Assessing Root Causes and Solutions to Address Cross-Programmatic Inefficiencies in a Subnational Health System: A Case Study of Anambra State, Nigeria.
Obinna Onwujekwe, Uchenna Ezenwaka, Prince Agwu, Chukwudi Nwokolo, Francis Ukwuije, Alexandra J Earle, Agnes Gatome-Munyua, Susan Sparkes
Author Information
Obinna Onwujekwe: Health Policy Research Group and Department of Health Administration and Management, University of Nigeria, Enugu, Nigeria.
Uchenna Ezenwaka: Department of Health Administration and Management, University of Nigeria, Enugu, Nigeria. ORCID
Prince Agwu: School of Humanities, Social Sciences, and Law, University of Dundee, Dundee, UK.
Chukwudi Nwokolo: Department of Economics/Centre for Entrepreneurship and Development Research, University of Nigeria, Enugu, Nigeria.
Francis Ukwuije: World Health Organization (WHO), Abuja, Nigeria.
Alexandra J Earle: World Health Organization (WHO), HQ, Geneva, Switzerland.
Agnes Gatome-Munyua: Results for Development, Nairobi, Kenya. ORCID
Susan Sparkes: World Health Organization (WHO), HQ, Geneva, Switzerland.
Cross-programmatic inefficiencies are duplications or misalignments that arise from undue fragmentation of health systems by vertical health programs. Identifying and addressing the root causes of cross-programmatic inefficiencies in a health system can ensure more efficient use of resources to make progress toward Universal Health Coverage. This paper examines the root causes of cross-programmatic inefficiencies related to governance and financing in the state health system of Anambra in southeast Nigeria. Data were collected from 38 in-depth interviews and four focus group discussions and analyzed thematically. The governance- and finance-related cross-programmatic inefficiencies identified were duplicative and misaligned roles within and between state and federal agencies, functions, and activities within and across health programs; misaligned donor priorities with that of the state; and poor formulation and implementation of the approved annual state health budget. The root causes of governance and financing cross-programmatic inefficiencies included weak policy development, communication, and enforcement; excessive influence of external donors and the federal government; weak accountability mechanisms affecting program coordination and service delivery; and a disharmony between state priorities and objectives with planning, budgeting, and execution of the budget. Addressing the root causes of cross-programmatic inefficiencies has the potential to significantly improve the overall efficiency and performance of the health system to contribute to improved health outcomes in Anambra state. This approach can serve as a model for other states and regions facing similar challenges.