Effects of an intervention to improve sexual and reproductive health on level and predictors of awareness and knowledge of condoms and dual protection amongst adolescents in Nigeria

BACKGROUND

Adolescents need both information about sexual behaviours and potential risks in order to make the right choices. This study compared adolescents' level of awareness and predictors of knowledge of condoms and dual protection where a multi-component sexual and reproductive health (SRH) intervention was implemented and in communities where the intervention was not implemented, so as to understand the effect of the intervention on awareness and knowledge and also identify predictors of knowledge of contraception methods.

METHODS

The study was an intervention study that was undertaken in six local government areas (three rural and three urban LGAs) in Ebonyi state, southeast Nigeria. Data were collected from 855 adolescent boys and girls, using a pre-tested interviewer administered questionnaire. Systematic random sampling technique was used to select eligible households from which adolescents were interviewed Analysis of data was carried out using bivariate and multivariate linear regression analyses. The level of statistical significance was determined by a p value of < 0.05.

RESULTS

The level of awareness of condoms and dual protection was similar in the intervention and non-intervention communities. However, the predictors of knowledge about condoms and dual protection were different between the intervention and non-intervention groups. The multivariate linear regression showed that the higher the level of education, the higher the level of awareness of contraception methods among adolescents (p < 0.05). Likewise, increasing age by one year and working for pay increased the awareness of condoms and dual protection(p < 0.05).

CONCLUSION

There was no difference in the level of awareness of pregnancy prevention methods, knowledge of condoms and dual protection in both arms of the study. Higher level of education, increasing age, and working for pay are factors associated with awareness of condom and dual protection. These factors should be prioritized for effective Adolescent sexual and reproductive health (ASRH) programming.

Targeting systems not individuals: Institutional and structural drivers of absenteeism among primary healthcare workers in Nigeria

Universal Health Coverage (UHC) can only be achieved if people receive good quality care from health workers, yet in Nigeria, as in many other low- and middle-income countries (LMICs), many health workers are absent from work. Absenteeism is a well-known phenomenon but is often considered as the self-serving behaviour of individuals, independent from the characteristics of health systems structures and processes and the broader contexts that enable it. We undertook a qualitative inquiry among 40 key informants, comprising health facility heads and workers, community leaders and state-level health policymakers in Nigeria. We employed a phenomenology approach to examine their lived experiences and grouped findings into thematic clusters. Absenteeism by health workers was found to be a response to structural problems at two levels -midstream (facility-level) and upstream (government level) - rather than being a result of moral failure of individuals. The problems at midstream level pointed to an inconsistent and unfair application of rules and regulations in facilities and ineffective management, while the upstream drivers relate mainly to political interference and suboptimal health system leadership. Reducing absenteeism requires two-pronged interventions that tackle defects in the upstream and midstream rather than just focusing on sanctioning deviant staff (downstream).

Implications of absenteeism of health workers on achieving universal health coverage in Nigeria: exploring lived experiences in primary healthcare

Primary healthcare facilities are the bedrock for achieving universal health coverage (UHC) because of their closeness to the grassroots and provision of healthcare at low cost. Unfortunately, in Nigeria, the access and quality of health services in public primary healthcare centres (PHCs) are suboptimal, linked with persistent occurrence of absenteeism of health workers. We used a UHC framework developed by the World Health Organization-African Region to examine the link between absenteeism and the possible achievement of UHC in Nigeria. We undertook a qualitative study to elicit lived experiences of healthcare providers, service users, chairpersons of committees of the health facilities, and policymakers across six PHCs from six local government areas in Enugu, southeast Nigeria. One hundred and fifty participants sourced from the four groups were either interviewed or participated in group discussions. The World Health Organization-African Region UHC framework and phenomenological approach were used to frame data analysis. Absenteeism was very prevalent in the PHCs, where it constrained the possible contribution of PHCs to the achievement of UHC. The four indicators toward achievement of UHC, which are demand, access, quality, and resilience of health services, were all grossly affected by absenteeism. Absenteeism also weakened public trust in PHCs, resulting in an increase in patronage of both informal and private health providers, with negative effects on quality and cost of care. It is important that great attention is paid to both availability and productivity of human resources for health at the PHC level. These factors would help in reversing the dangers of absenteeism in primary healthcare and strengthening Nigeria's aspirations of achieving UHC.

Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

To what extent did implementing a community-embedded intervention align with the goals and roles of stakeholders in adolescent sexual and reproductive health?

BACKGROUND

Adolescents' sexual and reproductive health (SRH) needs are largely unmet due to poor access to SRH information and services. A multicomponent community-embedded intervention, comprising advocacy to policymakers and community leaders, training of health workers on the provision of youth-friendly SRH services, and establishment of school health clubs, was implemented in Ebonyi State, Nigeria, to improve access to SRH information and services for adolescents aged 13-18 years in selected communities and secondary schools. This study explored the extent to which the intervention aligned with goals and roles of stakeholders in the State.

METHODS

Qualitative in-depth interviews (30) were conducted with key stakeholders in adolescent health programming in the State, and community gatekeepers (traditional and religious leaders) in the intervention communities. Sex-disaggregated focus group discussions (10) were conducted with health service providers, parents/guardians of adolescents. Data was analyzed deductively based on fit of strategy and two constructs of the Theoretical Framework for Acceptability - burden, and opportunity cost. The transcripts were coded in NVivo 12, and the subthemes that emerged from each construct were identified.

RESULTS

Stakeholders perceived the ASRH intervention activities to align with their individual goals of sense of purpose from serving the community and organizational goals of improving the visibility of adolescent reproductive health programs and aligned with their routine work. Hence, implementing or participating in the interventions was not considered a burden by many. Although the delivery of the interventions constituted additional workload and time commitment for the implementers, the benefits of partaking in the intervention were perceived to outweigh the inputs that they were required to make. Some of the community health workers in the intervention felt that provision of financial incentive will help with making the intervention less burdensome. To participate in the intervention, opportunity cost included forgoing work and business activities as well as family commitments.

CONCLUSION

Findings from the study show that the intervention aligned with individual/organizational goals of stakeholders. To improve acceptability of the ASRH interventions, interventions should leverage on existing programs and routine work of people who will deliver the interventions.

'Government don't know me and if I stop, they won't know': A qualitative study on the lived experiences of volunteer health workers in the Nigerian health system and their implications for the sustainable development goals

BACKGROUND

Volunteer health workers play an important, but poorly understood role in the Nigerian health system. We report a study of their lived experiences, enabling us to understand their motivations, the nature of their work, and their relationships with formally employed health workers in Primary Healthcare Centres (PHCs) in Nigeria, the role of institutional incentives, and the implications for attaining the health-related sustainable development goals (SDGs) targets.

METHODS

The study used ethnographic observation of PHCs in Enugu State, supplemented with in-depth interviews with volunteers, formally employed health workers and health managers. The analysis employed a combination of narrative and reflexive thematic approaches.

FINDINGS

The lived experiences of most volunteers unfold in four stages as they move into and out of their volunteering status. The first stage signifies hope, arising from the ease with which they are accepted and integrated into the PHC space. The anger stage emerges when volunteers confront the marked disparity in their treatment compared to formal staff, despite their substantial contributions to healthcare. Then, the bargaining stage sets in, where they strive for recognition and respect by pursuing formal employment and advocating for fair treatment and improved stipends. A positive response, such as improved stipends, can reignite hope among volunteers. If not, most volunteers transition to the acceptance stage - the acknowledgement that their status may never be formalised, prompting many to lose hope and disengage.

CONCLUSION

There should be a clear policy on recruitment, compensation, and protection of volunteers in the health systems, to enhance the contribution they can make to the achievement of the health-related SDG targets.

A qualitative assessment of the impact of a community-embedded intervention on beneficiaries' attitudes and beliefs about adolescent sexual reproductive health in Ebonyi State, Southeast, Nigeria

BACKGROUND

Adolescents and their communities in Ebonyi State, Nigeria have poor attitudes and beliefs towards adolescent sexual and reproductive health (SRH). This paper reports on the effects of a community-embedded intervention that focused on creating positive changes in the attitudes and beliefs of adolescents and community members to enhance adolescents' access to SRH information and services.

METHODS

This study adopted the Qualitative Impact Assessment approach to evaluate the changes in attitudes and beliefs about the SRH of adolescents from the perspectives of the beneficiaries of a community-embedded intervention namely, adolescents, parents, school teachers, and community leaders. The intervention was implemented in six local government areas in Ebonyi State, southeast Nigeria and the evaluation was undertaken four months after the implementation of the interventions commenced. Eighteen (18) interviews were conducted with 82 intervention beneficiaries including: (i) six in-depth interviews with school teachers; (ii) two sex-disaggregated FGDs with parents; (iii) two sex-disaggregated FGDs with community leaders; and (iv) eight sex-disaggregated FGDs with in school and out of school adolescents. A thematic analysis of data was performed with the aid of NVivo software, version 12.

RESULTS

The community-embedded intervention led to changes in individual attitudes and beliefs, as well as changes in community norms and values concerning adolescent SRH. Adolescents reported that following the community-embedded SRH intervention, they have become more comfortable discussing openly SRH issues with their peers, and they could more easily approach their parents and initiate SRH discussions. The parents of adolescents reported that following the intervention, they have become more willing to discuss sensitive SRH issues with adolescents, and frequently make out time to do so. It was also reported that parents no longer use euphemisms to describe sexual body parts, and community leaders now believe that it is all right to discuss SRH with adolescents. Hence, initiating or having SRH discussions with adolescents is no longer misconceived as encouraging sex, and menstruation in unmarried adolescents is no longer viewed as a sign of promiscuity. Respondents also highlighted changes in community norms of, (i) gendered parental communication of SRH matters, as both mothers and fathers have started discussing SRH issues with their adolescent boys and girls; and (ii) public shaming and discipline of pregnant teenage girls are on the decline.

