Table 2.

Summary of Key Findings

WHO Health System Building Block	Themes	Understanding	Key Findings		Recommendations	Opportunities
			Achievements	Challenges
Leadership/Governance	Government Leadership, Government Commitment, Political Will, Continuity, Strategic Plans and Policies, Coordination and Coordinating Structures	Country ownership (CO) involves government providing strategic direction, showing more commitment and taking up more responsibility in the management of its HIV response	Government is demonstrating CO through the takeover of HIV/AIDS services in 2 states	Nigeria’s HIV response has been largely donor driven while lack of political will and poor leadership are some of the factors hampering CO in Nigeria	Advocacy to top government officials can engender CO
		CO does not necessarily mean government should be responsible for direct implementation; CO also involves multiple stakeholders	Nigeria has strategic plans and policies that will engender CO	The Strategic Plan may not have the appropriate implementation plan	Respondents feel donor support should still continue for a while
		Plans and Policy frameworks are crucial for attainment of CO	Nigeria has made significant progress when it comes to coordination	Paucity of funds may affect optimal functioning of Logistics Management Coordinating Unit (LMCU)	Government should maximize the presence of donors to strengthen other aspects of the healthcare system
	Donor Support	Supply Chain System (SCS) must be adaptable	General in-country HIV coordination structures include, National Agency for the Control of AIDS (NACA) and National AIDS and STI Control Program (NASCP) at the national level, SACAs and LACAs at state and LGA levels respectively	Attention of donors may shift to other interventions or countries	Systems (possibly electronic) must be put in place to ensure accountability and the current administration appear to be pursing this vigorously
	Transparency and Accountability, Public-Private Partnership	Sustainability involves continuity of program after termination of donor(s)’ support	National Product and Supply Chain Management Programme (NPSCMP), Procurement and Supply Management Technical Working Groups (PSM TWGs) and LMCUs are the Supply Chain Coordination Structures in the country (covers other programs outside HIV)	Transparency and Accountability in government is poor as procurement processes are sometimes not followed	Government must demonstrate willingness to be accountable in order to encourage private sector funding
		Some level of program modification such as patients paying for HIV/AIDS services may be necessary for sustainability	There may be need and it appears plans are underway to establish LMCUs at local government level	Some shady deals may also be going on within the government settings	The private sector and partner can be of help to government in addressing certain challenges
			Nigeria has a near-perfect Public Procurement Act	NACA may not have all the necessary structures for grant management	Government may need to move away from running the supply chain and donors may be more comfortable working through the private sector due to better accountability
	Prevention				Government needs to prioritize prevention activities to reduce new infections
Healthcare financing	Domestic Funding, Bureaucratic Bottlenecks, Alternative Funding Sources	Funding of a large percentage of a country’s HIV response by the government is a marker of CO	There was a time a special intervention fund in form of President's comprehensive response plan (PCRP) was set up by government (this may still be on under a new name) and there are plans to increase funding	Inadequate domestic funding is the biggest challenge hampering CO which in turn has affected the ability of the government to bridge the gap left by donors.	Payment of subsidized fee for HIV services is recommended as a means of engendering sustainability and improving adherence	Private sector is involved in Nigeria’s HIV response and can be a possible source of financing Nigeria’s HIV response-even though government funding might just be sufficient
			PCRP has an element of fund mobilization from the private sector	The challenge of funding is further compounded by the poor economic situation of Nigeria	Private companies should not be compelled by law to fund HIV response but can be incentivized to do so
			There is evidence of sub-national fund allocation	There is evidence to show that funding for certain activities is being withdrawn	States can support HIV programme through their drug revolving fund (DRF)
			There is visibility into funding of donors and government only bridges gap	Out of pocket payment by HIV patients may not be a viable option for domestic financing	Expansion of National Health Insurance Scheme (NHIS) coverage to the informal sector is also important
				Funds budgeted by government are sometimes not released at all and when released are either not timely or not in full or both	High level advocacy to the relevant stakeholders can catalyze sub-national funding allocation
				Available resources may hinder implementation of test and treat policy	Government funding should extend beyond procurement but must also cover other supply chain expenses such as port clearance, distribution e.t.c.
					Significant co-funding by government may improve co-planning with donors
Health workforce	Human Resource for Health, Training and Mentoring, Capabilities and Behavioural Disposition		Most of the staff at the lower levels are Nigerians employed by government	There is adequate capacity at the national level (especially in the private sector) but not yet at the sub-national level	Advocacy to relevant authorities can help reduce transfer of trained staff to sites where there skills may not be needed	Private sector is involved and can be used for capacity building
			Donor intervention has contributed to capacity building for healthcare workers	There is dearth of manpower for service delivery and the current poor economic situation may not allow for recruitment in the immediate future, Capacity also needs to be built on an ongoing basis	Workers need to be motivated for optimal performance through regular salary payment, absorption of ad hoc staff under appropriate terms of service
			Pre-Service Training has been instituted in the schools of Pharmacy, Laboratory Science and Health Technology as a means of addressing the human resource capacity gap	Attrition of trained staff is a big challenge with remuneration differential contributing to this attrition as well as inequitable distribution of healthcare professionals	There may be need to prioritize certain professionals for some logistics roles
				Capacity gaps exist in areas such as quantification and program management at the state and national levels	There may be need for professional recognition of logisticians and special remuneration for those performing logistics functions
				Poor attitude to work is impacting negatively on CO	Task shifting will be of help in addressing the human resource challenge
					Clear performance benchmark can address some of the attitudinal challenges
					Proper planning and mentorship can help address capacity gap
					Capacity of government officials need to be built as some changes are dependent on them
					Government can also attract best brains from the private sector to improve public sector performance
					It might be helpful to institutionalize logistics as a professional postgraduate programme in Nigeria
Medical products, technologies	Local Manufacturing, Unification and Integration, Infrastructure, Public-Private Partnership	Local production HIV commodities is a marker of CO	Nigeria has a unified HIV/AIDS Supply Chain which leveraged on existing government structures		Even though there is no local production of ARVs, local production has the potential of fostering price reduction and continuous product availability	Nigeria is in the process of integrating supply chain systems across multiple programme areas and this should enhance overall program effectiveness and efficiency
			Nigeria has warehouses that can be used for commodity storage			The LMCU is the state-level technical arm for integration
			Warehouse-in-a-Box is planned to be managed through a public- private partnership arrangement
Information and research	Data availability, Data Quality and Data for Action		The LMCUs have increased visibility into happenings in other program areas and use of data for decision making	Quality of data in other programme areas may need more improvement	Electronic data capture system will help improve data quality
			Logistics data is available and of improved quality, there may however be need to put appropriate infrastructures in place
			Logistics data is now being used for advocacy and decision making
			LMCU is doing a lot on the use of data for action and is also serving as an avenue to stimulate improvement of the data quality for other program areas
Service delivery	Physical infrastructure Access, Integration		One of the major contributions of government towards CO is making available HFs for service delivery and payment of staff salaries		Infrastructures such as vehicles and even road network need to be improved upon
			Donor support has contributed significantly to infrastructural upgrades. Donors and partners also provided infrastructural donations to LMCU		Government should consider integration of health services as this can potentially reduce the reporting burden on healthcare workers and reduce stigmatization
			New sites are being activated to improve access but more needs to be done to improve coverage
			Stigma has reduced while treatment acceptance has improved
			Private health facilities are being used to improve access