Little is known about the role of the private sector in low and middle income countries moving towards universal health coverage (UHC). This thesis presents a case study of the role of the private sector (health maintenance organisations (HMOs) and healthcare providers) in the national health financing system in Nigeria. The analysis draws on both economic and policy analysis theories and frameworks. The analysis of the policy development process for national health insurance in Nigeria reveals that private sector actors and the political context influenced the pace and outcome of the policy-making process, including the institution of a role for HMOs to supply the government’s social health insurance (SHI) alongside their private health insurance (PHI) plans. However, an analysis of the market for the health insurance products supplied by HMOs revealed imperfect competition in the (PHI) sub-market which was characterised by product differentiation, multiple private pools, relatively higher premiums for benefits compared to the SHI, and adoption of harmful pricing strategies. The analysis of the agency relationship between HMOs as purchasers, and healthcare providers also revealed that healthcare providers respond to incentives created by the business strategies of purchasers, in such a way as to protect their own income, but their ability to do so rests on the distribution of power within the agency relationship. Finally, the weak regulatory system that emerged from the policy making process influenced (and was influenced by) the behaviours of actors in the HMO industry, and influenced the agency relationship between HMOs and healthcare providers. Overall, this thesis provides insights about the influence of context on policy processes for national health insurance proposals, and considers the effectiveness of PHI and private financing organisations in a national healthcare financing system that aims to achieve UHC.

The Federal Government of Nigeria (FGN) introduced the Ward Health System (WHS) in 200 I to facilitate the provision of sustainable and integrated Primary Health Care (PHC) services by revitalising the principle of community co-ownership and co-management of PHC facilities. To date, the extent to which the WHS scheme has achieved its objectives remains questionable and a strong case for further re-examination of its structure, process and function, including its overall place in the PHC subsystem has been made. The FGN has also shown considerable interest in attracting the private sector to boost investment and efficiency in the healthcare sector, although it is yet to formulate any strategies towards actualising that desire. Accordingly, this research aimed at developing a sustainable procurement strategy that will facilitate the achievement of community co-ownership or co-management of PHC facilities in Nigeria, was launched. The research utilised the best practices within the UK Local Improvement Finance Trust (LIFT) procurement strategy for integrated primary and social care facilities to recommend practices that can facilitate the achievement of sustained improvement in the Nigerian context. A variety of qualitative and quantitative research methods were employed including interviews, questionnaire survey and focus groups. Strategic evaluation of the WHS model was conducted in Nigeria through exploratory interviews. The investigations indicated that the planning and implementation of on-going strategies lack focus, impact and sustainability. Consequently, further exploratory interviews were undertaken in the UK to investigate some key implementation issues on the LIFT schemes that can be used to promote sustained improvements in the Nigerian context. The best practices identified relate to stakeholder identification, analysis, engagement and aligrunent; defmition of processes, roles, responsibilities and accountabilities; periodic reviews throughout the whole-life cycle of each project; and some new project roles and tasks. Accordingly, a procurement strategy based on the Public-Private Partnership (PPP) principle that will be responsive to the peculiar needs of the host community and have adequate accountability structure for sustaining PHC facilities in Nigeria was proposed. This proposal falls in line with the new macroeconomic strategy adopted for growth and the health reform agenda of the present government, which have variously emphasised the expansion of the approach to improving healthcare delivery through increased private sector participation, whenever feasible. It is expected that the active participation of various components of the communities will offer considerable social and economic benefits such as social inclusion, employment and training opportunities for the members of the host communities in addition to the attainment of other fundamental philosophies of PHC provisioning. In addition, a supplementary questionnaire survey was carried out in Nigeria to investigate the perceptions of Nigerian professionals on the success and risk factors associated with the use of PPPs for infrastructural developments in Nigeria. The results show that seven out of the top ten most important PPP risk factors in Nigeria are endogenous (risk events and consequences of which occur within the system boundaries of the project being considered). The results also show that while the majority of the endogenous risk factors could be assigned to the private sector partner, the public sector should retain political and site acquisition risks, while relationship-based risks should be shared between the private and public sector partners. The three most important PPP success factors in Nigeria were found to be favourable legal framework, well-organised public agency to negotiate on behalf of government and strong private consortium: The comparison of the fmdings of this study with similar previous study in the UK suggests commonalities in the success factors of PPP projects. On the basis of the results of the exploratory interviews and questionnaire survey, focus groups were held to assess the appropriateness of the proposed procurement strategy in the light of on-going procurement and healthcare reforms and recent legislative developments. On the basis of the positive feedback obtained from the validation, a modified procurement strategy was put forward. However, the. need for developing a comprehensive framework for achieving continuous improvement that will make learning followed-through from plarming, design and construction into occupancy, and post occupancy to become a natural part of the process of procuring PHC facilities was highlighted.