CONCLUSION

The community-based intervention had a positive impact on individual attitudes and beliefs, as well as community and societal values and norms about adolescent SRH. Interventions that take into account community norms and values regarding adolescent SRH should be prioritized to enable the achievement of the SRH-related target of SDG 3.

Understanding and Bridging Gaps in the Use of Evidence from Modeling for Evidence-Based Policy Making in Nigeria's Health System

Background. Modeled evidence is a proven useful tool for decision makers in making evidence-based policies and plans that will ensure the best possible health system outcomes. Thus, we sought to understand constraints to the use of models in making decisions in Nigeria's health system and how such constraints can be addressed. Method. We adopted a mixed-methods study for the research and relied on the evidence to policy and Knowledge-to-Action (KTA) frameworks to guide the conceptualization of the study. An online survey was administered to 34 key individuals in health organizations that recognize modeling, which was followed by in-depth interviews with 24 of the 34 key informants. Analysis was done using descriptive analytic methods and thematic arrangements of narratives. Results. Overall, the data revealed poor use of modeled evidence in decision making within the health sector, despite reporting that modeled evidence and modelers are available in Nigeria. However, the disease control agency in Nigeria was reported to be an exception. The complexity of models was a top concern. Thus, suggestions were made to improve communication of models in ways that are easily comprehensible and to improve overall research culture within Nigeria's health sector. Conclusion. Modeled evidence plays a crucial role in evidence-based health decisions. Therefore, it is imperative to strengthen and sustain in-country capacity to value, produce, interpret, and use modeled evidence for decision making in health. To overcome limitations in the usage of modeled evidence, decision makers, modelers/researchers, and knowledge brokers should forge viable relationships that regard and promote evidence translation.

Highlights

Despite the use of modeling by Nigeria's disease control agency in containing the COVID-19 pandemic, modeling remains poorly used in the country's overall health sector.Although policy makers recognize the importance of evidence in making decisions, there are still pertinent concerns about the poor research culture of policy-making institutions and communication gaps that exist between researchers/modelers and policy makers.Nigeria's health system can be strengthened by improving the value and usage of scientific evidence generation through conscious efforts to institutionalize research culture in the health sector and bridge gaps between researchers/modelers and decision makers.

The Promise of Grassroots Approaches to Solving Absenteeism in Primary Health-Care Facilities in Nigeria: Evidence from a Qualitative Study

Absenteeism among primary health-care (PHC) workers in Nigeria is widespread and is a major obstacle to achieving Universal Health Coverage (UHC). There is increasing research on the forms it takes and what drives them, but limited evidence on how to address it. The dominant approach has involved government-led topdown solutions (vertical approach). However, these have rarely been successful in countries such as Nigeria. This paper explores alternative approaches based on grassroots (horizontal) approaches. Data collected from interviews with 40 PHC stakeholders in Enugu, Nigeria, were organized in thematic clusters that explored the contribution of horizontal interventions to solving absenteeism in primary health-care facilities. We applied phenomenology to analyze the lived (practical) experiences of respondents. Absenteeism by PHC workers was prevalent and is encouraged by the complex configuration of the PHC system and its operating environment, which constrains topdown interventions. We identified several horizontal approaches that may create effective incentives and compulsions to reduce absenteeism, which include leveraging community resources to improve security of facilities, tapping the resources of philanthropic individuals and organizations to provide accommodation for health workers, and engaging trained health workers as volunteers or placeholders to address shortages of health-care staff. Nevertheless, a holistic response to absenteeism must complement horizontal approaches with vertical measures, with the government supporting and encouraging the health system to develop self-enforcing mechanisms to tackle absenteeism.

Acceptability of a community-embedded intervention for improving adolescent sexual and reproductive health in south-east Nigeria: A qualitative study

INTRODUCTION

Adolescents have limited access to quality sexual and reproductive health (SRH) services that are key to healthy sexual lives in many low and middle-income countries such as Nigeria. Hence, context-specific interventions are required to increase adolescents' access to and utilisation of SRH. This paper provides new knowledge on the acceptability of a community-embedded intervention to improve access to SRH information and services for adolescents in Ebonyi state, southeast Nigeria.

METHODS

A community-embedded intervention was implemented for six months in selected communities. Thereafter the intervention was assessed for its acceptability using a total of 30 in-depth interviews and 18 focus group discussions conducted with policymakers, health service providers, school teachers, community gatekeepers, parents and adolescents who were purposively selected as relevant stakeholders on adolescent SRH. The interview transcripts were coded in NVivo 12 using a coding framework structured according to four key constructs of the theoretical framework for acceptability (TFA): affective attitude, intervention coherence, perceived effectiveness, and self-efficacy. The outputs of the coded transcripts were analysed, and the emergent themes from each of the four constructs of the TFA were identified.

RESULTS

The intervention was acceptable to the stakeholders, from the findings of its positive effects, appropriateness, and positive impact on sexual behaviour. Policymakers were happy to be included in collaborating with multiple stakeholders to co-create multi-faceted interventions relevant to their work (positive affective attitude). The stakeholders understood how the interventions work and perceived them as appropriate at individual and community levels, with adequate and non-complex tools adaptable to different levels of stakeholders (intervention coherence). The intervention promoted mutualistic relations across stakeholders and sectors, including creating multiple platforms to reach the target audience, positive change in sexual behaviour, and cross-learning among policymakers, community gatekeepers, service providers, and adolescents (intervention effectiveness), which empowered them to have the confidence to provide and access SRH information and services (self-efficacy).

CONCLUSIONS

Community-embedded interventions were acceptable as strong mechanisms for improving adolescents' access to SRH in the communities. Policymakers should promote the community-embedded strategy for holistic health promotion of adolescents.

Examining multiple funding flows to public healthcare providers in low- and middle-income countries - results from case studies in Burkina Faso, Kenya, Morocco, Nigeria, Tunisia and Vietnam

Provider payment methods are traditionally examined by appraising the incentive signals inherent in individual payment mechanisms. However, mixed payment arrangements, which result in multiple funding flows from purchasers to providers, could be better understood by applying a systems approach that assesses the combined effects of multiple payment streams on healthcare providers. Guided by the framework developed by Barasa et al. (2021) (Barasa E, Mathauer I, Kabia E et al. 2021. How do healthcare providers respond to multiple funding flows? A conceptual framework and options to align them. Health Policy and Planning  36: 861-8.), this paper synthesizes the findings from six country case studies that examined multiple funding flows and describes the potential effect of multiple payment streams on healthcare provider behaviour in low- and middle-income countries. The qualitative findings from this study reveal the extent of undesirable provider behaviour occurring due to the receipt of multiple funding flows and explain how certain characteristics of funding flows can drive the occurrence of undesirable behaviours. Service and resource shifting occurred in most of the study countries; however, the occurrence of cost shifting was less evident. The perceived adequacy of payment rates was found to be the strongest driver of provider behaviour in the countries examined. The study results indicate that undesirable provider behaviours can have negative impacts on efficiency, equity and quality in healthcare service provision. Further empirical studies are required to add to the evidence on this link. In addition, future research could explore how governance arrangements can be used to coordinate multiple funding flows, mitigate unfavourable consequences and identify issues associated with the implementation of relevant governance measures.

Impact of a capacity-building intervention on views and perceptions of healthcare providers towards the provision of adolescent sexual and reproductive health services in southeast Nigeria: a cross-sectional qualitative study

OBJECTIVES

Negative views of healthcare providers towards adolescent sexual and reproductive health (SRH) services deter adolescents from seeking vital SRH services. This paper assessed the impact of an intervention on the views and perceptions of healthcare providers towards the provision of adolescent SRH services.

DESIGN AND SETTING

A descriptive, cross-sectional, qualitative study was conducted between 14 October and 19 November 2021 in six local government areas (LGAs) in Ebonyi state, southeast Nigeria, after the implementation of an intervention comprising of training and supportive supervision.

PARTICIPANTS AND DATA COLLECTION

Data were collected through: (1) two in-depth interviews (IDIs) with LGA healthcare managers; (2) six IDIs with LGA adolescent health programme managers; (3) two focus group discussions (FGDs) with 15 primary healthcare facility managers; (4) two FGDs with 20 patent medicine vendors and (5) two FGDs with 17 community health volunteers. A total of six FGDs were held with 52 healthcare providers. The interviews were conducted using pretested interview guides. Transcripts were coded in NVivo (V.12) and themes were identified through inductive analysis.

RESULTS

As a result of the intervention, most healthcare providers started recognising the rights of adolescents to obtain contraceptive services and no longer deny them access to contraceptive services. The providers also became friendlier and were no longer harsh in their interactions with adolescents. There were some unique findings relative to whether the providers were formal or informal healthcare providers. It was found that the informal healthcare providers were bolder and more comfortable delivering SRH services to adolescents and reported improved patronage by the adolescents. The formal healthcare providers made their facilities more conducive for adolescents by creating safe spaces and introducing extracurricular activities.

CONCLUSION

These findings highlight the importance of the constant capacity building of both formal and informal healthcare providers, which can address healthcare providers' biases, views and perceptions of delivering SRH services to adolescents.

Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria

BACKGROUND

The low demand for maternal and child health services is a significant factor in Nigeria's high maternal death rate. This paper explores demand and supply-side determinants at the primary healthcare level, highlighting factors affecting provision and utilization.

METHODS

This qualitative study was undertaken in Anambra state, southeast Nigeria. Anambra state was purposively chosen because a maternal and child health programme had just been implemented in the state. The three-delay model was used to analyze supply and demand factors that affect MCH services and improve access to care for pregnant women/mothers and newborns/infants.

RESULT

The findings show that there were problems with both the demand and supply aspects of the programme and both were interlinked. For service users, their delays were connected to the constraints on the supply side. On the demand side, the delays include poor conditions of the facilities, the roads to the facilities are inaccessible, and equipment were lacking in the facilities. These delayed the utilisation of facilities. On the supply side, the delays include the absence of security (fence, security guard), poor citing of the facilities, inadequate accommodation, no emergency transport for referrals, and lack of trained staff to man equipment. These delayed the provision of services.

