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Mensah K, Mosquera I, Tisler A, Üuskula A, Firmino-Machado J, Lunet N, Nicula F, Tăut D, Baban A, Basu P. Development and pilot implementation of a novel protocol to assess capacity and readiness of health systems to adopt HPV detection-based cervical cancer screening in Europe. Health Res Policy Syst 2024; 22:102. [PMID: 39135116 PMCID: PMC11318142 DOI: 10.1186/s12961-024-01190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 07/20/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND Cervical cancer remains a significant public health concern in Europe. Effective introduction and scaling up of human papillomavirus (HPV) detection-based cervical cancer screening (CCS) requires a systematic assessment of health systems capacity. However, there is no validated capacity assessment methodology for CCS programmes, especially in European contexts. Addressing this gap, our study introduces an innovative and adaptable protocol for evaluating the capacity of CCS programmes across varying European health system settings. METHODS Our research team developed a three-step capacity assessment framework, incorporating a health policy review checklist, a facility visit survey, and key informants' interview guide followed by a strengths, weaknesses, opportunities and threats (SWOT) analysis. Piloting this comprehensive approach, we explored the CCS capacity in three countries: Estonia, Portugal and Romania. These countries were selected due to their contrasting healthcare structures and resources, providing a diverse overview of the European context. RESULTS Conducted over a period of 9 months, the capacity assessment covered multiple resources, 27 screening centres, 16 colposcopy and treatment centres and 15 key informant interviews. Our analysis highlighted both shared and country-specific challenges. A key common issue was ensuring high compliance to follow-up and management of screen-positive women. We identified considerable heterogeneity in resources and organization across the three countries, underscoring the need for tailored, rather than one-size-fits-all, solutions. CONCLUSIONS Our study's novelty lies in the successful development of this capacity assessment methodology implementable within a relatively short time frame, proving its feasibility for use in various contexts and countries. The resulting set of materials, adaptable to different cancer types, is a ready-to-use toolkit to improve cancer screening processes and outcomes. This research marks a significant stride towards comprehensive capacity assessment for CCS programmes in Europe. Future directions include deploying these tools in other countries and cancer types, thereby contributing to the global fight against cancer.
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Affiliation(s)
- Keitly Mensah
- Early Detection, Prevention, and Infections Branch, International Agency for Research On Cancer, 25 Avenue Tony Garnier, 69366, Lyon Cedex 07, France
| | - Isabel Mosquera
- Early Detection, Prevention, and Infections Branch, International Agency for Research On Cancer, 25 Avenue Tony Garnier, 69366, Lyon Cedex 07, France.
| | | | | | - João Firmino-Machado
- Instituto de Saúde Pública da Universidade Do Porto, Porto, Portugal
- Departamento de Ciências Médicas, Universidade de Aveiro, Aveiro, Portugal
| | - Nuno Lunet
- Instituto de Saúde Pública da Universidade Do Porto, Porto, Portugal
| | | | - Diana Tăut
- Universitatea Babes Bolyai, Cluj-Napoca, Romania
| | | | - Partha Basu
- Early Detection, Prevention, and Infections Branch, International Agency for Research On Cancer, 25 Avenue Tony Garnier, 69366, Lyon Cedex 07, France
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Ogbozor PA, Hutchinson E, Goodman C, McKee M, Onwujekwe O, Balabanova D. The nature, drivers and equity consequences of informal payments for maternal and child health care in primary health centres in Enugu, Nigeria. Health Policy Plan 2023; 38:ii62-ii71. [PMID: 37995265 PMCID: PMC10666910 DOI: 10.1093/heapol/czad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 11/25/2023] Open
Abstract
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.
