'A seamless transition': how to sustain a community health worker scheme within the health system of Gombe state, northeast Nigeria

The sustainability of health interventions implemented in Africa: an updated systematic review on evidence and future research perspectives

BACKGROUND

Sustaining evidence-based interventions in resource-limited settings is critical to optimizing gains in health outcomes. In 2015, we published a review of the sustainability of health interventions in African countries, highlighting gaps in the measurement and conceptualization of sustainability in the region. This review updates and expands upon the original review to account for developments in the past decade and recommendations for promoting sustainability.

METHODS

First, we searched five databases (PubMed, SCOPUS, Web of Science, Global Health, and Cumulated Index to Nursing and Allied Health Literature (CINAHL)) for studies published between 2015 and 2022. We repeated the search in 2023 and 2024. The review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Studies were included if they reported on the sustainability of health interventions implemented in African countries. Study findings were summarized using descriptive statistics and narrative synthesis, and sustainability strategies were categorized based on the Expert Recommendations for Implementing Change (ERIC) strategies.

RESULTS

Thirty-four publications with 22 distinct interventions were included in the review. Twelve African countries were represented in this review, with Nigeria (n = 6) having the most representation of available studies examining sustainability. Compared to the 2016 review, a similar proportion of studies clearly defined sustainability (52% in the current review versus 51% in the 2015 review). Eight unique strategies to foster sustainability emerged, namely: a) multi-sectorial partnership and developing stakeholder relationships, b) tailoring strategies to enhance program fit and integration, c) active stakeholder engagement and collaboration, d) capacity building through training, e) accessing new funding, f) adaptation, g) co-creation of intervention and implementation strategies and h) providing infrastructural support. The most prevalent facilitators of sustainability were related to micro-level factors (e.g., intervention fit and community engagement). In contrast, salient barriers were related to structural-level factors (e.g., limited financial resources).

CONCLUSIONS

This review highlights some progress in the published reports on the sustainability of evidence-based intervention in Africa. The review emphasizes the importance of innovation in strategies to foster funding determinants for sustainable interventions. In addition, it underscores the need for developing contextually relevant sustainability frameworks that emphasize these salient determinants of sustainability in the region.

Multisectoral contributions to health security and formal policy availability at the community level in Nigeria

Introduction

Multisectoral plans and actions at the community level are one of the strategies that are deployed in the primary healthcare (PHC) system for improving the health and wellbeing of the people and also a means of addressing the social determinants of health. Multisectoral actions are also a means of implementing the Health in All Policies (HiAP) policy directions, which Nigeria has agreed to implement. However, there is a paucity of knowledge on the level of multisectoral involvement to ensure health security and promotion at the community level. This paper provides new knowledge on what multisectoral activities for health are undertaken at the community level and what can be done to strengthen them towards achieving universal health coverage in Nigeria. It elaborates on previous and current levels of multisectoral collaboration (MSC) activities for health at the community level.

Methods

A qualitative cross-sectional case study of three contextually different states in northern (Kano) and southern (Akwa Ibom and Anambra) states in Nigeria. Conceptually, the study was guided by the Expanded Health Systems framework, which recognises potential combinations of collaborations between the non-health sector and other societal partnerships (CSOs, NGOs, community groups, and informal health providers) to directly contribute to community health or indirectly through one or more social determinants of health. The study was also guided by the WHO PHC operational framework, which proposes multisectoral action as one of three key approaches to UHC. Data were collected and triangulated through 103 in-depth interviews with policymakers (health and non-health sectors), formal and informal health providers, and community leaders; 12 focus group discussions with community members (service users) and a review of health and non-health sector policy documents. Thematic data analysis was undertaken.