CONCLUSION

Our findings show that there were problems with both the demand and supply aspects of the programme, and both were interlinked. For service users, their delays were connected to the constraints on the supply side.

The nature, drivers and equity consequences of informal payments for maternal and child health care in primary health centres in Enugu, Nigeria

In Nigeria, most basic maternal and child health services in public primary health-care facilities should be either free of charge or subsidized. In practice, additional informal payments made in cash or in kind are common. We examined the nature, drivers and equity consequences of informal payments in primary health centres (PHC) in Enugu State. We used three interlinked qualitative methods: participant observation in six PHC facilities and two local government area (LGA) headquarters; in-depth interviews with frontline health workers (n = 19), managers (n = 4) and policy makers (n = 10); and focus group discussions (n = 2) with female service users. Data were analysed thematically using NVivo 12. Across all groups, informal payments were described as routine for immunization, deliveries, family planning consultations and birth certificate registration. Health workers, managers and policy makers identified limited supervision, insufficient financing of facilities, and lack of receipts for formal payments as enabling this practice. Informal payments were seen by managers and health workers as a mechanism to generate discretionary revenue to cover operational costs of the facility but, in practice, were frequently taken as extra income by health workers. Health workers rationalized informal payments as being of small value, and not a burden to users. However, informal payments were reported to be inequitable and exclusionary. Although they tended to be lower in rural PHCs than in wealthier urban facilities, participant observation revealed how, within a PHC, the lowest earners paid the same as others and were often left unattended if they failed to pay. Some female patients reported that extra payments excluded them from services, driving them to seek help from retail outlets or unlicensed health providers. As a result, informal payments reduced equity of access to essential services. Targeted policies are needed to improve financial risk protection for the poorest groups and address drivers of informal payments and unfairness in the health system.

Examining corruption risks in the procurement and distribution of COVID-19 vaccines in select states in Nigeria

BACKGROUND

Public health emergencies raise significant concerns about corruption and accountability; however, these concerns can manifest in different ways across diverse locations. For instance, more developed countries with a stronger rule of law may experience more corruption in vaccine procurement, whereas developing countries may experience more corruption at the point of distribution and delivery to end users. This research focuses on corruption concerns in Nigeria, specifically examining the procurement and distribution of COVID-19 vaccines.

METHODS

This paper utilizes a scoping review and a qualitative research approach. Key informants (n = 40) involved in the procurement and distribution of COVID-19 vaccines across two states in Nigeria were interviewed. Findings from the scoping review were summarized, and collected data were inductively coded and analysed in themes, revealing clear examples of implementation irregularities and corruption in the country's COVID-19 vaccination processes.

RESULTS

Vaccination programme budgeting processes were unclear, and payment irregularities were frequently observed, resulting in vaccinators soliciting informal payments while in the field. Recruitment and engagement of vaccination personnel was opaque, while target vaccination rates incentivized data falsification during periods of vaccine hesitancy. Accountability mechanisms, such as health worker supervision, vaccination data review, and additional technical support provided by donors were implemented but not effective at preventing corruption among frontline workers.

CONCLUSIONS

Future accountability measures should be evidence-driven based on findings from this research. Personnel recruitment, contracting, budgeting, and remuneration should focus on transparency and accountability.

What are the research priorities for strengthening public health emergency preparedness and response in Africa?

BACKGROUND

Research evidence is needed to strengthen capacities in emergency preparedness and response (EPR). However, the absence of a clear research agenda limits the optimal use of research evidence. This paper reports on the prioritization of research questions and topics that could contribute to evidence-informed strengthening of EPR capacities in the African region.

METHODS

The priority-setting consisted of desk review and stakeholder consultation workshop. Twenty-nine people participated in the workshop, including representatives from WHO regional office and EPR focal points in Africa, representatives of research institutions, and partners from Science for Africa Foundation, United Nations Children's Fund and Africa Center for Disease Control. Modified Delphi technique was used to systematically arrive at specific and cross-cutting research priorities in the three broad areas of the EPR, which are program Implementation, Clinical and Epidemiology. The research questions/topics were ranked on five-point Likert scale (1 = very low to 5 = very high) based on seven agreed-on criteria. Research priority score was calculated for each question as the mean of the criteria scores.

RESULTS

A total of 123 research questions comprising, 29 on Epidemiology, 22 on Clinical, 23 on program Implementation, and 49 on cross-cutting issues were ranked. The top ten research priorities were: knowledge and skills of healthcare workers in detecting and responding effectively to disease outbreaks; quality of data (accuracy, timeliness, completeness) for epidemic prone diseases; determinants of vaccine hesitancy; determinants of infection transmission among health care workers during PHE; effective measures for protecting health workers from highly infectious pathogens in PHE; strategies to improve the effectiveness of contact tracing for epidemic prone diseases; effectiveness of current case definitions as screening tools for epidemic and pandemic prone diseases; measures to strengthen national and sub-national laboratory capacity for timely disease confirmation within the Integrated Diseases Surveillance and Response framework; factors affecting prompt data sharing on epidemic-prone diseases; and effective strategies for appropriate community participation in EPR.

CONCLUSIONS

The collaborative multi-stakeholder workshop produced a starting list of priority research questions and topics for strengthening EPR capacities in Africa. Action needs to be taken to continuously update the research agenda and support member States to contextualize the research priorities and commission research for timely generation and uptake of evidence.

"I can't kill myself": Local narratives and meanings that foster absenteeism in Nigerian primary health centres

Background

Absenteeism in the health sector is increasingly seen as a form of harmful rule-breaking, with health workers receiving a salary although they are not present to provide care. It is a barrier to achieving universal health coverage yet remains widespread in primary health centres (PHCs) in Nigeria and many other low-resource settings. Traditional approaches to combatting absenteeism have relied on anti-corruption measures such as promoting accountability and transparency. However, more needs to be understood about the social and cultural realities, including perceptions and norms enabling or constraining the application of such measures in Nigeria and in similar contexts.

Methods

We conducted 34 in-depth interviews (IDIs) with frontline health workers and their managers/supervisors and two focus group discussions (FDGs) with service users (n = 22) in Enugu State, South Eastern Nigeria. We discussed their experiences and views about absenteeism, allowing the respondents' framings to emerge. We adopted a mixed approach of narrative analysis and phenomenology to examine respondents' narratives - identifying the concepts and social constructs within the narratives that manifested through the language used.

Results

Stakeholders acknowledged the problem of absenteeism but had differing perspectives on its dynamics. Health workers distinguished two forms of absenteeism: one as a mundane, everyday response to the poorly funded health system; and the other, brazen and often politically enabled absenteeism, where health workers whom powerful politicians protect are absent without facing consequences. There is a general feeling of powerlessness among both health service providers and service users confronted by politically backed absentees as the power dynamics in the health sector resonate with experiences in other spheres of life in Nigeria. Health workers rationalised mundane, technical absenteeism, adjusted to it and felt it should be accommodated in the health system. Service users are often unsure about who is absent and why, but when they notice absenteeism, they often ascribe it to wider system malpractices that characterise public services.

Conclusion

Interventions to tackle absenteeism and other forms of health sector corruption should be sensitive to socio-cultural and political contexts that shape everyday lives in specific contexts. Challenging narratives/beliefs that normalise absenteeism should be part of reform plans.

Analysing the progress in service delivery towards achieving universal health coverage in Nigeria: a scoping review

BACKGROUND

Attainment of universal health coverage (UHC) requires optimal utilization of health services. Poor coverage and inequitable access to healthcare could hinder improvement in service delivery towards UHC. The study analyzed the progress in service delivery coverage and equity in access to care within the Nigerian health systems based on the tracer indicators of the WHO framework for monitoring UHC.

METHODS

We searched the literature in databases: PubMed, Scopus, Directory of Open Access Journals, Google Scholar, Science Direct and websites of relevant health Ministries, Agencies, and Organizations between March to December 2022. Search terms were identified in four broader themes: Service delivery coverage, equity, UHC and Nigeria. Data were collected through a review of 37 published articles (19 peer-reviewed articles and 8 grey documents). We synthesized the findings in thematic areas using the WHO framework for monitoring UHC.

RESULTS

The findings show a slow improvement in service delivery coverage across the UHC tracer indicators; reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access. With regards to equity in access to care across the tracer indicators, there has been a great disparity in the utilization of healthcare services among rural dwellers, lower educational level individuals and those with poor socio-economic status over 20 years. However, there was remarkable progress in the ownership and use of long-lasting insecticide-treated nets among rural and lowest-wealth quantile households than their urban counterpart.

CONCLUSION

There is poor coverage and persistent inequitable access to care among the tracer indicators for monitoring progress in service delivery. Attaining UHC requires concerted efforts and investment of more resources in service delivery to address inequitable access to care and sustainable service coverage for improved health outcomes.

Examining the roles of partnerships in enhancing the health systems response to COVID-19 in Nigeria

BACKGROUND

The COVID-19 pandemic overwhelmed the health systems and socio-economic foundations of many countries, Nigeria inclusive. The study was carried out to assess, understand, document and report the activities/measures that are considered nationally and sub-nationally significant, both in terms of COVID-19 responses and in terms of strengthening the health system for the future, in response to future threats since this will not be the last pandemic This paper examines how partnerships contributed to the health system and other sectors' responses to COVID - 19 infection in Nigeria.

METHODS

This was a qualitative study. Data was collected using a scoping literature review and key informant interviews with 36 key stakeholders in the COVID-19 response in Nigeria, in Abuja (national level) Lagos and Enugu states (sub-national level). Interviews were recorded and transcribed verbatim. The qualitative data was analysed using thematic analysis.