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Affiliation(s)
- Pamela Adaobi Ogbozor
- Department of Psychology, Enugu State University of Science and Technology, PMB 01600, Agbani, Enugu, Nigeria
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, PMB 01129, Enugu, Nigeria
| | - Eleanor Hutchinson
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Catherine Goodman
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, PMB 01129, Enugu, Nigeria
- Department of Health Administration and Management, University of Nigeria, Enugu Campus, PMB 410001, Enugu, Nigeria
| | - Dina Balabanova
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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Etiaba E, Eboreime EA, Dalglish SL, Lehmann U. Aspirations and realities of intergovernmental collaboration in national- level interventions: insights from maternal, neonatal and child health policy processes in Nigeria, 2009-2019. BMJ Glob Health 2023; 8:bmjgh-2022-010186. [PMID: 36810159 PMCID: PMC9945032 DOI: 10.1136/bmjgh-2022-010186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/05/2023] [Indexed: 02/23/2023] Open
Abstract
In Nigeria's federal government system, national policies assign concurrent healthcare responsibilities across constitutionally arranged government levels. Hence, national policies, formulated for adoption by states for implementation, require collaboration. This study examines collaboration across government levels, tracing implementation of three maternal, neonatal and child health (MNCH) programmes, developed from a parent integrated MNCH strategy, with intergovernmental collaborative designs, to identify transferable principles to other multilevel governance contexts, especially low-income countries.National-level setting was Abuja, where policymaking is domiciled, while two subnational implementation settings (Anambra and Ebonyi states) were selected based on their MNCH contexts. A qualitative case study triangulated information from 69 documents and 44 in-depth interviews with national and subnational policymakers, technocrats, academics and implementers. Emerson's integrated collaborative governance framework was applied thematically to examine how governance arrangements across the national and subnational levels impacted policy processes.The results showed that misaligned governance structures constrained implementation. Specific governance characteristics (subnational executive powers, fiscal centralisation, nationally designed policies, among others) did not adequately generate collaboration dynamics for collaborative actions. Collaborative signing of memoranda of understanding happened passively, but the contents were not implemented. Neither state adhered to programme goals, despite contextual variations, because of an underlying disconnect in the national governance structure.Collaboration across government levels could be better facilitated via full devolution of responsibilities by national authorities to subnational governments, with the national level providing independent evaluation and guidance only. Given the existing fiscal structure, innovative reforms which hold government levels accountable should be linked to fiscal transfers. Sustained advocacy and context-specific models of achieving distributed leadership across government levels are required across similar resource-limited countries. Stakeholders should be aware of what drivers are available to them for collaboration and what needs to be built within the system context.
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Affiliation(s)
- Enyi Etiaba
- SOPH, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa .,Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu, Nigeria
| | | | - Sarah L Dalglish
- Department of International Health, University College London, London, UK,Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Uta Lehmann
- SOPH, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa,South African Medical Research Council, Tygerberg, South Africa
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Buitendyk M, Kosgei W, Thorne J, Millar H, Alera JM, Kibet V, Bernard CO, Payne BA, Bernard C, Christoffersen-Deb A. Impact of free maternity services on outcomes related to hypertensive disorders of pregnancy at Moi Teaching and Referral Hospital in Kenya: a retrospective analysis. BMC Pregnancy Childbirth 2023; 23:98. [PMID: 36747137 PMCID: PMC9901094 DOI: 10.1186/s12884-023-05381-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 09/27/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Preeclampsia is a major contributor to maternal and neonatal mortality worldwide. Ninety-nine percent of these deaths occur in resource limited settings. One of the greatest barriers to women seeking medical attention remains the cost of care. Kenya implemented a nation-wide policy change in 2013, offering free inpatient maternity services to all women to address this concern. Here, we explore the impact of this policy change on maternal and neonatal outcomes specific to the hypertensive disorders of pregnancy. METHODS We conducted a retrospective cross-sectional chart review of patients discharged or deceased with a diagnosis of gestational hypertension, preeclampsia, eclampsia or HELLP syndrome at a tertiary referral center in western Kenya one year before (June 1, 2012-May 31, 2013) and one year after (June 1, 2013-May 31, 2014) free maternity services were introduced at public facilities across the country. Demographic information, obstetric history, medical history, details of the current pregnancy, diagnosis on admission and at discharge, antepartum treatment, maternal outcomes, and neonatal outcomes were collected and comparisons were made between the time points. RESULTS There were more in hospital births after policy change was introduced. The proportion of women diagnosed with a hypertensive disorder of pregnancy was higher in the year before free maternity care although there was a statistically significant increase in the proportion of women diagnosed with gestational hypertension after policy change. Among those diagnosed with hypertensive disorders, there was no difference in the proportion who developed obstetric or medical complications. Of concern, there was a statistically significant increase in the proportion of women dying as a result of their condition. There was a statistically significant increase in the use of magnesium sulfate for seizure prophylaxis. There was no overall difference in the use of anti-hypertensives between groups and no overall difference in the proportion of women who received dexamethasone for fetal lung maturity. CONCLUSIONS Free maternity services, however necessary, are insufficient to improve maternal and neonatal outcomes related to the hypertensive disorders of pregnancy at a tertiary referral center in western Kenya. Multiple complementary strategies acting in unison are urgently needed.
