The experience of a donor- supported Reproductive, Maternal, Newborn and Child Health programme in four states in northern Nigeria illustrates how a Complex Adaptive System approach to health systems becoming more resilient. The programme worked with the array of political, cultural and social determinants which interact to shape the health systems and its functionality. It worked in an environment marked by weak governance with public accountability ntability and by very limited management capability in inadequately regulated markets. To these conditions of fragility was added the shock from the rapidly deteriorating security situation caused in 2011 by the Boko Haram insurgency and the government’s ensuing response.
A Complex Adaptive System theory of change provided the basis for the multi-faceted approach that identified critical points of leverage among institutions in social as well as professional systems and helped achieve significant improvements in health service delivery in the Reproductive, Maternal, Newborn and Child Health continuum of care. It also established the foundation for Primary Health Care Under One Roof, which has emerged as a central national strategy in Nigeria for strengthening health sector governance and services under the 2014 Health Act.
This article draws on the experience of work undertaken in Northern Nigeria over the course of the last 10 years. A team largely of Nigerian professionals from an array of disciplines worked widely across the health system, addressing issues of governance, finance, institutional management, community systems support, access and accountability, and service delivery—frequently at the same time. This experience provides lessons for efforts elsewhere on how to strengthen health systems during and after emergencies (such as Ebola in West Africa) and in situations affected by conflict.