A Health System Strengthening Framework for Sustainable Trachoma Elimination in Nigeria: Post-Validation Programme Science

Nigeria is among the world's most trachoma-endemic countries and faces complex programmatic challenges in achieving WHO elimination targets within its fragmented, multi-stakeholder health system. This study develops a health system strengthening framework to support sustainable trachoma elimination in Nigeria beyond the period of external programme support. A mixed-methods implementation science study will be conducted across three phases spanning four years. Phase one conducts a comprehensive situational analysis using data from Nigeria's National Trachoma Control Programme database, WHO dossier preparation records, and district-level implementation reports, examining 20 purposively selected districts at different stages of the elimination pathway. Phase two employs realist evaluation to identify which contextual factors, mechanisms, and actors enable or inhibit sustained SAFE strategy implementation. Phase three develops and consensus-validates a health system strengthening framework through participatory workshops with federal and state Ministry of Health officials, programme implementers, and community representatives. Theory of change analysis will map causal pathways from health system inputs to trachoma elimination outcomes. The dominant programme science evidence for trachoma elimination is derived from east African contexts with centralised health systems, distinct from Nigeria's federated, complex architecture. This study generates original implementation science knowledge tailored to Nigeria's governance reality. The resulting framework will be submitted to the Federal Ministry of Health for integration into trachoma elimination programming and contribute to WHO elimination dossier science. Recommendations will address post-elimination surveillance, health system integration, and community ownership strategies. Keywords: trachoma elimination, health system strengthening, implementation science, Nigeria, SAFE strategy