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Affiliation(s)
- Marie Buitendyk
- School of Medicine, Department of Obstetrics and Gynecology, University of Toronto, 27 King's College Circle, Toronto, ON, M5S, Canada. .,Moi Teaching and Referral Hospital, Eldoret, Kenya.
| | - Wycliffe Kosgei
- grid.513271.30000 0001 0041 5300Moi Teaching and Referral Hospital, Eldoret, Kenya ,grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Obstetrics and Gynecology, Moi University, Eldoret, Kenya
| | - Julie Thorne
- grid.17063.330000 0001 2157 2938School of Medicine, Department of Obstetrics and Gynecology, University of Toronto, 27 King’s College Circle, Toronto, ON M5S Canada ,grid.513271.30000 0001 0041 5300Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Heather Millar
- grid.17063.330000 0001 2157 2938School of Medicine, Department of Obstetrics and Gynecology, University of Toronto, 27 King’s College Circle, Toronto, ON M5S Canada
| | - Joy Marsha Alera
- grid.512535.50000 0004 4687 6948AMPATH (Academic Model Providing Access to Health Care) Kenya, P.O. Box 4606, Eldoret, Kenya
| | - Vincent Kibet
- grid.513271.30000 0001 0041 5300Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Christian Ochieng Bernard
- grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Obstetrics and Gynecology, Moi University, Eldoret, Kenya
| | - Beth A. Payne
- grid.17091.3e0000 0001 2288 9830School of Medicine, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia V6T 1Z4 Canada
| | - Caitlin Bernard
- grid.513271.30000 0001 0041 5300Moi Teaching and Referral Hospital, Eldoret, Kenya ,grid.411377.70000 0001 0790 959XSchool of Medicine, Department of Obstetrics and Gynecology, Indiana University, 107 S Indiana Ave, Bloomington, IN 47405 USA
| | - Astrid Christoffersen-Deb
- grid.513271.30000 0001 0041 5300Moi Teaching and Referral Hospital, Eldoret, Kenya ,grid.17091.3e0000 0001 2288 9830School of Medicine, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia V6T 1Z4 Canada
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Kesale AM, Mahonge C, Muhanga M. Effects of decentralization on the functionality of health facility governing committees in lower and middle-income countries: a systematic literature review. Glob Health Action 2022; 15:2074662. [PMID: 35960165 PMCID: PMC9377249 DOI: 10.1080/16549716.2022.2074662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/02/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Health facility governing committees (HFGCs) were established by lower and middle-income countries (LMICs) to facilitate community participation at the primary facility level to improve health system performance. However, empirical evidence on their effects under decentralization reform on the functionality of HFGCs is scant and inconclusive. OBJECTIVE This article reviews the effects of decentralization on the functionality of HFGCs in LMICs. METHODS A systematic literature review was conducted using various search engines to obtain a total number of 24 relevant articles from 14 countries published between 2000 and 2020. Inclusion criteria include studies must be on community health committees, carried out under decentralization, HFGCs operating at the individual facility, effects of HFGCs on health performance or health outcomes and peer-reviewed empirical studies conducted in LMICs. RESULTS The study has found varied functionality of HFGCs under a decentralization context. The study has found many HFGCs to have very low functionality, while a few HFGCs in other LMICs countries are performing very well. The context and decentralization type, members' awareness of their roles, membership allowance and availability of resource to the facility in which HFGCs operate to produce the desired outcomes play a significant role in facilitating/limiting them to effectively carry out the devolved duties and responsibilities. CONCLUSION Fiscal decentralization has largely been seen as important in making health committees more autonomous, even though it does not guarantee the performance of HFGCs.
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Affiliation(s)
- Anosisye M Kesale
- Department of Local Government Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania
| | - Christopher Mahonge
- Department of Policy Planning and Management, College of Social Sciences and Humanities, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Mikidadi Muhanga
- Department of Development Studies, College of Social Sciences and Humanities, Sokoine University of Agriculture, Morogoro, Tanzania
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Komolafe AO, Oyelade OO, Adedini SA, Irinoye OO. Understanding context in the implementation of emergency obstetric and neonatal care in health facilities in Osun State, Nigeria- a mixed-methods study. BMC Pregnancy Childbirth 2022; 22:934. [PMID: 36514021 PMCID: PMC9746005 DOI: 10.1186/s12884-022-05278-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Successful implementation of Emergency Obstetric and Neonatal Care (EmONC) is likely to improve pregnancy outcomes and is essential for quality maternity care. Context in implementation is described as factors that enabled or disabled implementation of interventions. While the context of implementation is important for the effectiveness of evidence-based interventions, the context of EmONC implementation has not been widely studied in Nigeria. METHODS The research design was cross-sectional descriptive. A mixed-methods approach was used to assess and explore the context of implementing EmONC in referral centres in Osun state. A purposive sampling technique was used to select the three tertiary health facilities in Osun State and six secondary health facilities from the six administrative zones in the State. A total of 186 healthcare providers in these referral centres participated in the quantitative part of the study, and eighteen in-depth interviews were conducted for its qualitative aspect. An adapted questionnaire from Context Assessment Index and an interview guide were used to collect data. Quantitative data were analysed using descriptive and inferential statistics at 0.05 significance level, while qualitative data were analysed using the thematic approach. RESULTS The percentage mean score of context strength in EmONC implementation was 63% ± 10.46 in secondary and 68% ± 10.47 in tertiary health facilities. There was a significant difference in the leadership (F (1, 184) = 8.35, p < 0.01), evaluation (F (1, 184) = 5.35, p = 0.02) and overall context (F (1, 184) = 6.46, p = 0.01) of EmONC implementation in secondary and tertiary health facilities. Emerging themes in EmONC context were: Resources for EmONC implementation; Demand for EmONC; Efficiency of funding; Institutional leadership; and Performance evaluation. CONCLUSIONS The context of EmONC implementation in the referral health facilities was generally weak. The secondary health facilities' weaknesses were worse compared to the tertiary health facilities. The five key contextual factors could inform strategies for improving EmONC implementation in health facilities to ensure improved access to care that will reduce deaths from obstetric complications in Nigeria.