RESULTS

It was found that many partnerships were formed when responding to the COVID-19 pandemic in Nigeria. The health system leaned towards a horizontal dimension of partnership with non-health governmental sectors, non-governmental sectors, and other countries. All the components of the health system building blocks had a measure of partnership contributing to its accomplishments The partnerships came in varied forms, ranging from advocacy, funding, provision of palliatives to the citizens because of lockdowns, technical assistance, support to research, development of guidelines and health educational materials.

CONCLUSION

The health sector's collaboration with other sectors strengthened all the building blocks of the health system and was invaluable in enhancing the response to COVID-19, which needed a whole of government and a multi-sectoral approach. Formal frameworks for quickly initiating whole-of-government and multi-sectoral partnerships should be developed, with clear roles and responsibilities. This should be deployed for health system resilience and for response to shocks such as the COVID-19 pandemic.

Addressing security threats affecting primary healthcare service delivery and uptake in Nigeria

BACKGROUND

Security of health facilities in low- and middle-income countries (LMICs) is of vital importance in ensuring that health care can be provided in safe conditions. There is paucity of literature on the issue of threats to the personal safety of primary healthcare (PHC) providers and service users in Nigeria and what should be done. Thus, the current study seeks to fill this gap.

METHOD

Key-informant interviews with 12 health workers and non-participant observations were utilised for data collection in Enugu, Nigeria. Their responses were analysed using a descriptive qualitative analysis approach in structuring narratives in themes.

RESULT

There is lack of vital security infrastructure across the health facilities, and we recorded reports on armed robbery attacks, theft of drugs and other items, including a case of a stolen newborn. These findings are structured in three themes that reveal experienced threats in PHC facilities, their implications on health service delivery, and responses that can be taken to make PHC facilities safe.

CONCLUSION

Security challenges constrain both access and provision of essential and affordable healthcare services at the primary healthcare level in Enugu, Nigeria.

Determinants of awareness, value perception, and societal support for sexual and reproductive health services among in-school adolescents in South-eastern Nigeria

BACKGROUND

Adolescents are vulnerable to sexual and reproductive health (SRH) risks yet, have poor utilisation of SRH services due to personal, social, and demographic influences. This study aimed to compare the experiences of adolescents that had received targeted adolescent SRH interventions and those that did not and evaluated the determinants of awareness, value perception, and societal support for SRH service utilisation among secondary school adolescents in eastern Nigeria.

METHODS

We undertook a cross-sectional study of 515 adolescents in twelve randomly selected public secondary schools, grouped into schools that had received targeted adolescent SRH interventions and those that did not, across six local government areas in Ebonyi State, Nigeria. The intervention comprised training of schools' teachers/counsellors and peer educators and community sensitisation and engagement of community gatekeepers for demand generation. A pre-tested structured questionnaire was administered to the students to assess their experiences with SRH services. Categorical variables were compared using the Chi-square test, and predictors were determined through multivariate logistic regression. The level of statistical significance was determined at p < 0.05 and a 95% confidence limit.

RESULTS

A higher proportion of adolescents in the intervention group, 126(48%), than in the non-intervention group, 35(16.1%), were aware of SRH services available at the health facility (p-value < 0.001). More adolescents in the intervention than the non-intervention group perceived SRH services as valuable- 257(94.7%) Vs 217(87.5%), p-value = 0.004. Parental/community support for SRH service utilisation was reported by more adolescents in the intervention group than in the non-intervention group- 212 (79.7%) Vs 173 (69.7%), p-value = 0.009. The predictors are (i) awareness-intervention group (β = 0.384, CI = 0.290-0.478), urban residence (β=-0.141, CI=-0.240-0.041), older age (β-0.040, CI = 0.003-0.077) (ii) value perception - intervention group (β = 0.197, 0.141-0.253), senior educational class (β = 0.089, CI = 0.019-0.160), work-for-pay (β=-0.079, CI=-0.156-0.002), awareness (β = 0.192, CI = 0.425-0.721) (iii) parental/community support - work-for-pay (β = 0.095, CI = 0.003-0.185).

CONCLUSIONS

Adolescents' awareness, value perception, and societal support for sexual and reproductive health services were influenced by the availability of SRH interventions and socio-economic factors. Relevant authorities should ensure the institutionalisation of sex education in schools and communities, targeting various categories of adolescents, to reduce disparity in the utilisation of sexual and reproductive health services and promote adolescents' health.

A narrative review of evidence to support increased domestic resource mobilization for family planning in Nigeria

BACKGROUND

Family planning (FP) is an important public health intervention that is proven to reduce unplanned pregnancies, unsafe abortions, and maternal mortality. Increasing investments in FP would ensure stability and better maternal health outcomes in Nigeria. However, evidence is needed to make a case for more domestic investment in family planning in Nigeria. We undertook a literature review to highlight the unmet needs for family planning and the situation of its funding landscape in Nigeria. A total of 30 documents were reviewed, including research papers, reports of national surveys, programme reports, and academic/research blogs. The search for documents was performed on Google Scholar and organizational websites using predetermined keywords. Data were objectively extracted using a uniform template. Descriptive analysis was performed for quantitative data, and qualitative data were summarized using narratives. Frequencies, proportions, line graphs and illustrative chart were used to present the quantitative data. Although total fertility rate declined over time from 6.0 children per woman in 1990 to 5.3 in 2018, the gap between wanted fertility and actual fertility increased from 0.2 in 1990 to 0.5 in 2018. This is because wanted fertility rate decreased from 5.8 children per woman in 1990 to 4.8 per woman in 2018. Similarly, modern contraceptive prevalence rate (mCPR) decreased by 0.6% from 2013 to 2018, and unmet need for family planning increased by 2.5% in the same period. Funding for family planning services in Nigeria comes from both external and internal sources in the form of cash or commodities. The nature of external assistance for family planning services depends on the preferences of funders, although there are some similarities across funders. Irrespective of the type of funder and the length of funding, donations/funds are renewed on annual basis. Procurement of commodities receives most attention for funding whereas, commodities distribution which is critical for service delivery receives poor attention.

CONCLUSION

Nigeria has made slow progress in achieving its family planning targets. The heavy reliance on external donors makes funding for family planning services to be unpredictable and imbalanced. Hence, the need for more domestic resource mobilization through government funding.

Role and use of evidence in health system response to COVID-19 in Nigeria: a mixed method study

Introduction

evidence-based decision-making in health is an aspiration needed to effectively respond to current outbreaks and prepare for future occurrences. This paper examines the roles and use of evidence in health systems response to COVID-19 in Nigeria.

Methods

this was a mixed method study comprising nine key informant interviews and rapid review of 126 official online documents, journal articles and media reports published from December 2019 to December 2020 with a national and sub-national focus. Key informants were drawn from the government agencies that were involved in making or implementing decisions on the health sector response to COVID-19. Data collection was performed by three researchers. Thematic analysis and narrative synthesis of data was done.

Results

various forms of evidence were used to make decisions on Nigeria´s health system response to COVID-19, and these are broadly classified into three, namely, i) lessons learned from past experiences such as community engagement activities, early recognition of risks and deployment of non-pharmaceutical pandemic control measures, ii) proven interventions with contextual relevance like the emphasis on hand hygiene education for health workers, and iii) risk assessment and situation analysis reports like adopting a multi-sector response to COVID-19 control, expanding COVID-19 diagnostic laboratories to new sites across the country, and relax lockdown restrictions while maintaining key limitations to curb a spike in COVID-19 cases.

Conclusion

Nigeria´s health system response to COVID-19 upheld the use of evidence in making critical decisions on the prevention and control of the pandemic.

Stakeholders’ Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study

BACKGROUND

Countries in sub-Saharan Africa, including Nigeria, continue to depend on donor funding to achieve their national HIV response goals. The Government of Nigeria has made limited progress in translating political commitment to reduce donor dependency into increased domestic investment to ensure the sustainable impact of the HIV response. We explored the context-specific factors affecting the financial sustainability of the HIV response in Nigeria.

METHODS

Between November 2021 and March 2022, we conducted document reviews (n=13) and semistructured interviews with purposively selected national and subnational stakeholders (n=35). Data were analyzed thematically using the framework of health financing functions comprising revenue generation, pooling, and purchasing.

RESULTS

Stakeholders reported that there is a low level of government funding for the HIV response, which has been compounded by the weak engagement of Ministry of Finance officials and the unpredictable and untimely release of budgeted funds. Opportunities for domestic funding include philanthropy and an HIV Trust Fund led by the private sector. Integration of HIV treatment services into social health insurance schemes has been slow. Commodity purchasing has been inefficient due to ineffective coordination. Government stakeholders have been reluctant to support one-stop-shop facilities that target key and priority populations.

CONCLUSION

Opportunities exist in the government and private sectors for improving domestic health financing to support transitioning from donor support and ensuring the financial sustainability of the HIV response in Nigeria. To ensure that domestic financing for the HIV response is stable and predictable, the amount of domestic funding needs to increase and a framework that incorporates donor transition milestones must be developed, implemented, and monitored.

A systematic review of actors, actions, and outcomes of community-based efforts to prevent or reduce methamphetamine use

Background

There has been an increase in methamphetamine use across the globe, despite widespread control of the drug, prevention, and treatment. Community-based approaches have proven effective in tackling diverse health-related challenges including substance use; however, little is known regarding community programs targeting methamphetamine use. We conducted a systematic literature review on community programs aimed at tackling the use of methamphetamine across the globe.

Method

Relevant literature from peer-reviewed and gray literature sources were systematically identified. A grid template was used to extract and synthesize findings from retrieved literature regarding themes of actors, actions, and outcomes related to identified programs.

Results

A total of 19 documents met our inclusion criteria. Some of the dominant actors in efforts to reduce methamphetamine use in communities were local councils, drug enforcement units, influential persons in the community, people who use or had used methamphetamine, business corporations, and already-existing health promoting platforms. Actions taken were typically education/awareness/information campaigns. Drug enforcement agencies appeared to make little gains when acting alone, and appeared to drive dealers and users underground. Many of the efforts made at the community level were alluded to be beneficial; however, it was difficult to quantify the impact of programs. Community-level efforts also tended to cascade to other drugs.

