RESEARCH ARTICLE Aligning policymaking in decentralized health systems: Evaluation of strategies to prevent and control non-communicable diseases in Nigeria Whenayon Simeon Ajisegiri ID 1 *, Seye Abimbola ID 1,2 , Azeb Gebresilassie Tesema ID 1,3 , Olumuyiwa O. Odusanya 4 , Dike B. Ojji ID 5,6 , David Peiris ID 1‡ , Rohina Joshi ID 1,7‡ 1 The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Australia, 2 School of Public Health, University of Sydney, Sydney, Australia, 3 School of Public Health, Mekelle University, Mekelle, Ethiopia, 4 Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Ikeja, Nigeria, 5 Cardiovascular Research Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria, 6 University of Abuja, Abuja, Nigeria, 7 The George Institute for Global Health, New Delhi, India ‡ These authors are joint senior authors on this work. * doctorajisegiri@yahoo.com, wajisegiri@georgeinstitute.org.au Abstract Noncommunicable diseases (NCDs) are leading causes of death globally and in Nigeria they account for 29% of total deaths. Nigeria’s health system is decentralized. Fragmenta- tion in governance in federalised countries with decentralised health systems is a well-rec- ognised challenge to coherent national health policymaking. The policy response to the rising NCD burden therefore requires strategic intent by national and sub-national govern- ments. This study aimed to understand the implementation of NCD policies in Nigeria, the role of decentralisation of those policies, and to consider the implications for achieving national NCD targets. We conducted a policy analysis combined with key informant inter- views to determine to what extent NCD policies and strategies align with Nigeria’s decentra- lised health system; and the structure and process within which implementation occurs across the various tiers of government. Four inter-related findings emerged: NCD national policies are ‘top down’ in focus and lack attention to decentralisation to subnational and frontline care delivery levels of the health system; there are defective coordination mecha- nisms for NCD programmes which are underpinned by weak regional organisational struc- tures; financing for NCDs are administratively burdensome and fragmented; and frontline NCD service delivery for NCDs are not effectively being integrated with other essential PHC services. Despite considerable progress being made with development of national NCD pol- icies, greater attention on their implementation at subnational levels is needed to achieve more effective service delivery and progress against national NCD targets. We recommend strengthening subnational coordination mechanisms, greater accountability frameworks, increased and more efficient funding, and greater attention to integrated PHC service deliv- ery models. The use of an effective bottom-up approach, with consideration for decentraliza- tion, should also be engaged at all stages of policy formulation. PLOS GLOBAL PUBLIC HEALTH PLOS Global Public Health | https://doi.org/10.1371/journal.pgph.0000050 November 10, 2021 1 / 18 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Ajisegiri WS, Abimbola S, Tesema AG, Odusanya OO, Ojji DB, Peiris D, et al. (2021) Aligning policymaking in decentralized health systems: Evaluation of strategies to prevent and control non-communicable diseases in Nigeria. PLOS Glob Public Health 1(11): e0000050. https:// doi.org/10.1371/journal.pgph.0000050 Editor: Yodi Mahendradhata, Gadjah Mada University, INDONESIA Received: July 18, 2021 Accepted: October 18, 2021 Published: November 10, 2021 Peer Review History: PLOS recognizes the benefits of transparency in the peer review process; therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. The editorial history of this article is available here: https://doi.org/10.1371/journal.pgph.0000050 Copyright: © 2021 Ajisegiri et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data contributing to the findings are within the study. The raw data (transcript from qualitative study) are