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Affiliation(s)
| | | | - Sunday Adepoju Adedini
- Demography and Social Statistics Department, Federal University Oye-Ekiti, Oye-Ekiti, Nigeria
- Demography and Population Studies Programme, Schools of Public Health and Social Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Odii A, Onwujekwe O, Hutchinson E, Agwu P, Orjiakor CT, Ogbozor P, Roy P, McKee M, Balabanova D. Absenteeism in primary health centres in Nigeria: leveraging power, politics and kinship. BMJ Glob Health 2022; 7:bmjgh-2022-010542. [PMID: 36593645 PMCID: PMC9730370 DOI: 10.1136/bmjgh-2022-010542] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Aloysius Odii
- Sociology/Anthropology, University of Nigeria, Nsukka, Nigeria
| | - Obinna Onwujekwe
- Health Administration & Management and Pharmacology and Therapeutics, University of Nigeria - Enugu Campus, Enugu, Nigeria
| | - Eleanor Hutchinson
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Prince Agwu
- Social Work, University of Nigeria, Nsukka, Nigeria
| | | | - Pamela Ogbozor
- Psychology, Enugu State University of Science and Technology, Enugu, Nigeria
| | - Pallavi Roy
- Centre for International Studies and Diplomacy, SOAS, London, UK
| | - Martin McKee
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Dina Balabanova
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Koduah A, Baatiema L, de Chavez AC, Danso-Appiah A, Kretchy IA, Agyepong IA, King N, Ensor T, Mirzoev T. Implementation of medicines pricing policies in sub-Saharan Africa: systematic review. Syst Rev 2022; 11:257. [PMID: 36457058 PMCID: PMC9714131 DOI: 10.1186/s13643-022-02114-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/02/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND High medicine prices contribute to increasing cost of healthcare worldwide. Many patients with limited resources in sub-Saharan Africa (SSA) are confronted with out-of-pocket charges, constraining their access to medicines. Different medicine pricing policies are implemented to improve affordability and availability; however, evidence on the experiences of implementations of these policies in SSA settings appears limited. Therefore, to bridge this knowledge gap, we reviewed published evidence and answered the question: what are the key determinants of implementation of medicines pricing policies in SSA countries? METHODS We identified policies and examined implementation processes, key actors involved, contextual influences on and impact of these policies. We searched five databases and grey literature; screening was done in two stages following clear inclusion criteria. A structured template guided the data extraction, and data analysis followed thematic narrative synthesis. The review followed best practices and reported using PRISMA guidelines. RESULTS Of the 5595 studies identified, 31 met the inclusion criteria. The results showed thirteen pricing policies were implemented across SSA between 2003 and 2020. These were in four domains: targeted public subsides, regulatory frameworks and direct price control, generic medicine policies and purchasing policies. Main actors involved were government, wholesalers, manufacturers, retailers, professional bodies, community members and private and public health facilities. Key contextual barriers to implementation were limited awareness about policies, lack of regulatory capacity and lack of price transparency in external reference pricing process. Key facilitators were favourable policy environment on essential medicines, strong political will and international support. Evidence on effectiveness of these policies on reducing prices of, and improving access to, medicines was mixed. Reductions in prices were reported occasionally, and implementation of medicine pricing policy sometimes led to improved availability and affordability to essential medicines. CONCLUSIONS Implementation of medicine pricing policies in SSA shows some mixed evidence of improved availability and affordability to essential medicines. It is important to understand country-specific experiences, diversity of policy actors and contextual barriers and facilitators to policy implementation. Our study suggests three policy implications, for SSA and potentially other low-resource settings: avoiding a 'one-size-fits-all' approach, engaging both private and public sector policy actors in policy implementation and continuously monitoring implementation and effects of policies. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020178166.