Conclusion

Community-based actors and actions are diverse and critical to the prevention of methamphetamine use. There is a need to better coordinate and integrate different actors and interventions so that outcomes can be better monitored and evaluated for greater effectiveness in reducing methamphetamine use.

Ensuring Safety of Patients in Complex Health Systems: A Focus on Primary Healthcare Service Relations in Nigeria

Patient-centered healthcare is a goal for all health systems. However, given the inherent complexities of the health system as one with many nonlinear and dynamic components, the safety of patients could be affected. Therefore, there is the need to study these complexities to manage them toward optimal service delivery. The present study is a qualitative inquiry into the complexities of primary healthcare (PHC) in Nigeria and effects on patients' safety across four PHC facilities in Enugu state in southeast Nigeria. It utilizes a framework that draws on the components of interprofessional collaboration, inclusive of health financing and health workforce satisfaction, to understand the complex PHC system and patient safety. The study findings show that the PHC system in the study area performs suboptimally on the three counts, which implies poor management of the complexities of the system such that patients are highly susceptible to harm. Making a commitment to addressing the shortcomings present in each of the three components will help to decomplexify PHC in line with the World Health Organization agenda of achieving resilient and strong health systems. Importantly, optimizing the psychosocial space in Nigeria's PHC by employing qualified social workers and other psychosocial professionals is crucial for patient safety and a range of psychosocial activities that can enhance job satisfaction of health workers.

Effects of corruption and unaccountability on responses of frontline health workers to COVID-19 in Nigeria: Lessons and considerations for the social work profession

COVID-19 stretched health systems, exacerbated by concerns about those that are corrupt and lack equity. Twelve (12) health workers and 12 hospital social workers across Nigeria were purposively sampled and virtually interviewed to explore unaccountability and corruption effects on COVID-19 responses. Findings show that corruption and unaccountability negatively affected responses of frontline health workers to the pandemic. Lack of social care and justice services for patients and health workers across health facilities in Nigeria worsened the negative effects. Effectively mainstreaming social care and justice services into Nigeria's healthcare led by well-trained social workers will improve the health sector via anticorruption.

Absenteeism in primary health centres in Nigeria: leveraging power, politics and kinship

BACKGROUND

Primary health centres (PHCs) in Nigeria suffer critical shortages of health workers, aggravated by chronic absenteeism that has been attributed to insufficient resources to govern the system and adequately meet their welfare needs. However, the political drivers of this phenomenon are rarely considered. We have asked how political power and networks influence absenteeism in the Nigerian health sector, information that can inform the development of holistic solutions.

METHODS

Data were obtained from in-depth interviews with three health administrators, 30 health workers and 6 health facility committee chairmen in 15 PHCs in Enugu State, Nigeria. Our analysis explored how political configurations and the resulting distribution of power influence absenteeism in Nigeria's health systems.

RESULTS

We found that health workers leverage social networks with powerful and politically connected individuals to be absent from duty and escape sanctions. This reflects the dominant political settlement. Thus, the formal governance structures that are meant to regulate the operations of the health system are weak, thereby allowing powerful individuals to exert influence using informal means. As a result, health managers do not confront absentees who have a relationship with political actors for fear of repercussions, including retaliation through informal pressure. In addition, we found that while health system structures cannot effectively handle widespread absenteeism, networks of local actors, when interested and involved, could address absenteeism by enabling health managers to call politically connected staff to order.

CONCLUSION

The formal governance mechanisms to reduce absenteeism are insufficient, and building alliances (often informal) with local elites interested in improving service delivery locally may help to reduce interference by other powerful actors.

Effects of a structured health education on prevention of HIV risky behaviours among adolescents in Nigeria - a pragmatic randomized controlled trial

Infection with HIV/AIDS continues to be a major public health concern around the world, particularly in low- and middle-income nations. To assess the effectiveness of structured health education on the prevention of HIV/AIDS risky behaviours among adolescents in secondary school. A pretest-posttest-control group randomized controlled trial where a sample of 647 adolescents was drawn from the population of 2,890 secondary school students and was block-randomized into the intervention (n = 400) and control (n = 224) groups. Data were collected using a content-validated (CVI = 4.2/5) and reliable (k = 0.791) self-developed structured questionnaire. Data were analyzed using descriptive statistics and with inferential statistics of independent and paired t-tests at α = 0.05. Pre-intervention risky behaviours in both groups were below average though lower in the intervention than in the control group. Pre-intervention risky behaviour was significantly higher among males than females in the rural school (p < 0.001) and in both schools together (p < 0.001). Health education significantly affected risky behaviour with the intervention group being associated with lesser risky behaviour than the control group. There was no significant difference in the post-intervention risky behaviour between males and females in the rural (0.285), urban (0.179) and both schools together (p = 0.956). Post-intervention reduced risky behaviours more significantly in the intervention than in the control groups. HIV/AIDS health education should be part of schools' curriculum, guidance and counsellor teachers should be trained as HIV counsellors.

Stakeholders' perspectives on internal accountability within a sub-national immunization program: A qualitative study in Enugu State, South-East Nigeria

BACKGROUND

Weak accountability hinders the effectiveness of routine immunization (RI) systems in low- and middle-income countries, yet studies on accountability of immunization programs are scarce. Aim: The study explored stakeholders' perspectives on the functioning of internal accountability within the National Program on Immunization in Enugu State, southeast Nigeria.

SUBJECTS AND METHODS

We used semi-structured in-depth interviews to collect data from RI officials at state government, local government, and health facility levels (n = 35) in Enugu State between June and July 2021. We adopted maximum variation sampling to purposively select individuals with roles in immunization. The interview guide was developed based on an accountability framework with three dimensions-the axes of power, ability, and justice. Data were analyzed thematically using NVivo software (version 11). The major themes were role clarity, performance standards, supervision, data use, human resources, funding, motivation, sanctions, political influence, and community engagement.

RESULTS

Performance targets for immunization coverage and reporting timeline were not always met due to multiple accountability failures. Weaknesses in the formal rules that distribute roles among the immunization workforce comprise a lack of deployment letters, unavailability of job descriptions, and inadequate staff orientation. Local officials have a narrow decision space regarding staff posting, transfer, and discipline. Performance accountability was constrained by staff shortages, uneven staff distribution, absenteeism, infrequent supervision, weak data monitoring system, and underfunding. Despite being motivated by job recognition and accomplishments, low motivation from an insecure working environment and lack of financial incentives undermined the constructive agency of service delivery actors. The sanctions framework exists but is weakly enforced due to fear of victimization. Political commitment to the immunization program was low. Yet, political decision-makers interfered with staff recruitment, distribution, and discipline. Community engagement improved resource availability through paid volunteer health workers and maintenance of facilities. However, health facility committees were poorly resourced, non-functional, and lacked the power to sanction erring health workers.

CONCLUSIONS

Immunization service delivery actors can be held accountable for program performance when there are sufficient formal instruments that provide roles and responsibilities, needed resources, motivated and supervised staff, an effective sanctions framework, genuine political participation, and strong community engagement.

An analysis on the roles and involvements of different stakeholders in the provision of adolescent sexual and reproductive health services in Southeast Nigeria

Introduction

Sexual and reproductive health of young people involve a lot of stakeholders, traverse different sectors, and cut across all levels of government. For a clearer understanding of the activities of these stakeholders in adolescent sexual and reproductive health (ASRH) services, this paper was designed to explore the positions, attitudes and involvements of government/public institutions and non-governmental organizations (NGOs) in ASRH policy-making processes and implementations in Ebonyi State, Nigeria.

Methods

The evidence was generated from a cross-sectional qualitative study, with data collected through in-depth interviews and focus group discussions from 81 and 59 stakeholders in adolescent sexual and reproductive health, respectively. A mapping tool was used for the stakeholder analysis.

Results

The State Ministry of Health (MOH) was identified as playing a major role in ASRH policy development and so was categorized as a ‘savior’. However, out of nine public institutions, four were categorized as ‘trip wire’ because they had non-supportive attitudes, weak powers and passive interests in ASRH policies and programs. All the NGOs were categorized as ‘friend’, because of their weak, but favorable disposition to ASRH policy-making processes. Regarding the implementation of ASRH programs, most public institutions were categorized as ‘savior’. Similarly, most of the institutions were classified as ‘trip wire’ at the local government level, in relation to ASRH policy development. Only, the offices of traditional rulers/village heads and local government administrative secretaries were regarded as ‘friend’, while the public schools were classified as an ‘acquaintance’. Concerning the implementation of ASRH programs at this level, public secondary schools, the offices of local government administrative secretaries and local government focal persons on ASRH were categorized as ‘savior’, while town union/ward development chairmen were considered ‘friend’. Few stakeholders, including, religious leaders were classified as ‘savior’ regarding engagement with local authorities on ASRH matters.

Conclusion

Although key stakeholders appear to play supportive roles in the implementation of ASRH programs in Ebonyi State, many of the relevant government and non-government institutions are not involved in the policy-making process. There is a need for more intentional and active involvement of relevant stakeholders in policy-making for better ownership and sustainability of ASRH interventions.

Economic Burden of Diabetes and Hypertension: A Study of Direct and Indirect Cost of Treatment in Southeast Nigeria

The prevalence of diabetes mellitus and hypertension is increasing yearly in many low- and middle-income countries such as Nigeria. The increasing burden of these noncommunicable diseases has led to an increase in the overall cost of health care. This study aimed at determining the direct and indirect health care costs of diabetes mellitus and hypertension occurring both singly and in co-morbidity. The study was undertaken in the Enugu State University Teaching Hospital (a tertiary hospital) in Enugu State, Southeast Nigeria. Data were collected using a pre-tested questionnaire. Out of 817 patients interviewed, 37% had only diabetes mellitus, 35% had hypertension, and 28% had both diabetes mellitus and hypertension in co-morbidity. Direct costs of treating diabetes mellitus and hypertension in the month before the survey were $28.40 and $19.35, respectively, while the indirect costs of treatment in the month before the study were $7.36 and $5.51, respectively. Direct and indirect costs for diabetes mellitus and hypertension in co-morbidity were $37.00 and $4.62, respectively. A concentration index showed that diabetes mellitus and hypertension were more evident among the poor than the rich. The economic cost when compared with patients' income revealed that >25% of their income is spent monthly on health care.

