Using PDIA approach for sustainable and integrated health system strengthening in Nigeria

Guest blog by Aisha Allamin Daggash

This is a blog series written by the alumni of the Implementing Public Policy Executive Education Program at the Harvard Kennedy School. Participants successfully completed this 6-month online learning course in December 2020. These are their learning journey stories.

My expectations for the IPP Online Program when I signed up was to gain insight into strategies and frameworks that will support my work in getting government to be more effective and efficient in implementing innovative, integrated and sustainable solutions for health systems strengthening in Nigeria. However, this course has exceeded my expectations in combining leadership management and the PDIA, which has equipped me with the right resources, knowledge and skills to build the teams and networks required to succeed in the work that I do.

Some of the key learnings from the course that enabled me to identify opportunity areas for change in providing technical assistance to the government of Nigeria for sustainable and integrated health systems strengthening include:

  • Using the PDIA toolkit, which is a step-by-step guide, to sequentially construct and deconstruct my policy challenge with my team and subsequently with stakeholders. This provided an avenue for identifying the relevant entry points, development of ideas, building and maintaining relationships with the authorizers/decision makers, collaboratively designing solutions with stakeholders and documenting lessons learnt to inform the future iterations and adaptations that fit the local contexts.
  • Leveraging on the 4P model of leadership which emphasizes the importance of ‘perception’, ‘projection’, ‘people’, and ‘process’ as a framework for building great leadership skills required for implementing complex public policies like mine. This allowed me to evaluate the internal and external biases affecting the progress of the policy challenge, be intentional about being more emotionally intelligent in the workplace, be more open minded and have a wider, more receptive view of ideas and concepts from other stakeholders, while ensuring strategic alignment to the ultimate goal. This model highlighted how the people I work with are the connecting pillars and how its crucial to build meaningful relationships in the workplace that allow collaboration within a framework of autonomy and interdependence, at the right time and for the right reasons.
  • Building teams and trust with both internal and external stakeholders has been one of the major game changers for my complex policy challenge, as technical assistance for sustainable and integrated health systems strengthening requires a lot of multi-sectorial collaboration between the Ministry of Health, donors, development partners, implementers and other government institutions across various sectors that have some level of authority or influence on the policy challenge (e.g. agriculture, women’s affairs/empowerment and finance etc). The engagements for specific strategies that will move the policy challenge forward, have been very participatory, igniting new conversations around technical assistance for sustainable and integrated health systems strengthening like never before – including broader, long-term thinking on how to build systems to develop capacity that will allow Nigeria to set the direction for its health sector.
  • Lastly, the flexibility of the PDIA approach makes it easy for the learnings to be documented and incorporated as the policy challenge progresses. Therefore, simplifying the pathway for iterations, adaptations, feedback and learning processes amongst stakeholders.

The challenge I am working on builds on existing work I have been involved in as a development partner in Nigeria and that is, re-imagining technical assistance for sustainable and integrated health systems strengthening. It is estimated that ~5 billion USD is spent annually by international donors and multilaterals on technical assistance for health systems strengthening in Nigeria. However, these investments rarely translate to transformational and sustainable impact that reduce the maternal, newborn and childhood mortality and morbidity rates in the country.  Furthermore, Nigerians bureaucratic leadership affects the multiple dimensions of health system strengthening and highlights the difference between a policy commitment on paper, compared to noble aims like equity – reinforced by strategic planning, coordinated action and resources for integrated, sustainable health systems strengthening to improve the quality of essential health service delivery, especially in these uncertain times of COVID-19.

There has been significant progress for this policy challenge, albeit rather slowly. This includes a renewed thinking around technical assistance for health systems strengthening amongst the partners and government we work with. Additionally, the PDIA process has enabled us to build on existing guidelines and frameworks for Nigeria to redesign approaches for interactions to build local ownership for health systems strengthening and create strategies for greater sustainability amongst government and partners. Additionally, this has strengthened feedback loops through the routine update meetings to support strategic decision-making, and identify sustainable, non-financial incentives to build greater health workforce capacity at managerial and service delivery levels to maximize impact. This remains work in progress but as a team, we are optimistic about the possibilities of long-term gains within the health system.

What motivated me is seeing first-hand how involving stakeholders in the PDIA process allows them to have more influence over the decision-making for the policy challenge and in turn strengthening government ownership. This was the premise for conducting the problem construction and deconstruction session all over again in week 10 with the stakeholders, as a strategy to build trust and gain buy-in. Additionally, this provided an opportunity to gain and adapt to other perspectives, which further strengthened the toolkit of proposed solutions for some of the projects that utilized the re-imagined technical assistance for sustainable and integrated health systems strengthening in Nigeria. In the future, I will continue to work collaboratively with the government and other partners to co-create, strategize and think-through the solutions, challenges and lessons learned as a team and enhance alignment among stakeholders for priorities in the health sector.

I will also persist in applying knowledge gained from this course in my daily work interactions with stakeholders to build trust, ownership, accountability and relationships with authorizers that can continue to drive the solutions for this policy challenge. Although the policy is nowhere near resolved or fixed, with consistency, the small steps towards progress will in a few years lead to significant milestones and an overall strengthened system, as the aim to re-imagine technical assistance for sustainable and integrated health systems strengthening is so that TA investments can have greater potential to save lives on an enduring basis.

My word of advice to fellow PDIA practitioners around the world is to remain passionate, patient, and consistent throughout the learning journey. It’s also important to remember that we can only reap benefits, when we have addressed the root causes to our problems, which in these uncertain times of COVID-19 has made multiple sectors and systems more fragile. It is therefore important to actively seek out the problems and context specific solutions with an open mind and room for adaptations to the current realities that we face as a community.

One thought on “Using PDIA approach for sustainable and integrated health system strengthening in Nigeria”

  1. A very significant problem area in Nigeria that’s being approached using PDIA. I will suggest that while considering the Nigerian health system as a whole to be strengthened, its system areas and their linkages for eg, human resources and supply chain (procurement) should also be looked into as this is crucial in achieving local ownership of the health system and less dependence on technical assistance.

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