Table 1

No	Indicator	Performance of the State	Global Benchmark
1	Per capita expenditure on health	N1, 645, which is about US1)	US$87
2	Government health expenditure as a share of GDP	0.50%	At least 5%
3	Osun State Government's health spending as a share of total government spending	9%	15% (WHO Abuja declaration)
4	Health prioritisation: Health budget as a share of the state budget	5%	15%
5	Health sector overall budget performance (total)	69%	100%
6	Health sector capital budget performance	19%	100%

Table I: Analysis of Osun State Health Financing Landscape (2013 – 2017) Showing Key Health Spending Performance Indicators against Global Benchmarks

Table 2

Stakeholder	Interest	Influence /Power	Position	Strategy
Osun State Ministry of Health	Overall coordination of health policy and TB budget preparation and performance	High	Supportive	Coordinate stakeholder activities, advocate for increased funding for TB control, oversee implementation of TB programs and provide technical support
Osun State TB and Leprosy Control Program	Effective TB control with funding	High	Supportive	Collaborate with stakeholders to advocate for increased and sustainable funding, provide expertise and TB data
Osun State Health Insurance Agency	Facilitating and Ensuring TB Coverage on the Benefit Package of the SHIS	High	Supportive	Provide technical support and support advocacy for the inclusion of TB in the benefit package of the Osun State Social Health Insurance Scheme
Department of Health Planning Research and Statistics (MoH)	Coordination of Annual Health Sector Budget Preparation, resource allocation, Data Collection and Analysis	High	Supportive	Assist in utilizing data on TB burden, partner support and funding gap to support increasing the TB funding on the Annual Budget for the Health Sector
Osun State Agency for the Control of AIDS (Osun SACA)	Integration of TB-HIV services	High	Supportive	Collaborate with stakeholders on joint TB-HIV programs, advocate for funding integrated services and leverage the sharing of resources and expertise
Hospitals Management Board	Healthcare service delivery at public Secondary Healthcare Facilities and resource allocation	Moderate	Supportive	Advocate for quality TB service delivery and equitable allocation of resources (infrastructure and human resources) for TB care at secondary healthcare facilities.
Osun State Primary Health Care Development Board	Healthcare service delivery at the PHC facilities and resource allocation	High	Supportive	Advocate for quality TB service delivery and equitable allocation of resources (infrastructure and human resources) for TB care at the PHC
Ministry of Finance	Collection and distribution of Government Revenue, financial policy formulation, fiscal management, and financial oversight	High	Supportive	Advocate for increased TB budget allocation, facilitate the release of appropriated funds for TB control, ensure proper utilization of funds and financial oversight
Ministry of Budget and Economic Planning	Formulate and prepare cost long, medium and short-term development plans, preparation of the Annual Budget of the State Government, processing annual budgets of all MDAs, review spending patterns in line with appropriated funds	High	Supportive	Advocate increased and adequate funding for TB in Health-Sector annual budgets, facilitate the release of appropriated funds for TB control
Office of the State Accountant General	Financial accountability, release of approved funds (cash backing)	High	Supportive	Ensure the release of appropriated and approved funds for TB control activities, provide oversight for fund utilization, and ensure transparency and accountability in TB financing
Desk Officer Resource Mobilization, Health Financing and Equity (MoH)	Mobilization of additional resources from non-government sources for healthcare interventions	High	Supportive	Advocate for innovative financing mechanisms, especially from the organized private sector, also to provide technical support
National Health Insurance Scheme	Policy Influence and Health Insurance Coverage	High	Supportive	Advocate for inclusion of TB services on the health insurance benefit package
Association of Nigerian Private Medical Practitioners	Policy Influence and Quality TB service provision at Private Hospitals (Primary, Secondary and Tertiary)	Moderate	Supportive	Collaborate on TB care provision at private hospitals, advocate for policies supporting increased government funding for TB control and inclusion of TB in health insurance benefit package. Support private sector engagement for mobilizing additional resources for TB control
Representative of HMO	Policy Influence and Health Insurance Coverage	Moderate	Supportive	Collaborate for TB coverage on health insurance benefit package, support private sector engagement for mobilizing additional resources for TB control
Tertiary Hospital	Specialised healthcare provision, Policy influence	Moderate	Supportive	Provide specialised TB care, collaborate with stakeholders to influence policy, participate in advocacy for increased government budget for TB control and support mobilization of additional resources from the private sector
Representative of Civil Society Organizations and other TB Partners	Policy influence, advocacy and service provision	High	Supportive	Collaborate with stakeholders to influence policy, participate in advocacy for increased government budget for TB control and support mobilization of additional resources from the private sector
WHO	Technical support and guidance	High	Supportive	Provide technical expertise, advocate for increased funding for TB control from the government and private sector, assist in policy formulation and implementation
Representative of Implementing Partners	Service provision, technical support, advocacy, policy influence	High	Supportive	Collaborate on TB service provision, share expertise (technical and operational) and resources on TB control, advocate for increased funding for TB control from the government and private sector, assist in policy formulation and implementation

Table II: Stakeholder Analysis to Identify, Understand and Prioritize Stakeholders

