Africa: Building a Resilient Health System: Lessons from Northern Nigeria

The overarching aim of this paper is to address the issue of building resilient health systems in the context of the Ebola outbreak in West Africa which has brought renewed attention to this challenge. The paper highlights insight gained from two decades work creating resilient health systems in Nigeria—in Northern Nigeria in particular.

In highlighting how the “simple” basics of outbreak control tie into larger, complex adaptive systems, this paper summarises key learning from the Nigerian experience as a basis for suggesting both how such outbreaks can be averted in the future and how sustainable development goals around eliminating excess mortality and improving health equity can be realised in practice.

Building resilient health systems requires:

  • A set of interventions that cover all the six (plus 1) health systems strengthening (HSS) building blocks;
  • Resources (financial and human) that can flexibly respond to challenges and opportunities;
  • Investment over a long period of time; and
  • A methodology that combines an appropriate and ongoing engagement approach, integrating governance reform with systems strengthening and building policy-maker and community support for systems strengthening.

In many situations HSS interventions only address one or more of the building blocks and their results tend to be short-lived, because different elements of the system are integrally inter-connected and inter-dependent. For sustainability and impact, whole systems need to be addressed.

Building a Resilient Health System

In the programmes, the team worked on there was the ability to work widely across the health system, addressing issues of governance, finance, institutional management, demand and accountability, service delivery, etc.–frequently at the same time. The impact is shown in the results described in this paper.

Based on the experience from Nigeria and other contexts, key steps that should be taken to build resilient health systems include:

  • Ongoing policy dialogue to build political commitment from affected country governments and international organisations and governments
  • Development of comprehensive and realistic plans to build health systems that are resilient to anticipated shocks and disruptions in the affected countries
  • Reorganisation of health services to reduce fragmentation
  • Development and implementation of a minimum service package approach
  • Mobilisation of experienced technical assistance to build the needed resilient health systems
  • Strengthening specific components of all six (plus one) HSS building blocks
  • Agreement on joint review and monitoring systems to promote accountability and transparency.

Thus, in building the health system in post Ebola West Africa, experience in the fragile circumstances of Northern Nigeria and South Sudan point to the importance of systems thinking even before the epidemic has abated. Thinking deliberately about how the health system in these countries might behave, given the complex adaptive systems analysis, should inform activities to address the epidemic and lay the foundation for post epidemic health systems strengthening.

Building a Resilient Health System


Andrew McKenzie is a South African health manager with 30 years of experience with extensive know-how in capacity building and facilitation and an excellent understanding of managing health systems and services, health sector reform and district development in sub-Saharan Africa.

Ahmad Abdulwahab is a Nigerian physician who has worked in and managed health services for over 15 years. Having worked with programmes at the national, state and facility level, he has practical knowledge and understanding of public health and the health sector in Nigeria, especially in the North, and of the workings of government, governance and Hausa-Fulani society more widely.

Emmanuel Sokpo is a Nigerian physician with extensive postgraduate training related to health system strengthening. With extensive experience in health policy, strategy and planning as well as in the reorganisation and management of primary and secondary health services, he is a seasoned health administrator and an experienced project manager with expertise in institutional capacity building, supply management and logistics; maternal, newborn and child health programming, neglected tropical disease and quality assurance/improvement in health.

Jeffrey W. Mecaskey is an American health and political economist. He has more than 30 years’ experience with a focus on health and political economics, health policy and management. He has overseen research portfolio development and management as well as planning, implementation and evaluation of health programmes.

The report PDF can be downloaded here.


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