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Affiliation(s)
- Augustina Koduah
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Accra, Ghana.
| | - Leonard Baatiema
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Anna Cronin de Chavez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Anthony Danso-Appiah
- Department of Epidemiology and Disease Control, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Irene A Kretchy
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | | | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Timothy Ensor
- Nuffield Centre for International Health, University of Leeds, Leeds, UK
| | - Tolib Mirzoev
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Ogbuabor DC, Ghasi N, Nwangwu N, Okenwa UJ, Ezenwaka U, Onwujekwe O. Stakeholders' perspectives on internal accountability within a sub-national immunization program: A qualitative study in Enugu State, South-East Nigeria. Niger J Clin Pract 2022; 25:2030-2038. [PMID: 36537462 DOI: 10.4103/njcp.njcp_522_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- D C Ogbuabor
- Department of Health Administration and Management; Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - N Ghasi
- Department of Management, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - N Nwangwu
- Department of Sociology, Enugu State University of Science and Technology, Enugu, Nigeria
| | - U J Okenwa
- Enugu State Ministry of Health, Enugu, Nigeria
| | - U Ezenwaka
- Department of Health Administration and Management; Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - O Onwujekwe
- Department of Health Administration and Management; Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Nsukka, Nigeria
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Ezenwaka U, Abimbola S, Onwujekwe O. 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. Int J Health Plann Manage 2022; 37:3192-3204. [PMID: 35975682 DOI: 10.1002/hpm.3548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/21/2022] [Accepted: 07/11/2022] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Uchenna Ezenwaka
- Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu-Campus, Enugu, Nigeria
| | - Seye Abimbola
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria Enugu-Campus, Enugu, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu-Campus, Enugu, Nigeria
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11
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Odjidja EN, Ansah-Akrofi R, Iradukunda A, Kwanin C, Saha M. The effect of health financing reforms on incidence and management of childhood infections in Ghana: a matching difference in differences impact evaluation. BMC Public Health 2022; 22:1494. [PMID: 35932052 PMCID: PMC9354374 DOI: 10.1186/s12889-022-13934-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 08/01/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction In 2003, Ghana abolished direct out of pockets payments and implemented health financing reforms including the national health insurance scheme in 2004. Treatment of childhood infections is a key component of services covered under this scheme, yet, outcomes on incidence and treatment of these infections after introducing these reforms have not been covered in evaluation studies. This study fills this gap by assessing the impact on the reforms on the two most dominant childhood infections; fever (malaria) and diarrhoea. Methods Nigeria was used as the control country with pre-intervention period of 1990 and 2003 and 1993 and 1998 in Ghana. Post-intervention period was 2008 and 2014 in Ghana and 2008 and 2018 in Nigeria. Data was acquired from demographic health surveys in both countries and propensity score matching was calculated based on background socioeconomic covariates. Following matching, difference in difference analysis was conducted to estimate average treatment on the treated effects. All analysis were conducted in STATA (psmatch2, psgraph and pstest) and statistical significance was considered when p-value ≤ 0.05. Results After matching, it was determined that health reforms significantly increased general medical care for children with diarrhoea (25 percentage points) and fever (40 percentage points). Also for those receiving care specifically in government managed facilities for diarrhoea (14 percentage points) and fever (24 percentage points). Conclusions Introduction of health financing reforms in Ghana had positive effects on childhood infections (malaria and diarrhoea).
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Affiliation(s)
- Emmanuel Nene Odjidja
- Department of Monitoring and Evaluation, Kigutu Village Health Works, Kirungu, Burundi.