Table 3

No	Political Economy Dimension	TWG Members
1	Leadership politics	Special Adviser to the Executive Governor on Public Health
2	Bureaucratic politics	Permanent Secretary Ministry of Budget and Economic Planning; Permanent Secretary Ministry of Finance; State Accountant General; Executive Secretary Osun State Health Insurance Agency; Executive Secretary Osun State Primary Health Care Development Agency; Program Manager State Agency for the Control of AIDS; Director of Budget Ministry of Budget and Economic Planning; Health Sector Manager Ministry of Budget and Economic Planning; Director of Public Health MoH; Director of Planning Research and Statistics MoH; State TB Program Manager; Desk Officer Resource Mobilization, Health Financing and Equity MoH.
3	Budget politics	Permanent Secretary, Ministry of Budget and Economic Planning; Permanent Secretary, Ministry of Finance; State Accountant General; Director of Budget, Ministry of Budget and Economic Planning; Health Sector Manager, Ministry of Budget and Economic Planning; Director of Planning, Research and Statistics, MoH
4	Interest group politics	State Coordinator, National Health Insurance Authority (NHIA); Chairman, Osun State Association of Nigerian Private Medical Practitioners (ANPMP); Representative of Health Maintenance Organizations (HMOs); Consultant Pulmonologist from Tertiary Health, Research and Academia Community (Osun State University Teaching Hospital); and Representative of Civil Society Organizations (CSOs)
5	External actor politics	Representative of the World Health Organisation, Institute of Human Virology, Nigeria (IHVN)
6	Beneficiary politics	Representative of Civil Society Organisations

Table III: List of TWG Members and Political Economy Dimension they represented

Table 4

No	Category / Dimension	Political Economy Factor	Strategic Engagement Used
1	Leadership politics	The buy-in and commitment of political leaders are critical to the success of any DRM project, they must be engaged and carried along every step of the process. In this project, we engaged the Executive Governor of the State; the Chairman and entire Health Committee of the State House of Assembly; the Commissioners of the Ministries of Health, Budget & Economic Planning and Finance; the Special Adviser to the Executive Governor on Public Health; Chairmen of the State Health Insurance Agency and Primary Health Care Development Agency	They were all engaged via an entry-level advocacy meeting at the inception phase of the project. Their suggestions and inputs were factored into all interventions during the implementation phase of the project. They were also strategically engaged through ongoing one-on-one advocacy visits throughout the lifetime of the project
2	Bureaucratic politics	To foster effective communication and achieve inter-ministerial cooperation between the Health MDAs and Budget/Finance MDAs, high-level bureaucrats (Permanent Secretaries, Directors, and Sector Managers) were engaged in the Ministries of Health, Budget & Economic Planning and Finance as well as the State Accountant General and General Manager of Osun State Public Procurement Agency (PPA)	The high and mid-level leadership of the MoH, TB Control Program and State Health Insurance Team were engaged in the political economy analysis process using the framework at the planning and inception stage of the project. Permanent Secretaries, Executive Secretaries, and Directors from these MDAs were strategically engaged through several high-level advocacy meetings and membership of the Osun TB DRM TWG.
3	Budget politics	State resources are limited and several other sectors are competing for the limited funds available. Top and mid-level bureaucrats from the Ministry of Health must have an effective working relationship with their counterparts in the Budget and Finance Ministries. This is critical for the negotiation and justification for increased Government budgetary allocation and release of funds to the MoH and TB programs. Finance and Budget Ministries and the Office of the Accountant General were engaged to ensure Health and TB budgets are prioritized in the annual State Budget preparation process as well as ensure cash-backing for approved Memos	Commissioners, Permanent Secretaries and Directors from the Finance and Budget MDAs were engaged through High-Level advocacy meetings and membership of the Osun TB DRM TWG.
4	Interest group politics	Interest groups were engaged to leverage their various kinds and levels of power and political influence on politicians and policymakers. They include the National Health Insurance Authority (NHIA); Association of Nigerian Private Medical Practitioners (ANPMP); Health Maintenance Organisations (HMOs); the Tertiary Health, Research and Academia Community (Osun State University Teaching Hospital); and Civil Society Organisations (CSOs)	They were engaged through advocacy visits, and they had representatives on the Osun State TB DRM TWG
5	External actor politics	External donors and multilateral organisations such as USAID, Global Fund, Agencies of the UN and Implementing Partners play major roles through their interests, expertise, ideas and funds that are necessary to support the DRM project.	They were engaged through advocacy meetings and coopted to participate in advocacy meetings with Politicians and Bureaucrats including the Executive Governor, SSG, Commissioners and PS for increased Government Budget for TB control. WHO and the Institute of Human Virology Nigeria (IHVN) were invited to participate in the Osun State TB DRM TWG
6	Beneficiary politics	The end users of the outcomes of the improved Health System and TB Control in the State are the major beneficiaries. Frontline CSOs were engaged as direct representatives and end users to ensure their interests and influence are leveraged for successful DRM	CSO was engaged through Advocacy Meetings and representation on the Osun State TB DRM TWG

Table IV: Summary of Political Economy Analysis using the Political Economy Framework

Tables at a glance

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Figures at a glance

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FIGURE 1

Figure 1: 2021 TB Funding Gap in Nigeria Showing TB Funding Gap of over 70%

FIGURE 2

Figure II: Six-Step TB Services Integration Process

FIGURE 3

Figure III: Framework for Integrating TB Services into the OHIS for Sustainability

FIGURE 4

Figure IV: Ministry of Health and TB Budget Trend in Osun State 2020 - 2023