Results

Several community and household-level activities were identified as having been borne out of multisectoral actions. Most activities were initiated by health sector stakeholders in health, whereas others were initiated by non-health sectors (education, environment, agriculture, security, women affairs, social welfare, nutrition, water, sanitation, and hygiene-WASH) or communities. The multisectoral activities contributed to primary healthcare activities and the health security of communities, directly or indirectly, through improving one or several social determinants of health (water supply, housing, environment, security, food, and nutrition). However, most activities, which involved collaborative engagements with non-health sectors, were not backed by any formal, explicit non-health sectoral policies or guidelines. Rather, they were organically initiated and developed to support health security. The support of community leaders and groups facilitated the initiation and sustenance of multisectoral activities, whilst inadequate formal policy backing and funding were the major constraints. Although there are calls in the country for non-health sectors to mainstream health in their sectors, there is yet no clearly established framework or guidelines through which this can be implemented and sustained. A multisectoral action plan for non-communicable diseases has been developed but has not been implemented and evaluated.

Conclusion

Multisectoral collaboration for health at the community level is important for harnessing resources from outside the health sector that will be used to enhance the health security of communities. Such MSC is potentially a powerful tool for strengthening primary healthcare, towards UHC, and achieving SDG3, as shown by our findings. However, entrenched and sustained MSC should be undertaken through explicitly intentional policy reforms and their implementation through identifying, promoting, and financing MSC actions.

"Like a broom tied together": A qualitative exploration of social cohesion and its role in community capacity strengthening to support integrated health in Nigeria

Social cohesion, broadly understood as the degree of connectedness, solidarity, and trust across various community groups and between individuals, is critical for community capacity. This paper examines social cohesion and its role in community capacity strengthening for sustaining integrated health gains in Nigeria. This study took place in the context of a mid-course qualitative evaluation of a Community Capacity Strengthening approach that focuses on engaging Ward Development Committees (WDC) to increase community agency, coordinate and support the ward-level health ecosystem and ensure sustained community-level activities supporting behaviour change for improved health outcomes. This qualitative study was conducted in four selected wards per state in Bauchi and Sokoto states, targeting WDC members, Village Development Committee members, Community Volunteers, local government officials, traditional leaders, and Community Capacity Strengthening project staff. Thematic content analysis findings show that recognition and legitimacy were operationalized through the election of members into committees which in turn gave them a sense of identity and credibility. At the community level, WDCs leveraged the influence of social networks in the community to achieve their goal. Trust was also identified as a prerequisite to the acceptance and accomplishment of social and behaviour change programming. At the institutional level, our findings revealed strong conflict management skills and high collective efficacy of committee members for programme implementation. This study found high cohesion among committee members, promoting a sense of belonging and agency, and facilitating social and behavior change activities for improved health outcomes. However, we found clear limits to the extent to which high social cohesion can contribute to community capacity to sustain health implementation and improvements. While cohesive community organizations present a good opportunity for health programmes, there is a need for more investment of resources to address funding, logistics, and service delivery limitations.

Opportunities to sustain a multi-country quality of care network: Lessons on the actions of four countries Bangladesh, Ethiopia, Malawi, and Uganda

The Quality of Care Network (QCN) is a global initiative that was established in 2017 under the leadership of WHO in 11 low-and- middle income countries to improve maternal, newborn, and child health. The vision was that the Quality of Care Network would be embedded within member countries and continued beyond the initial implementation period: that the Network would be sustained. This paper investigated the experience of actions taken to sustain QCN in four Network countries (Bangladesh, Ethiopia, Malawi, and Uganda) and reports on lessons learned. Multiple iterative rounds of data collection were conducted through qualitative interviews with global and national stakeholders, and non-participatory observation of health facilities and meetings. A total of 241 interviews, 42 facility and four meeting observations were carried out. We conducted a thematic analysis of all data using a framework approach that defined six critical actions that can be taken to promote sustainability. The analysis revealed that these critical actions were present with varying degrees in each of the four countries. Although vulnerabilities were observed, there was good evidence to support that actions were taken to institutionalize the innovation within the health system, to motivate micro-level actors, plan opportunities for reflection and adaptation from the outset, and to support strong government ownership. Two actions were largely absent and weakened confidence in future sustainability: managing financial uncertainties and fostering community ownership. Evidence from four countries suggested that the QCN model would not be sustained in its original format, largely because of financial vulnerability and insufficient time to embed the innovation at the sub-national level. But especially the efforts made to institutionalize the innovation in existing systems meant that some characteristics of QCN may be carried forward within broader government quality improvement initiatives.

