Table 2.

Summary of findings on the nine components of Vogus and Graff’s framework

Components of the framework	Summary of findings
Policy environment	There are many health policies and strategies; however, policy implementation is a major challenge. The National Health Act (NHA) and the Basic Healthcare Provision Fund (BHCPF) are the two major policies to protect the vulnerable population and make progress towards achieving UHC.
Institutionalization of the process	Visible steps have been taken to institutionalize service delivery processes toward sustainable immunization services and responsive primary healthcare (PHC) in line with UHC. There is a shift in the implementation approach within the HIV control programme to engage Nigeria more directly in programme implementation to enable sustainability of HIV services.
Integration of programmes into the wider health system	Some steps have been taken to integrate the immunization programme into PHC services and private services. There is ongoing discussion on integrating HIV services with other health services, and on the possibility of covering HIV services under the NHIS.
Identification of alternative funding processes	There is very little government funding for the HIV response. Major commitments have been made by the government to increase domestic funding of immunization. There are three health funding gaps in Nigeria:
Leadership and management	Leadership is laden with corruption, poor management processes and poor government commitment to health. The health system is overly dependent on donor funds, even in priority health areas such as HIV and immunization. Multiple health policies and commitments are made by the government without implementation. Accountability frameworks are developed and endorsed, but are rarely implemented. Coordinating the implementation of frameworks is a huge challenge. The health system lacks high-quality data for projections, proper management and planning. The dysfunctional structure of the Nigerian health system stands in the way of good management and proper coordination and hampers proper coordination across the multiple vertical programmes. The sharing of power across the three levels of government within the health system, with each level having some autonomy, makes the system difficult to negotiate.
Political and economic factors	Nigeria’s political environment is encumbered with political instability that results from changes in government tenure. With every change in government comes an abrupt end of health programmes instituted by the outgoing government, and the launch of new programmes by the incoming government. This lack of continuity in some health programmes wastes resources and constitutes a barrier to sustaining gains and making progress. It is challenging to persuade the government to allocate funds to health. Economic instability is a hindrance to transition of health programmes to domestic funding.
Stakeholder engagement	There are gaps in stakeholder engagement—grassroots actors are poorly engaged. Some respondents had concerns about poor stakeholder engagement in charting the course for the BHCPF.
Strength of procurement processes and supply	There are corrupt practices and inefficiencies in the supply chain. There are gaps in procurement processes.
Identification of staffing and training needs	There are gaps in human resources for health leading to poor retention of skilled workers. Most staff involved in HIV and immunization are supported by donor funds, and so withdrawal of funds will create even greater gaps and widen inequities.