SARS CoV-2 Seroprevalence in Selected States of High and Low Disease Burden in Nigeria

IMPORTANCE

The global impact of COVID-19 has led to an increased need to continuously assess disease surveillance tools. The utility of SARS-CoV-2 serologic tools in determining immunity levels across different age groups and locations in helping to quickly assess the burden of COVID-19 with significant health policy implications is unknown.

OBJECTIVE

To determine the prevalence of SARS-CoV-2 antibodies with respect to the age group and sex of participants.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional survey of 4904 individuals across 12 states with high and low COVID-19 disease burden in Nigeria was carried out between June 29 and August 21, 2021.

MAIN OUTCOMES AND MEASURES

Enzyme-linked immunosorbent assay was used for the detection of specific SARS-CoV-2 immunoglobulin G and immunoglobulin M antibodies, such as the nucleocapsid protein-NCP and spike protein S1. Interviewer-administered questionnaires provided information on participants' history of disease and associated risk factors.

RESULTS

A total of 4904 individuals participated in the study (3033 were female [61.8%]; mean [SD] age, 26.7 [6.51] years). A high seroprevalence of SARS-CoV-2 (78.9%) was obtained. Seropositivity was consistent across the states surveyed, ranging from 69.8% in Lagos to 87.7% in Borno. There was no association between sex and seropositivity (female, 2414 [79.6%]; male, 1456 [77.8%]; P = .61); however, an association was noted between age and seropositivity, with the peak prevalence observed in participants aged 15 to 19 years (616 [83.6%]; P = .001). Similarly, loss of appetite (751 [82.3%]; P = .04) and smell (309 [84.4%]; P = .01) were associated with seropositivity.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, a high SARS-CoV-2 seroprevalence was obtained among the study population during the low level of vaccination at the time of the survey. Thus, there is a need for both an efficacy and antibody neutralization test study to ascertain the efficacy of the antibody detected and the potential for herd immunity in Nigeria.

Gender norms and ideologies about adolescent sexuality: A mixed-method study of adolescents in communities, south-eastern, Nigeria

BACKGROUND

Sexual and reproductive health choices and behaviors of adolescents are shaped by gender norms and ideologies which are grounded in cultural beliefs. This study examined the perspectives of adolescents about the influence of gender norms and ideologies on sexuality.

METHODS

A cross-sectional study was undertaken in three urban and three rural communities in south-eastern Nigeria using quantitative and qualitative research methods. A modified cluster sampling procedure was used to select respondents. Data were collected from 1,057 adolescents and twelve focus group discussions with unmarried adolescents aged 13 to 18 years. For the quantitative data, univariate, bivariate and probit regression analyses were performed using Stata while the thematic framework approach was used to analyze qualitative data.

RESULTS

The dominant beliefs among adolescents are that: it is wrong for unmarried adolescents to have sex (86.4%); unmarried adolescents should abstain from sex (89.3%); consent should be obtained before sexual intercourse (89.1%); it is a girl's responsibility to ensure she does not get pregnant (66.5%), and sex should be initiated by boys (69.6%). Gender (boy or girl) was a predictor of belief in premarital abstinence (t-value = -3.88), belief that premarital sexual intercourse is acceptable provided contraceptive is used (t-value = 3.49, CI 1.14-0.49), belief that premarital sexual intercourse is wrong (t-value = -2.24) and, belief that sex should be initiated by boys only (t-value = -4.37). Adolescent boys were less likely to believe in pre-marital abstinence and less likely to believe that pre-marital sex among adolescents is wrong compared to girls. They were also more likely to believe adolescents can have sex provided contraceptive is used compared to girls. Qualitative findings revealed adolescents' beliefs that girls feel shy initiating sex and that boys experience more urge for sex hence, boys were perceived to be responsible for initiating sex. Both boys and girls experience pressure to have sex however, boys were described to experience more pressure from peers to have sex. Peer-to-peer communication, quest for material possessions and low socioeconomic conditions contribute to peer pressure to engage in sex.

CONCLUSION

Adolescents' beliefs about sexuality underline the need to contextualize interventions to address these norms and ideologies.

An assessment of Nigeria's health systems response to COVID-19

Objectives

This study aims to understand and report on selected health system interventions considered nationally and sub-nationally of particular significance both in terms of COVID-19 responses and in strengthening the health system for the future.

Design

A review of published and grey literature, including journals, news/ media and official documents, was conducted from 1st December 2019 to 31st December 2020. The reviewers read and extracted relevant data using FACTIVA in a uniform data extraction template. Responses that related to service delivery were captured.

Setting

The assessment considered responses at the national and two state levels: Lagos and Enugu, representing the epicentre and a low COVID-19 burden centre.

Inclusion criteria

Documents and news that mentioned COVID-19 response, particularly service delivery aspects, were included in this review.

Results

The identified interventions were mostly technical support targeted at health workers: including training of about 17,000 health workers, supervising and engaging more health workers, upgrading laboratories and building new ones to improve screening and diagnosis, and motivation of health workforce with incentives. Furthermore, the influx of philanthropic contributions improved the data and information systems supply of medicines, medical products and non-pharmaceutical protective materials through local production. The presence of political will and the government's efforts in health system's response to COVID-19 facilitated these interventions.

Conclusions

Interventions of state and non-state actors have strengthened the health systems to some extent. However, more needs to be done to sustain these gains and make the health system resilient to absorb unprecedented shocks.

Funding

IDRC Canada Grant # 109479-001.

How (not) to promote sub-national ownership of national initiatives in decentralised health systems: The free maternal and child health programme in Nigeria, 2008-2015

BACKGROUND

Promoting the sub-national ownership of national health initiatives is essential for efforts to achieve national health goals in federal systems where sub-national governments are semi-autonomous. Between 2008 and 2015, Nigerian government implemented a pilot free maternal and child health (MCH) programme in selected states to improve MCH by reducing physical and financial barriers of access to services. This study was conducted to better understand why the programme was neither adopted nor scaled-up by sub-national governments after pilot phase.

METHODS

We conducted a qualitative evaluation of the programme in Imo and Niger States, with data from programme documents, in-depth interviews (45) and focus group discussions (16) at State and community levels. Data was analysed using manual thematic coding approach.

RESULT

Our analysis indicates that the programme design had two mutually dependent goals, which were also in tension with one another: 1. To ensure programme performance, the designers sought to shield its implementation from sub-national government politics and bureaucracy; and 2. To gain the buy-in of the same sub-national government politicians and bureaucrats, the designers sought to demonstrate programme performance. The potential for community advocacy for sub-national adoption and scale-up was not considered in the design. Therefore, limited involvement of sub-national governments in the programme design limited sub-national ownership during implementation. And limited oversight of implementation by sub-national government policymakers limited programme performance.

CONCLUSION

Efforts to promote sub-national ownership of national initiatives in decentralised health systems should prioritise inclusiveness in design, implementation, and oversight, and well-resourced community advocacy to sub-national governments for adoption and scale-up.

The Gendered Drivers of Absenteeism in the Nigerian Health System

The ability to deliver primary care in Nigeria is undermined by chronic absenteeism but an understanding of its drivers is needed if effective responses are to be developed. While there is a small but growing body of relevant research, the gendered dynamics of absenteeism remain largely unexplored. We apply a gendered perspective to understanding absenteeism and propose targeted strategies that appear likely to reduce it. We did so by means of a qualitative study that was part of a larger project examining corruption within the health system in six primary healthcare facilities across rural and urban regions in Enugu State, south-east Nigeria. We conducted thirty in-depth interviews with frontline health workers, healthcare managers, and community members of the health facility committee. Six Focus Group Discussions were held with male and female service users. Data were analysed using thematic analysis. Participants described markedly gendered differences in the factors contributing to health worker absenteeism that were related to gender norms. Absence by female health workers was attributed to domestic and caregiving responsibilities, including housekeeping, childcare, cooking, washing, and non-commercial farming used to support their families. Male health workers were most often absent to fulfil expectations related to their role as breadwinners, with dual practice and work in other sectors to generate additional income generation as their formal salaries were considered irregular and poor. Demands arising from sociocultural and religious events affected the attendance of both male and female health workers. Both men and women were subject to sanctions, but managers and facility chairs were more lenient with women when absence was due to caregiving and other domestic responsibilities. In summary, gender roles influence absenteeism amongst primary healthcare workers in Nigeria and thus should be taken into account in developing nuanced responses that take account of the social, economic, and cultural factors that underpin these roles.

Did an Intervention Programme Aimed at Strengthening the Maternal and Child Health Services in Nigeria Improve the Completeness of Routine Health Data Within the Health Management Information System?

BACKGROUND

During 2012-2015, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme, a health system strengthening (HSS) programme with a Maternal and Child Health component (Subsidy Reinvestment and Empowerment Programme [SURE-P]/MCH), which was monitored using the Health Management Information Systems (HMIS) data reporting tools. Good quality data is essential for health policy and planning decisions yet, little is known on whether and how broad health systems strengthening programmes affect quality of data. This paper explores the effects of the SURE-P/MCH on completeness of MCH data in the National HMIS.

METHODS

This mixed-methods study was undertaken in Anambra state, southeast Nigeria. A standardized proforma was used to collect facility-level data from the facility registers on MCH services to assess the completeness of data from 2 interventions and one control clusters. The facility data was collected to cover before, during, and after the SURE-P intervention activities. Qualitative in-depth interviews were conducted with purposefully-identified health facility workers to identify their views and experiences of changes in data quality throughout the above 3 periods.