The concept of the ‘managed clinical network’ has provoked significant attention for its promise as a means of improving services for people where their condition requires care across a range of organisations and agencies. The concept suggests a model of service organisation and governance that gives privilege to working relationships among organisations, clinical work groups, and/or individual clinicians and so promotes coordination and integration of scarce care resources, knowledge and practice. Despite repeated calls by the World Health Organisation for the adoption of managed clinical networks in developing countries, the feasibility of the network model of service delivery in this setting has not been demonstrated. Taking the implementation of programme clusters for care and support of HIV/AIDS in Nigeria as a ‘more feasible’ case study, this thesis examines the process of transfer of the idea of the managed clinical network into less advanced settings. The empirical findings in this dissertation suggest that the two programme clusters, as suggested by the expressed ‘Theory of Change’, altered networks of relationships and produced new forms of collaborative practice within these HIV/AIDS programme clusters in response to understanding of the disease as a ‘wicked problem’, requiring collective action. Though operationally feasible, the findings of this research study also indicate that, because these networks challenge existing institutional arrangements in Nigeria, the ability of collaborating partners to sustain the networks without reform within the institutional context is unclear. Further research is recommended, to explore ‘whether’, ‘how’, and ‘why’ the policy/idea of the managed clinical network, as an alternative means of service integration, might be situated in an institutional context that is characterized by a mix of modes of governance (hierarchy and markets) typical of Nigeria, and the possibility of ‘sustainable transfer’ into this environment.

Abstracts in English and Zulu / Immunisation is a cost-effective public health intervention that contributes to the attainment of the Sustainable Development Goals (SDGs). About 40% of children under the age of five years die from vaccine-preventable diseases in Nigeria. Routine immunisation has been quite low in Nigeria, where national coverage is estimated to be 33%, according to a 2016–2017 survey. This empirical research was aimed at determining the key socio-economic and gender determinants of immunisation in the Federal Capital Territory (FCT), identifying gaps and proffering solutions. Mixed methods of data collection and analysis were used. Data were gathered from several secondary sources and from 11 key informants using semi-structured interviews and 501 household and 26 health-facility surveys using questionnaires mounted on Open Data Kit. Lot quality assurance sampling and probability to population size methodology were used to size the samples and identify survey locations. Odds ratio analysis and logistic regression analysis were conducted to gauge the statistical association between the determinants and the coverage of immunisation. The main finding that was reached on the basis of the documents reviewed and the feedback received from the key informants was that they were gender blind at worst and gender neural at best. Most of the current strategies give little attention to socio-economic and gender barriers. Over 40 immunisation variables were identified. The analysis, particularly using the 2x2 odds ratio, yielded mixed results. The majority of the variables exhibited a close statistical association as far as immunisation indices were concerned. These variables included urban residency, married couples, literacy, birth at a health facility, antenatal care experience, vaccination card possession, immunisation knowledge, child health information, non-farming earnings, socio-economic status and tolerance of spouse beating. On the other hand, variables that were found to have no statistical significance included sex, marital status, marriage type, age, religion, tetanus toxoid (TT) vaccination and adequacy of income. Immunisation and gender are intertwined, particularly because of mothers’ biological and social attachment to their children. At the same time, conducting vaccination avails the opportunity to access almost all