The District Health System in Enugu State, Nigeria: An analysis of policy development and implementation


The District Health System is a form of decentralization that was introduced in Enugu state, Nigeria, as a policy to reform the health sector through increasing its functionality, leading to improvements in the health status of the citizens. Past studies on such policies have had limited consideration for the underlying factors shaping policy design and implementation and their constraints to achievement. It is therefore important to investigate the policy development and implementation process of DHS so as to understand how and where these factors could impede or facilitate its successful implementation.

Two district health authorities were chosen as case studies, one politically marginalized and worse performing; the other, politically favoured and better performing. Information was collected through document review and in-depth interviews with state level policy makers and key actors including district/local level policy makers and implementers, and health workers. Focus Group Discussions were also held with community members.

The study revealed that the policy guidelines were developed by the state and technical team, and covered the re-organization of the district and state structures, donor investment in physical infrastructure improvement and training, and improved health worker availability. Cascaded supervision between the levels of state organization actors and additional supervision from donor technical team across levels was also evident; however, some key actors like the Local Government Areas were not involved in the policy development. Additionally, rhetorical political commitment was not translated into action as government did not pay its counterpart funding and did not employ enough staff to cope with the increased workload. Following the implementation of DHS, improved physical infrastructure, supervision and health worker availability was apparent although there were some differentials between district 1 and 2 and in favour of district 1, probably due to political influences.

The study concluded that the initiation of radical change within the health system in order to improve access to health care was enabled by a strong political and bureaucratic leadership, combined with considerable resource investment assisted by a donor agency. The study also demonstrated, however, that efforts should be made to engage important actors and political favouritism should be minimized in the design and implementation of new policies such as the DHS. Additionally, it was shown that without dedicated funding from government health system actors may be able to do little to support effective implementation.


Uzochukwu, B.S.C.; Onwujekwe, O.E.; Soludo, E.; Nkoli, E.; Uguru, N.P. The District Health System in Enugu State, Nigeria: An analysis of policy development and implementation. (2009) 29 pp.

The District Health System in Enugu State, Nigeria: An analysis of policy development and implementation

Published 1 January 2009