| | - Ruth Ansah-Akrofi
- Department of Statistics and Computer Science, University of Ghana, Accra, Ghana
| | | | - Charles Kwanin
- Ghana Health Service, University of Geneva, Geneva, Switzerland
| | - Manika Saha
- Faculty of Information Technology, Monash University, Melbourne, Australia
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12
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Dasgupta RR, Mao W, Ogbuoji O. Addressing child health inequity through case management of under-five malaria in Nigeria: an extended cost-effectiveness analysis. Malar J 2022; 21:81. [PMID: 35264153 PMCID: PMC8905868 DOI: 10.1186/s12936-022-04113-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 03/02/2022] [Indexed: 11/27/2022] Open
Abstract
Background Under-five malaria in Nigeria is a leading cause of global child mortality, accounting for 95,000 annual child deaths. High out-of-pocket medical expenditure contributes to under-five malaria mortality by discouraging care-seeking and use of effective anti-malarials in the poorest households. The significant inequity in child health outcomes in Nigeria stresses the need to evaluate the outcomes of potential interventions across socioeconomic lines. Methods Using a decision tree model, an extended cost-effectiveness analysis was done to determine the effects of subsidies covering the direct and indirect costs of case management of under-five malaria in Nigeria. This analysis estimates the number of child deaths averted, out-of-pocket (OOP) expenditure averted, cases of catastrophic health expenditure (CHE) averted, and cost of implementation. An optimization analysis was also done to determine how to optimally allocate money across wealth groups using different combinations of interventions. Results Fully subsidizing direct medical, non-medical, and indirect costs could annually avert over 19,000 under-five deaths, 8600 cases of CHE, and US$187 million in OOP spending. Per US$1 million invested, this corresponds to an annual reduction of 76 under-five deaths, 34 cases of CHE, and over US$730,000 in OOP expenditure. Due to low initial treatment coverage in poorer socioeconomic groups, health and financial-risk protection benefits would be pro-poor, with the poorest 40% of Nigerians accounting for 72% of all deaths averted, 55% of all OOP expenditure averted, and 74% of all cases of CHE averted. Subsidies targeted to the poor would see greater benefits per dollar spent than broad, non-targeted subsidies. In an optimization scenario, the strategy of fully subsidizing direct medical costs would be dominated by a partial subsidy of direct medical costs as well as a full subsidy of direct medical, nonmedical, and indirect costs. Conclusion Subsidizing case management of under-five malaria for the poorest and most vulnerable would reduce illness-related impoverishment and child mortality in Nigeria while preserving limited financial resources. This study is an example of how focusing a targeted policy-intervention on a single, high-burden disease can yield large health and financial-risk protection benefits in a low and middle-income country context and address equity consideration in evidence-informed policymaking. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04113-w.
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Affiliation(s)
- Rishav Raj Dasgupta
- Trinity College of Arts and Sciences, Duke University, Durham, NC, USA. .,Center for Policy Impact in Global Health at Duke Global Health Institute, Durham, NC, USA.
| | - Wenhui Mao
- Center for Policy Impact in Global Health at Duke Global Health Institute, Durham, NC, USA
| | - Osondu Ogbuoji
- Center for Policy Impact in Global Health at Duke Global Health Institute, Durham, NC, USA. .,Duke Margolis Center for Health Policy, Durham, NC, USA.
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13
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Onwujekwe O, Mbachu CO, Okeke C, Ezenwaka U, Ogbuabor D, Ezenduka C. Strategic Health Purchasing in Nigeria: Exploring the Evidence on Health System and Service Delivery Improvements. Health Syst Reform 2022; 8:2111785. [PMID: 35993994 DOI: 10.1080/23288604.2022.2111785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
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.
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Affiliation(s)
- Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Chinyere Ojiugo Mbachu
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Chinyere Okeke
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Uchenna Ezenwaka
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Daniel Ogbuabor
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Charles Ezenduka
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
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Okonofua F, Ntoimo LF, Yaya S, Igboin B, Solanke O, Ekwo C, Johnson EAK, Sombie I, Imongan W. Effect of a multifaceted intervention on the utilisation of primary health for maternal and child health care in rural Nigeria: a quasi-experimental study. BMJ Open 2022; 12:e049499. [PMID: 35135763 PMCID: PMC8830217 DOI: 10.1136/bmjopen-2021-049499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/05/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to determine the effectiveness of a set of multifaceted interventions designed to increase the access of rural women to antenatal, intrapartum, postpartum and childhood immunisation services offered in primary healthcare facilities. DESIGN The study was a separate sample pretest-post-test quasi-experimental research. SETTING The research was conducted in 20 communities and primary health centres in Esan South East and Etsako East Local Government Areas in Edo State in southern Nigeria PARTICIPANTS: Randomly selected sample of ever married women aged 15-45 years. INTERVENTIONS Seven community-led interventions implemented over 27 months, consisting of a community health fund, engagement of transport owners on emergency transport of pregnant women to primary health centres with the use of rapid short message service (SMS), drug revolving fund, community education, advocacy, retraining of health workers and provision of basic equipment. PRIMARY AND SECONDARY OUTCOME MEASURES The outcome measures included the number of women who used the primary health centres for skilled pregnancy care and immunisation of children aged 0-23 months. RESULTS After adjusting for clustering and confounding variables, the odds of using the project primary healthcare centres for the four outcomes were significantly higher at endline compared with baseline: antenatal care (OR 3.87, CI 2.84 to 5.26 p<0.001), delivery care (OR 3.88, CI 2.86 to 5.26), postnatal care (OR 3.66, CI 2.58 to 5.18) and childhood immunisation (OR 2.87, CI 1.90 to 4.33). However, a few women still reported that the cost of services and gender-related issues were reasons for non-use after the intervention. CONCLUSION We conclude that community-led interventions that address the specific concerns of women related to the bottlenecks they experience in accessing care in primary health centres are effective in increasing demand for skilled pregnancy and childcare in rural Nigeria.