households. Moreover, it is important to recognise that socio-economic and gender determinants are not totally in control of one ministry. Single agenda interventions will not produce the desired result. A paradigm shift and the concerted effort of various sectors and partners are required. Therefore, the Nigerian government should galvanise the relevant stakeholders to bring gender and socio-economic variables into the mainstream throughout the immunisation ecosystem and to implement integrated development initiatives by prioritising vulnerable communities. / Ugonyo yindlela engcono yokungenela kwezempilo yabantu engathela esivivaneni ekufinyeleleni izinhloso zentuthuko eqhubekela phambili ezaziwa ngelokuthi yi- Sustainable Development Goals (SDGs). Cishe izingane ezifinyelela ku 40% ezingaphansi kweminyaka emihlanu zibulawa yizifo ezivimbelekayo ngomgcabo emitholampilo eNigeria. Ukugonya njalo kusezingeni eliphansi eNigeria, laphokhona ukwengamela kuzwelonke kulinganiselwa ku 33%, ngokuya kocwaningo olwenziwe phakathi kuka 2016-2017. Ucwaningo lokuthola ubufakazi lwalunenhloso yokubona imithelela yezesimo sabantu nomnotho (socio-economic) kanye nobulili ngokugonya kwi-Federal Capital Territory (FCT) ukubona amagebe kanye nokutholakala kwezixazululo. Amamethodi axubene okuqokelela ulwazi kanye nohlaziyo kwasetshenziswa. Ulwazi lwaqokelelwa ngokufunda imithombo yemibhalo (secondary sources) kanye nakubantu ababalulekile abanolwazi (key informants) abangu 11 ngokusebenzisa ama-semi-structured interview kanye nemizi engu 501 kanye namasurvey amafasilithi ezempilo angu 26 ngokusebenzisa uhla lwemibuzo yamaquestionnaire ebifakelwe kwi-Open Data Kit. Kwasetshenziswa nemethodi ye-Lot quality assurance sampling ne-probability, ngemethodoloji yobuningi babantu, ukwenza usayizi wamasampuli kanye nokubona izindawo okumele kwenziwe kuzo ama-survey. Kwenziwa nohlaziyo lwe-Odds ratio analysis kanye ne-logisic regression analysis ukubona ukuhambelana kwamastatistiki phakathi kwezinto eziwumthelela kanye nokunaba kongamelo lokwenziwa kogonyo. Okukhulu okutholakele ngokulandela amadokhumende okufundwe kuwo, kanye nezimpendulo ezivela kulabo abanolwazi ababalulekile (key informants) kube wukuthi bekungaboneleli ubulili (gender blind) kanti futhi bekungachemile ngokulandela ubulili (gender neutral) ngezinga elibi nangokungcono kakhulu. Amasu amaningi amanje awanakekeli kakhulu izihibe ezimayelana nabantu nezomnotho kanye nezobulili. Kwaphawulwa cishe izinto ezehlukene zama-variable ezingu 40 mayelana nogonyo. Uhlaziyo, ikakhulukazi ngokusebenzisa i 2x2 odds ratio, lwaveza imiphumela exubene. Ezinto zama-variable ehlukene eziningi zikhombise ukuhlobana phakathi kwamastatistiki mayelana namaindices ogonyo. Lama variable, abandakanye ukuhlala emadolobheni, abantu abashadile, ikhono lokubhala nokufunda, ukuzalwa kwezingane kumafasilithi ezempilo, izipiliyoni zonakekelo lwengane ngaphambi kokuzalwa, ukuba nekhadi lomgcabo ix wasemitholampilo, ulwazi ngogonyo, ulwazi ngempilo yengane, ukuthola imali ngemisebenzi engeyona eyokulima, isimo sabantu mayelana nezomnotho, kanye nokuqinisela ukuhlukunyezwa ngokushaywa kwabesimame. Kanti ngakolunye uhlangothi, ama-variable atholakale engenakho ukubaluleka ngokwamastatistiki, abandakanya ubulili, isimo ngokomendo, inhlobo yomendo, iminyaka yobudala, inkolo, umgcabo we-tetanus toxoid (TT), kanye nokwenela kwengeniso lemali. Ugonyo kanye nobulili kuyangenelana nokuhambelana, ikakhulukazi ngenxa yokusondelana komama kanye nezingane zabo. Ngaso leso sikhathi, ukwenziwa kogonyo kuhlinzeka ngethuba lokufinyelela cishe kuwo yonke imizi eminingi. Nangaphezu kwalokho, kubalulekile ukwamukela ukuthi isimo sabantu mayelana nezomnotho kanye nobulili kuyizinto ezinomthelela, azinalo ulawulo oluphelele kumnyango kangqongqoshe owodwa. Ungenelo ngento eyodwa ngeke kwaveza imiphumela efiswayo. Ukugudluka ngokomqondo (paradigm shift), kanye nemizamo eqhubekela phambili yemikhakha ehlukene kanye nabasebenzisani kuyadingeka. Ngakho-ke uhulumeni waseNigeria, kumele agqugquzele ababambiqhaza abafanele ukuhlanganisa nokufaka emkhakheni ofanele izinto ezimayelana nabantu nomnotho kanye nobulili, kuyo yonke inqubo yokusebenzisana kwemikhakha okumele isebenzisane nehlangene ukusebenza ngokulandela inqubo yentuthuko ehlangane ngokubonelela imiphakathi ekwizimo ezibucayi / Development Studies / D. Phil. (Development Studies)