RESULTS

Quantitative analysis of the facility data showed that data completeness improved substantially, starting before SURE-P and continuing during SURE-P but across all clusters (ie, including the control). Also health workers felt data completeness were improved during the SURE-P, but declined with the cessation of the programme. We also found that challenges to data completeness are dependent on many variables including a high burden on providers for data collection, many variables to be filled in the data collection tools, and lack of health worker incentives.

CONCLUSION

Quantitative analysis showed improved data completeness and health workers believed the SURE-P/MCH had contributed to the improvement. The functioning of national HMIS are inevitably linked with other health systems components. While health systems strengthening programmes have a great potential for improved overall systems performance, a more granular understanding of their implications on the specific components such as the resultant quality of HMIS data, is needed.

The Role of the Private Sector in the COVID-19 Pandemic: Experiences From Four Health Systems

As societies urbanize, their populations have become increasingly dependent on the private sector for essential services. The way the private sector responds to health emergencies such as the COVID-19 pandemic can determine the health and economic wellbeing of urban populations, an effect amplified for poorer communities. Here we present a qualitative document analysis of media reports and policy documents in four low resource settings-Bangladesh, Ghana, Nepal, Nigeria-between January and September 2020. The review focuses on two questions: (i) Who are the private sector actors who have engaged in the COVID-19 first wave response and what was their role?; and (ii) How have national and sub-national governments engaged in, and with, the private sector response and what have been the effects of these engagements? Three main roles of the private sector were identified in the review. (1) Providing resources to support the public health response. (2) Mitigating the financial impact of the pandemic on individuals and businesses. (3) Adjustment of services delivered by the private sector, within and beyond the health sector, to respond to pandemic-related business challenges and opportunities. The findings suggest that a combination of public-private partnerships, contracting, and regulation have been used by governments to influence private sector involvement. Government strategies to engage the private sector developed quickly, reflecting the importance of private services to populations. However, implementation of regulatory responses, especially in the health sector, has often been weak reflecting the difficulty governments have in ensuring affordable, quality private services. Lessons for future pandemics and other health emergencies include the need to ensure that essential non-pandemic health services in the government and non-government sector can continue despite elevated risks, surge capacity to minimize shortages of vital public health supplies is available, and plans are in place to ensure private workplaces remain safe and livelihoods protected.

The Role of Contextual Factors in Private Sector Engagement: A Case Study of Private Sector Contribution to COVID-19 Mitigation in Nigeria

The Private Sector Coalition against COVID-19 (CACOVID) was established on the 27th of March 2020 to mobilize private sector resources toward supporting the government's response to the COVID-19 pandemic. More specifically, CACOVID set out to provide leadership functions, raise public awareness, provide buy-in for COVID-19 prevention, and provide direct support to strengthen the health system's capacity to respond to the crisis. In this paper, we examine the contextual factors that shaped the private sector's engagement in the fight against the pandemic with a view to identifying progress and learning opportunities. A desk review of the existing literature and documents from relevant stakeholders (government, organized private sector, and civil society organizations) was carried out. Using both the Grindle and Thomas (1) and Husted and Salazar (2) frameworks, we identified individual characteristics (industry expertise and position, philanthropy, and personal/economic interest); the economic crises created by the pandemic; a weak health system; and the multi-sectoral nature of the response to the pandemic.as contextual factors that influenced public-private collaboration in tackling the COVID-19 pandemic in Nigeria. That is, the private sector collaborated with the government based on several interrelated contexts that confront them with issues they need to address; determine what options are feasible politically, economically, and administratively; set limits on what solutions are eventually considered; and respond to efforts to alter existing policies and institutional practices. The identified contextual factors provide learning opportunities for enhancing public-private partnership in advancing healthcare not just in Nigeria, but also in related countries in Africa and other developing countries.

Stakeholders' perceptions of adolescents' sexual and reproductive health needs in Southeast Nigeria: a qualitative study

OBJECTIVES

This study explored the perceptions of adult stakeholders on adolescents sexual and reproductive health (SRH) needs, variations of perceived needs by different social stratifiers and adolescent's perceived interventions to address these needs. This will provide evidence that could be useful for policy and programme reviews for improving access and use of services in to meet the SRH needs of adolescents.

DESIGN

A qualitative cross-sectional study was conducted in Ebonyi state, Southeast, Nigeria. Data were analysed using thematic framework and content analysis approaches.

SETTING AND PARTICIPANTS

This qualitative study was conducted in six selected local government areas in Ebonyi state, Nigeria. The study participants comprised of adult stakeholders including community leaders, adolescent boys and girls aged 13-18 years. Adolescents were purposively selected from schools, skill acquisition centres and workplaces. A total of 77 in-depth interviews, 6 (with community leaders) and 12 (with adolescents) focus group discussions were conducted using pretested question guides.

RESULTS

Adolescent SRH needs were perceived to be unique and special due to their vulnerability, fragility and predisposition to explore new experiences. Recurring adolescent SRH needs were: SRH education and counselling; access to contraceptive services and information. These needs were perceived to vary based on sex, schooling and marital status. Adolescent girls were perceived to have more psychological needs, and more prone to negative health outcomes. Out-of-school adolescents were described as more vulnerable, less controlled, less supervised and more prone to sexual abuse. Unmarried adolescents were perceived more vulnerable to sexual exploitation and risks, while married were perceived to have more maternal health service needs.

CONCLUSIONS

Perceptions of adolescents' SRH needs converge among stakeholders (including adolescents) and are thought to vary by gender, schooling and marital status. This calls for well-designed gender-responsive interventions that also take into consideration other social stratifiers and adolescent's perceived SRH intervention strategies.

Who benefits from tuberculosis outpatient services in Enugu state, Nigeria? A benefit incidence analysis

OBJECTIVES

Nigeria is one of the 30 high-burden countries for TB and currently, recurrent costs of TB treatment services are largely dependent on donor-funding, with government providing the health facilities. This study aims to assess the benefit incidence of TB treatment services so as to determine if the poor and rural dwellers preferentially benefit from such services that were subsidized by government and donors.

METHODS

A survey of patients (n = 202) accessing TB treatment services was conducted between 2019 and 2020 in five purposively selected rural and urban health facilities in Enugu state. Socio-economic status (SES) was estimated using household assets ownership. Benefits of TB services were measured by multiplying the unit cost of utilization of different services while the net benefit was calculated by subtracting out-of-pocket (OOP) payments incurred from the benefits. We estimated the benefit for 1 month and the benefit for the whole TB treatment course (6 months). Concentration index was used to determine the level of equity in spending across the socio-economic quintiles.

RESULTS

56.4% of the respondents were from urban facilities. 100% had used TB drugs in the past months, 73% had undergone a Gene-Xpert test, and 67% had had a consultation. All patients received TB drugs without OOP payment, but 90% paid for X-ray. Urban respondents captured a disproportionally higher share of benefit from TB services. The concentration index was -0.025 for net benefit from TB services across different quintiles, indicating the pro-poor distribution of TB services in Nigeria.

CONCLUSIONS

The benefit from TB services had a pro-poor distribution, but urban respondents obtained a disproportionally higher share of gross and net benefit from TB services. Funding for TB services needs to be secured to promote the equitable access to TB services.

Stakeholders' perspectives and willingness to institutionalize linkages between the formal health system and informal healthcare providers in urban slums in southeast, Nigeria

BACKGROUND

The widely available informal healthcare providers (IHPs) present opportunities to improve access to appropriate essential health services in underserved urban areas in many low- and middle-income countries (LMICs). However, they are not formally linked to the formal health system. This study was conducted to explore the perspectives of key stakeholders about institutionalizing linkages between the formal health systems and IHPs, as a strategy for improving access to appropriate healthcare services in Nigeria.

METHODS

Data was collected from key stakeholders in the formal and informal health systems, whose functions cover the major slums in Enugu and Onitsha cities in southeast Nigeria. Key informant interviews (n = 43) were conducted using semi-structured interview guides among representatives from the formal and informal health sectors. Interview transcripts were read severally, and using thematic content analysis, recurrent themes were identified and used for a narrative synthesis.

RESULTS

Although the dominant view among respondents is that formalization of linkages between IHPs and the formal health system will likely create synergy and quality improvement in health service delivery, anxieties and defensive pessimism were equally expressed. On the one hand, formal sector respondents are pessimistic about limited skills, poor quality of care, questionable recognition, and the enormous challenges of managing a pluralistic health system. Conversely, the informal sector pessimists expressed uncertainty about the outcomes of a government-led supervision and the potential negative impact on their practice. Some of the proposed strategies for institutionalizing linkages between the two health sub-systems include: sensitizing relevant policymakers and gatekeepers to the necessity of pluralistic healthcare; mapping and documenting of informal providers and respective service their areas for registration and accreditation, among others. Perceived threats to institutionalizing these linkages include: weak supervision and monitoring of informal providers by the State Ministry of Health due to lack of funds for logistics; poor data reporting and late referrals from informal providers; lack of referral feedback from formal to informal providers, among others.

CONCLUSIONS

Opportunities and constraints to institutionalize linkages between the formal health system and IHPs exist in Nigeria. However, there is a need to design an inclusive system that ensures tolerance, dignity, and mutual learning for all stakeholders in the country and in other LMICs.

Examining healthcare purchasing arrangements for strategic purchasing in Nigeria: a case study of the Imo state healthcare system

BACKGROUND

Strategic healthcare purchasing (SHP), as a critical function of health financing, enhances the optimal attainment of health system goals through the efficient use of financial resources. Countries committed to universal health coverage (UHC) have made progress towards strategic purchasing through relevant reforms in their healthcare financing systems. This study examined the purchasing arrangements and practices in the Imo state healthcare system to track progress towards SHP committed to UHC.