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Affiliation(s)
- Friday Okonofua
- Women's Health and Action Research Centre, Benin City, Nigeria
- Centre of Excellence in Reproductive Health Innovation (CERHI), University of Benin, Benin City, Nigeria
| | - Lorretta Favour Ntoimo
- Women's Health and Action Research Centre, Benin City, Nigeria
- Department of Demography and Social Statistics, Federal University Oye-Ekiti, Oye-Ekiti, Nigeria
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
- The George Institute for Global Health, University of Oxford, Oxford, UK
| | - Brian Igboin
- Women's Health and Action Research Centre, Benin City, Nigeria
| | | | - Chioma Ekwo
- Women's Health and Action Research Centre, Benin City, Nigeria
| | | | - Issiaka Sombie
- West African Health Organisation, Bobo-Dioulasso, Burkina Faso
| | - Wilson Imongan
- Women's Health and Action Research Centre, Benin City, Nigeria
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15
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Orangi S, Kairu A, Ondera J, Mbuthia B, Koduah A, Oyugi B, Ravishankar N, Barasa E. Examining the implementation of the Linda Mama free maternity program in Kenya. Int J Health Plann Manage 2021; 36:2277-2296. [PMID: 34382238 PMCID: PMC9290784 DOI: 10.1002/hpm.3298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 07/13/2021] [Accepted: 07/30/2021] [Indexed: 11/11/2022] Open
Abstract
Background In 2013, Kenya introduced a free maternity policy in all public healthcare facilities. In 2016, the Ministry of Health shifted responsibility for the program, now called Linda Mama, to the National Hospital Insurance Fund (NHIF) and expanded access beyond public sector. This study aimed to examine the implementation of the Linda Mama program. Methods We conducted a mixed‐methods cross‐sectional study at the national level and in 20 purposively sampled facilities across five counties in Kenya. We collected data using in‐depth interviews (n = 104), administered patient‐exit questionnaires (n = 108), and carried out document reviews. Qualitative data were analysed using a framework approach while quantitative data were analysed descriptively. Results Linda Mama was designed and resulted in improved accountability and expand benefits. In practice however, beneficiaries did not access some services that were part of the revised benefit package. Second, out of pocket payments were still being incurred by beneficiaries. Health facilities in most counties had lost financial autonomy and had no access to reimbursements from NHIF for services provided; but those with financial autonomy were able to boost facility revenue and enhance service delivery. Further, fund disbursements from NHIF were characterised by delays and unpredictability. Implementation experiences reveal that there was inadequate communication, claim processing challenges and reimbursement rates were deemed insufficient. Conclusions Our findings show that there are challenges associated with the implementation of the Linda Mama program and highlights the need for process evaluations for programs to track implementation, ensure continuous learning, and provide opportunities for course correcting programs' implementation.
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Affiliation(s)
- Stacey Orangi
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya
| | - Angela Kairu
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya
| | | | | | - Augustina Koduah
- Department of Pharmacy Practice and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Boniface Oyugi
- Centre for Health Services Studies, University of Kent, Canterbury, UK.,The University of Nairobi, Kenyatta National Hospital, Nairobi, Kenya
| | | | - Edwine Barasa
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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16
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Udenigwe O, Okonofua FE, Ntoimo LFC, Imongan W, Igboin B, Yaya S. "We have either obsolete knowledge, obsolete equipment or obsolete skills": policy-makers and clinical managers' views on maternal health delivery in rural Nigeria. Fam Med Community Health 2021; 9:e000994. [PMID: 34344765 PMCID: PMC8336186 DOI: 10.1136/fmch-2021-000994] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective of this paper is to explore policy-makers and clinical managers' views on maternal health service delivery in rural Nigeria. DESIGN This is a qualitative study using key informant interviews. Participants' responses were audio recorded and reflective field notes supplemented the transcripts. Data were further analysed with a deductive approach whereby themes were organised based on existing literature and theories on service delivery. SETTING The study was set in Esan South East (ESE) and Etsako East (ETE), two mainly rural local government areas of Edo state, Nigeria. PARTICIPANTS The study participants consisted of 13 key informants who are policy-makers and clinical managers in ESE and ETE in Edo state. Key informants were chosen using a purposeful criterion sampling technique whereby participants were identified because they meet or exceed a specific criterion related to the subject matter. RESULTS Respondents generally depicted maternal care services in primary healthcare centres as inaccessible due to undue barriers of cost and geographic location but deemed it acceptable to women. Respondents' notion of quality of service delivery encompassed factors such as patient-provider relationships, hygienic conditions of primary healthcare centres, availability of skilled healthcare staff and infrastructural constraints. CONCLUSION This study revealed that while some key aspects of service delivery are inadequate in rural primary healthcare centres, there are promising policy reforms underway to address some of the issues. It is important that health officials advocate for strong policies and implementation strategies.
