities physically exist does not mean that they function.
The organization of health services in Nigeria is pluralistic and complex. It includes a wide range of providers in both the public and private sectors: private for profit providers, NGOs, community-based organizations, religious and traditional care providers. The National Health Policy is based on the national philosophy of social justice and equity . Primary Health Care (PHC) is the cornerstone of the health system. The policy provides for a health system with three levels: primary, secondary and tertiary. According to the National Health Policy, the federal government is responsible for policy formulation, strategic guidance, coordination, supervision, monitoring and evaluation at all levels. It also has operational responsibility for disease surveillance, essential drugs supply and vaccine management. The National Health Policy is based on the fundamental principles of the second National Development Plan 1970–1974 which describes five national goals: a free and democratic society; a just and egalitarian society; a united, strong and self reliant nation; a great and dynamic economy; a land of bright and full opportunities for all citizens .
The policy development process in Nigeria
In Nigeria, policy development is a complex political process. The more the process is understood, the greater the ability to incorporate research findings in policy. This is true both for the researcher and the policymaker. The gaps and major problems in policy making in Nigeria can be said to lie in the types of research being conducted and the results from such research works. Often times many of these research works are not relevant to real life, or results are written up in esoteric language and published only in inaccessible journals. Some constraints to use research exist and these include lack of understanding of health systems and policy processes on the part of the researchers, research that fails to address the most pressing concerns of decision-makers, research reports that are difficult to read, research results that are not timely, and research recommendations that are an unrealistic “shopping list” with little regard to cost . The problem of accessibility is another important factor. Even when evidence is available, policymakers may have problems obtaining it because they may not have access to the sources due to lack of funds for sustained subscription. In addition, some of the policy makers particularly at the state or local levels may not have basic information technology skill to access research evidence .
Another major problem is that associated with usability of data. The most commonly cited reason attributed to the limited usability of existing data was that policymakers’ needs do not drive research. Instead, much of the information is produced by service providers or product makers who both have a vested interest in the implications and provide answers to narrower, business questions . In addition, academic researchers generally follow their own interests when choosing what studies to conduct or tailor them to specific requests for grants. Although decision makers need to understand the uncertainties and weaknesses in the data, they often are not provided. The problem of interest groups also adversely affects policy making in Nigeria as reported in some other countries . Some of these interest groups can greatly influence policymakers, often in ways that hinder evidence-informed decision making. Interest groups can inundate the policy setting with bad-quality evidence, champion poorly designed studies, and limit the critical analysis of information through the social relations they develop with officials. For instance in Nigeria many health industry associations, particularly of pharmaceutical companies have substantial resources for lobbying efforts. Finally conflicts over fundamental political or religious values often limit the relevance of evidence to the decision-making process at various levels .
The strength and weakness of health policy development structure in Nigeria
Policymaking context has become highly political and rapidly changing, and depends on a variety of factors, inputs, and relationships . The complex nature of policymaking suggest several key challenges and needs for health policy and systems research (HPSR) in the typical Nigeria society which constitutes a rapidly changing political, socioeconomic and cultural environment. To assess the strength and weakness of policy making structure in evidence use, it is important to identify the major stages involved in policy making structure. The three stages involved are; (i) The problem is framed; a variety of questions are raised; feasibility and implementation issues are discussed. (ii) The research evidence is synthesized and evaluated, and assessed to support/justify a decision on quality, generalizability, recognition, appreciation, determination of relevance, appropriateness, applicability, acceptability, and utility. (iii) Collective sources of evidence are weighted, prioritized, and/or transformed .