METHODS

A critical review and analysis of healthcare financing schemes in Imo state, south-eastern Nigeria, was undertaken to assess their purchasing practices based on a descriptive qualitative case study approach. Relevant documents were collected and reviewed including in-depth interviews with stakeholders. Information was collected on external factors and governance, purchasing practices and other capacities of the state's health financing schemes. The analytical framework was guided by comparing purchasing practices of the financing schemes with the ideal strategic purchasing actions (SPAs) developed by RESYST (Resilient and Responsive Health Systems), based on the three pairs of principal-agent relationships.

RESULTS

Healthcare purchasing in the state is dominated by the State Ministry of Health (SMOH) using a general tax-based and public health system, making government revenue a major source of funding and provision of healthcare services. However, purchasing of health services is passive and the stewardship role of government is significantly weak, characterized by substantial insufficient budgetary allocations, inadequate infrastructure and poor accountability. However, the health benefit package significantly reflects the needs of the population. As an integrated system, there is no purchaser-provider split. Provider selection, monitoring and payment processes do not promote quality and efficiency of service delivery. There is very limited institutional and technical capacity for SHP. However, the state recently established the Imo State Health Insurance Agency (IMSHIA), a social agency whose structure and organization support SHP functions, including benefit packages, provider selection processes, appropriate provider payment mechanisms and regulatory controls.

CONCLUSION

Healthcare purchasing in Imo state remains mostly passive, with very limited strategic purchasing arrangements. The main challenges stem from the entrenched institutional mechanism of passive purchasing in the government's health budgets that are derived from general tax revenue, lack of purchaser-provider split, and poor provider payment and performance monitoring mechanisms. The establishment of the social insurance agency represents an opportunity for boosting SHP in the state for enhanced progress towards UHC. Building capacity and awareness of the benefits of SHP among policy-makers and programme managers will improve the efficiency and equity of health purchasing in the state.

Population health outcomes in Nigeria compared with other west African countries, 1998-2019: a systematic analysis for the Global Burden of Disease Study

BACKGROUND

Population-level health and mortality data are crucial for evidence-informed policy but scarce in Nigeria. To fill this gap, we undertook a comprehensive assessment of the burden of disease in Nigeria and compared outcomes to other west African countries.

METHODS

In this systematic analysis, using data and results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we analysed patterns of mortality, years of life lost (YLLs), years lived with disability (YLDs), life expectancy, healthy life expectancy (HALE), and health system coverage for Nigeria and 15 other west African countries by gender in 1998 and 2019. Estimates of all-age and age-standardised disability-adjusted life-years for 369 diseases and injuries and 87 risk factors are presented for Nigeria. Health expenditure per person and gross domestic product were extracted from the World Bank repository.

FINDINGS

Between 1998 and 2019, life expectancy and HALE increased in Nigeria by 18% to 64·3 years (95% uncertainty interval [UI] 62·2-66·6), mortality reduced for all age groups for both male and female individuals, and health expenditure per person increased from the 11th to third highest in west Africa by 2018 (US$18·6 in 2001 to $83·75 in 2018). Nonetheless, relative outcomes remained poor; Nigeria ranked sixth in west Africa for age-standardised mortality, seventh for HALE, tenth for YLLs, 12th for health system coverage, and 14th for YLDs in 2019. Malaria (5176·3 YLLs per 100 000 people, 95% UI 2464·0-9591·1) and neonatal disorders (4818·8 YLLs per 100 000, 3865·9-6064·2) were the leading causes of YLLs in Nigeria in 2019. Nigeria had the fourth-highest under-five mortality rate for male individuals (2491·8 deaths per 100 000, 95% UI 1986·1-3140·1) and female individuals (2117·7 deaths per 100 000, 1756·7-2569·1), but among the lowest mortality for men older than 55 years. There was evidence of a growing non-communicable disease burden facing older Nigerians.

INTERPRETATION

Health outcomes remain poor in Nigeria despite higher expenditure since 2001. Better outcomes in countries with equivalent or lower health expenditure suggest health system strengthening and targeted intervention to address unsafe water sources, poor sanitation, malnutrition, and exposure to air pollution could substantially improve population health.

FUNDING

The Bill & Melinda Gates Foundation.

Strategic Health Purchasing in Nigeria: Investigating Governance and Institutional Capacities within Federal Tax-Funded Health Schemes and the Formal Sector Social Health Insurance Programme

For Nigeria to make progress on its commitment to universal health coverage, additional public funding will be required. But more resources alone will not be enough. Government health spending must be more efficient and effective, through more strategic purchasing-a critical policy tool. Studies on health purchasing in Nigeria's health financing schemes are limited, however. This study examines the purchasing arrangements in schemes funded by the federal budget and in the Formal Sector Social Health Insurance Programme (FSSHIP) within the National Health Insurance Scheme. We adopted a qualitative, descriptive case-study approach and collected data through document reviews and key informant interviews based on the Strategic Health Purchasing Progress Tracking Framework. Our analysis used a thematic framework approach. Our findings reveal that legal frameworks and governance structures for strategic purchasing are in place for both schemes. Steps toward strategic purchasing are more advanced in FSSHIP, particularly in the design of benefit packages, accreditation and monitoring of health maintenance organizations (HMOs) and providers, and provider payment mechanisms. The limited share of health funding flowing through these mechanisms, and further fragmentation of that funding, impede strategic purchasing. Strategic purchasing is also hampered by weak regulation and monitoring of providers and purchasers, delays in provider payment, and corrupt practices by HMOs. Improving strategic purchasing in Nigeria will require a concerted effort to reduce fragmentation of health spending, significant investment in human resources, technical know-how, and information systems of purchasing institutions, and actions to improve the accountability of all actors in the system.

Strategic Health Purchasing in Nigeria: Exploring the Evidence on Health System and Service Delivery Improvements

Well-functioning purchasing arrangements allocate pooled funds to health providers, and are expected to deliver efficient, effective, quality, equitable and responsive health services and advance progress toward universal health coverage (UHC). This paper explores how improvements in purchasing functions in three Nigerian schemes-the Formal Sector Social Health Insurance Program (FSSHIP), the Saving One Million Lives Program for Results (SOML PforR), and Enugu State's Free Maternal and Child Health Program (FMCHP)-may have contributed to better resource allocation, incentives for performance, greater accountability and improved service delivery. The paper uses a case-study approach, with data analyzed using the Strategic Health Purchasing Progress Tracking Framework. Data were collected through review of program documents and published research articles, and semi-structured interviews of 33 key informant interviews. Findings were triangulated within each case study across the multiple sources of information. Improvements in benefits specification and provider payment contributed to some service delivery improvements in all three schemes: higher satisfaction with the quality of care in FSSHIP; increased use of insecticide-treated nets; greater prevention of mother-to-child HIV transmission; expanded pentavalent-3 coverage in SOML PforR; and greater service utilization in FMCHP. Resource allocation to public health facilities was enhanced and lines of accountability were better defined. These scheme-level improvements have not translated to system change, because of the small amount of funding flowing through these schemes and the high level of health financing fragmentation. The institutionalization of strategic purchasing in Nigeria to advance UHC will require raising awareness among decision makers, strengthening purchasing agencies' capacity, and reducing fragmentation.

Can Strategic Health Purchasing Reduce Inefficiency and Corruption in the Health Sector? The Case of Nigeria

Despite limited government budgets for health in many sub-Saharan African countries, some countries have improved health outcomes at low cost by being strategic in allocating and spending available resources. Strategic health purchasing is receiving increasing attention as a way to improve health system performance within financial constraints. Health purchasing, one of the health financing functions of health systems, is the transfer of pooled funds to health providers to deliver covered services. Strategic health purchasing uses evidence and information about population health needs and health provider performance to make decisions about which health services should have priority for public funding, which providers will provide these services, and how and how much providers will be paid to deliver those services. Strategic purchasing has enabled some countries to make progress on health sector goals while improving efficiency, equity, transparency, and accountability. However, when countries have high levels of corruption and low levels of accountability, as in Nigeria, strategic purchasing may be less effective and more money for health may not yield the expected public health benefits. This commentary uses the Strategic Health Purchasing Progress Tracking Framework developed by the Strategic Purchasing Africa Resource Center (SPARC) and its technical partners to examine health purchasing functions in Nigeria's main health financing schemes, how corruption affects the effectiveness of health purchasing in Nigeria, and opportunities to use strategic purchasing as a tool to address corruption in health financing by improving the transparency and accountability of health resource allocation and use.

Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation

Background

Community health workers play an important role in linking communities with formal health service providers, thereby improving access to and utilization of health care. A novel cadre of community health workers known as village health workers (VHWs) were recruited to create demand for maternal health services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In this study, we investigated the role of contextual factors and underlying mechanisms motivating VHWs.

Methods

We used realist evaluation to understand the impact of a multi-intervention maternal and child health programme on VHW motivation using Anambra State as a case study. Initial working theories and logic maps were developed through literature review and stakeholder engagement; programme theories were developed and tested using focus group discussions and in-depth interviews with various stakeholder groups. Interview transcripts were analysed through an integrated approach of Context, Mechanism and Outcomes (CMO) categorisation and connecting, and matching of patterns of CMO configurations. Motivation theories were used to explain factors that influence VHW motivation. Explanatory configurations are reported in line with RAMESES reporting standards.

Results

The performance of VHWs in the SURE-P maternal and child health programme was linked to four main mechanisms of motivation: feelings of confidence, sense of identity or feeling of acceptance, feeling of happiness and hopefulness/expectation of valued outcome. These mechanisms were triggered by interactions of programme-specific contexts and resources such as training and supervision of VHWs by skilled health workers, provision of first aid kits and uniforms, and payments of a monthly stipend. The monthly payment was considered to be the most important motivational factor by VHWs. VHWs used a combination of innovative approaches to create demand for maternity services among pregnant women, and their performance was influenced by health system factors such as organisational capacity and culture, and societal factors such as relationship with the community and community support.

Conclusion

This paper highlights important contextual factors and mechanisms for VHW motivation that can be applied to other interventions that seek to strengthen community engagement and demand creation in primary health care. Future research on how to sustain VHW motivation is also required.