How valid are women's reports of the antenatal health services they receive from Community Health Workers in Gombe State north-eastern Nigeria?

BACKGROUND

Community health workers (CHWs) in low- and middle-income countries are key to increasing coverage of maternal and newborn interventions through home visits to counsel families about healthy behaviours. Household surveys enable tracking the progress of CHW programmes but recent evidence questions the accuracy of maternal reports. We measured the validity of women's responses about the content of care they received during CHW home visits and examined whether the accuracy of women's responses was affected by CHW counselling skills.

METHODS

We conducted a criterion validity study in 2019, in Gombe State-Nigeria, and collected data from 362 pregnant women. During accompanied CHW home visits the content of CHW care and the presence or absence of 18 positive counselling skills were observed and documented by a researcher. In a follow-up interview three months later, the same women were asked about the care received during the CHW home visit. Women's reports were compared with observation data and the sensitivity, specificity, and area under receiver curve (AUC) calculated. We performed a covariate validity analysis that adjusted for a counselling skill score to assess the variation in accuracy of women's reports with CHW counselling skills.

RESULTS

Ten indicators were included in the validity analysis. Women consistently overestimated the content of care CHWs provided and no indicator met the condition for individual-level accuracy set at AUC ≥ 0.6. The CHW counselling skill score ranged from 9-18 points from a possible 18, with a mean of 14.3; checking on client history or concerns were the most frequently missed item. There was evidence that unmarried women and the relatively most poor women received less skilled counselling than other women (mean counselling scores of 13.2 and 13.7 respectively). There was no consistent evidence of an association between higher counselling skill scores and better accuracy of women's reports.

CONCLUSIONS

The validity of women's responses about CHW care content was poor and consistently overestimated coverage. We discuss several challenges in applying criterion validity study methods to examine measures of community-based care and make only cautious interpretation of the findings that may be relevant to other researchers interested in developing similar studies.

Availability and functionality of neonatal care units in healthcare facilities in Mtwara region, Tanzania: The quest for quality of in-patient care for small and sick newborns

BACKGROUND

Evidence shows that delivery of prompt and appropriate in-patient newborn care (IPNC) through health facility (HF)-based neonatal care and stabilization units (NCU/NSUs) reduce preventable newborn mortalities (NMs). This study investigated the HFs for availability and performance of NCU/NSUs in providing quality IPNC, and explored factors influencing the observed performance outcomes in Mtwara region, Tanzania.

METHODS

A cross-sectional study was conducted using a follow-up explanatory mixed-methods approach. HF-based records and characteristics allowing for delivery of quality IPNC were reviewed first to establish the overall HF performance. The review findings were clarified by healthcare staff and managers through in-depth interviews (IDIs) and focus group discussions (FGDs).

RESULTS

About 70.6% (12/17) of surveyed HFs had at least one NCU/NSU room dedicated for delivery of IPNC but none had a fully established NCUs/NSU, and 74.7% (3,600/4,819) of needy newborns were admitted/transferred in for management. Essential medicines such as tetracycline eye ointment were unavailable in 75% (3/4) of the district hospitals (DHs). A disparity existed between the availability and functioning of equipment including infant radiant warmers (92% vs 73%). Governance, support from implementing patterns (IPs), and access to healthcare commodities were identified from qualitative inquiries as factors influencing the establishment and running of NCUs/NSUs at the HFs in Mtwara region, Tanzania.

CONCLUSION

Despite the positive progress, the establishment and performance of NCUs/NSUs in providing quality IPNC in HFs in Mtwara region is lagging behind the Tanzania neonatal care guideline requirements, particularly after the IPs of newborn health interventions completed their terms in 2016. This study suggests additional improvement plans for Mtwara region and other comparable settings to optimize the provision of quality IPNC and lower avoidable NMs.