The first stage is influenced by the extent of dissemination transfer; the nature of diffusion and transmission activities (which affect what evidence is introduced); and the link between research and practitioner/policymaking communities. The second stage is influenced by participant inter-relationships; personal conflicts of interest; receptivity, cognitive, and scientific skills; existing beliefs, intuitions, and assumptions. The third stage is influenced by capacity constraints (system level); political “saleability”; economic feasibility; ideological compatibility; prioritization of evidence; perceived legitimacy; anticipated disruptiveness and displacement; levels of trust; associated prestige; cost of application and implementation . The strength of this policy making structure is that it ensures the adoption of due process in the development and implementation of policies which enhance sustainability. However, the policy making structure in Nigeria has a political undertone. Consequently, policy makers appear not be receptive to research unless it serves political gain, that is, demonstrates proof for a predetermined decision; evidence seemed to be sought to justify the problem. This is a major weakness in evidence use in Nigeria.
Translating health system research into policy
Since the policy processes involve understanding not only the mechanics of decision-making and implementation, but also more complex underlying practices of policy framing, an exploration of the research to policy interface becomes more challenging in the developing world such as Nigeria. To address this challenge three steps have been identified in a recent report by Hyder et al.  as follows:
(i). Recognizing policy as political and complex processes
The traditional model of policy making is a linear process in which rational decisions are taken by those with authority and responsibility for a particular policy area . Policy therefore proceeds through a set of stages from understanding the nature of the problem (agenda-setting), to exploring possible problem resolution options, weighing up costs and benefits, making a rational choice about best options (decision-making), and finally implementation, possibly followed by evaluation. 'Evidence' may be called upon at any or all of these stages . Policy-making is also complex because it takes place at multiple levels – from international to local. Similarly, implementation of these policies occurs at multiple levels and involves discretion and negotiation at all levels. The perceptions of different officials (both governmental and non-governmental) at various tiers are critical to consider. National officials are often strongly influenced by forward-looking policy debates, projections of future developments, and international experiences. Sub-national officials often tend to respond to local constraints and support local innovations, while being skeptical of the relevance of ideas from the top. There is a clear need to understand how evidence influences decision making at each of these levels and in addition how the levels interact with each other .
(ii). Engaging key stakeholders
The key actors that are essential to consider when analyzing health sector policy include the government, health providers, scientists, and the community. There has been a growing realization among both researchers and decision makers that research can improve management decisions and the performance of national health systems . However, there is a lack of scientific knowledge on the mechanisms to promote such engagement and their level of success, especially in low-income countries including Nigeria. Conduct of research or existence of evidence does not guarantee input into the policy development process unless decision makers are appropriately engaged . The process of translation of research findings into pro-policy information is a critical and informal and formal mechanisms used for such translation and the types of people involved, especially in entities like health policy units, are particularly important to consider. There is a need to understand how decision makers view research and what will stimulate them to promote health systems research. Scientists can contribute to framing policy issues by defining what evidence can be produced and its policy significance; decision makers can frame scientific enquiry by defining areas of relevance and pertinent areas for investigation . In many cases, the stakeholder group most neglected is the community – the beneficiaries of the health system. Health policymaking is incomplete if the focus is solely on government and providers; community participation cannot be overlooked. The examination of how decision makers and researchers in developing countries currently place the role of such approaches, or how communities view the national policy making process, is a research agenda. In particular, exploration of how communities affect local policy making and implementation, but perhaps more importantly how these local decisions affect national policy may prove particularly enlightening .
(iii). Enhancing accountability
The role of measuring and monitoring accountability in policy proposals and policy implementation warrants careful analysis. In Nigeria information is particularly lacking on health policy accountability. The role of equity analysis in the research-policy interface needs to be specifically documented and this may include research on the response of the health system to needs of the poor or specific vulnerable groups . A better understanding of the role of civil society organizations that represent the interests of the poor and the sources of knowledge they use is also needed. The human rights dimensions of health research for policy cannot be ignored . Health policies have an undoubted impact on the human rights of particularly vulnerable populations as well as on mainstream populations.
CJ Uneke Department of Medical Microbiology/Parasitology, Faculty of Clinical Medicine Ebonyi State University, PMB 053 Abakaliki, Nigeria. Tel: 234-08038928597 E-mail: firstname.lastname@example.org