Sustainability of Donor-Funded Health-Related Programs Beyond the Funding Lifecycle in Africa: A Systematic Review

This study aimed to determine if implemented donor-funded health related-programs in Africa were sustained beyond the funding lifecycle and determine their facilitators and impeders. A systematic review was conducted after the documentation of a study protocol. A database search was done across three databases namely Google Scholar, PubMed, and Medline between January 27 and February 15, 2022. All peer-reviewed articles on sustainability of health interventions in Africa published between 2015 and 2021 that provided one or more context-relevant definitions of sustainability were included. Publications with no use of quantitative or qualitative methods and studies with no information on project evaluation after initial implementation were excluded. Screening of titles and abstracts was done, and the full texts of all relevant articles were retrieved. The risk of bias in systematic reviews (ROBIS) tool was used to assess the risk of bias in the systematic review. Overall, 4,876 articles were retrieved, and only nine articles were eligible for inclusion in the review following the removal of duplicates. Overall, sustainability was described in only three of the five regions in Africa. Donor-funded projects were sustained beyond the funding lifecycle in seven (77.8%) studies. Facilitators of sustainability in Africa included community ownership of the project through the engagement of community stakeholders in the design and implementation of such projects, use of locally available resources, sound infrastructure, and the constitution of interdisciplinary team to facilitate capacity building. Impeders to the sustainability of donor-funded projects included weak health systems exemplified in poor documentation and integration of records, lack of financial leadership, shortage of resources, political interference, poor feedback mechanism, and weak donor-community interactions. From the ROBIS tool, a low risk of bias existed in the studies included in the review. Although the included studies appropriately considered the review's research question, seven studies had a low risk of bias in the domains one to three, and two studies had high risk of bias in domain four. To derive maximum benefits from donor-funded health interventions, sustainability of such projects is key. During program planning phase, context-based facilitators of sustainability should be promoted, while impeders are immediately addressed.

Improving maternal and newborn health services in Northeast Nigeria through a government-led partnership of stakeholders: a quasi-experimental study

OBJECTIVES

This study aimed to quantify change in the coverage, quality and equity of essential maternal and newborn healthcare interventions in Gombe state, Northeast Nigeria, following a four year, government-led, maternal and newborn health intervention.

DESIGN

Quasi-experimental plausibility study. Repeat cross-sectional household and linked health facility surveys were implemented in intervention and comparison areas.

SETTING

Gombe state, Northeast Nigeria.

PARTICIPANTS

Each household survey included a sample of 1000 women aged 13-49 years with a live birth in the previous 12 months. Health facility surveys comprised a readiness assessment and birth attendant interview.

INTERVENTIONS

Between 2016-2019 a complex package of evidence-based interventions was implemented to increase access, use and quality of maternal and newborn healthcare, spanning the six WHO health system building blocks.

OUTCOME MEASURES

Eighteen indicators of maternal and newborn healthcare.

RESULTS

Between 2016 and 2019, the coverage of all indicators improved in intervention areas, with the exception of postnatal and postpartum contacts, which remained below 15%. Greater improvements were observed in intervention than comparison areas for eight indicators, including coverage of at least one antenatal visit (71% (95% CI 62 to 68) to 88% (95% CI 82 to 93)), at least four antenatal visits (46% (95% CI 39 to 53) to 69% (95% CI 60 to 75)), facility birth (48% (95% CI 37 to 59) to 64% (95% CI 54 to 73)), administration of uterotonics (44% (95% CI 34 to 54) to 59% (95% CI 50 to 67)), delayed newborn bathing (44% (95% CI 36 to 52) to 62% (95% CI 52 to 71)) and clean cord care (42% (95% CI 34 to 49) to 73% (95% CI 66 to 79)). Wide-spread inequities persisted however; only at least one antenatal visit saw pro-poor improvement.

CONCLUSIONS

This intervention achieved improvements in life-saving behaviours for mothers and newborns, demonstrating that multipartner action, coordinated through government leadership, can shift the needle in the right direction, even in resource-constrained settings.