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Affiliation(s)
- Ogochukwu Udenigwe
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
| | - Friday E Okonofua
- Women's Health and Action Research Centre, Benin City, Nigeria
- Centre of Excellence in Reproductive Health Innovation, Benin City, Nigeria
| | - Lorretta F C Ntoimo
- Department of Demography and Social Statistics, Federal University Oye-Ekiti, Ekiti, Nigeria
| | - Wilson Imongan
- Women's Health and Action Research Centre, Benin City, Nigeria
| | - Brian Igboin
- Women's Health and Action Research Centre, Benin City, Nigeria
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada
- The George Institute for Global Health, Imperial College London, London, UK
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Ogbuabor DC, Nwankwor C. Perception of Person-Centred Maternity Care and Its Associated Factors Among Post-Partum Women: Evidence From a Cross-Sectional Study in Enugu State, Nigeria. Int J Public Health 2021; 66:612894. [PMID: 34335137 PMCID: PMC8284591 DOI: 10.3389/ijph.2021.612894] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 05/07/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: This study validated a person-centred maternity care (PCMC) scale and assessed perception of PCMC and its associated factors among post-partum women. Methods: A cross-sectional study was conducted among 450 post-partum women in two districts in Enugu State, Nigeria, using a 30-item PCMC scale. Exploratory and confirmatory factor analyses, descriptive, bivariate and Generalized Linear Models analyses were conducted. Results: Twenty-two items were retained in the PCMC scale with high internal reliability and goodness-of-fit indices. About 25% of women received high PCMC. Marrying at 20–29 years (β = 3.46, ρ = 0.017) and 30–49 years (β = −5.56, ρ = 0.020); self-employment (β = −7.50, ρ = 0.005); marrying government worker (β = 7.12, ρ = 0.020); starting antenatal care in the third trimester (β = −6.78, ρ = 0.003); high participation in decision-making (β = −10.41, ρ < 0.001); domestic violence experience (β = 3.60, ρ = 0.007); delivery at health centre (β = 18.10, ρ < 0.001), private/mission hospital (β = 4.01, ρ = 0.003), by non-skilled attendant (β = −16.55, ρ < 0.001) and community health worker (β = −10.30, ρ < 0.001); and pregnancy complication (β = 4.37, ρ = 0.043) influenced PCMC. Conclusion: The PCMC scale is valid and reliable in Nigeria. PCMC requires improvement in Enugu State. This study identified factors that may be considered for inclusion in intervention strategies.
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Affiliation(s)
- Daniel C Ogbuabor
- Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria.,Department of Health Systems and Policy, Sustainable Impact Resource Agency, Enugu, Nigeria
| | - Chikezie Nwankwor
- Department of Health Administration and Management, College of Medicine, University of Nigeria, Enugu, Nigeria
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Uzochukwu B, Onyedinma C, Okeke C, Onwujekwe O, Manzano A, Ebenso B, Etiaba E, Ezuma N, Mirzoev T. What makes advocacy work? Stakeholders' voices and insights from prioritisation of maternal and child health programme in Nigeria. BMC Health Serv Res 2020; 20:884. [PMID: 32948165 PMCID: PMC7501647 DOI: 10.1186/s12913-020-05734-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 09/14/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The Nigerian government introduced and implemented a health programme to improve maternal and child health (MCH) called Subsidy Reinvestment and Empowerment programme for MCH (SURE-P/MCH). It ran from 2012 and ended abruptly in 2015 and was followed by increased advocacy for sustaining the MCH (antenatal, delivery, postnatal and immunization) services as a policy priority. Advocacy is important in allowing social voice, facilitating prioritization, and bringing different forces/actors together. Therefore, the study set out to understand how advocacy works - through understanding what effective advocacy implementation processes comprise and what mechanisms are triggered by which contexts to produce the intended outcomes. METHODS The study used a Realist Evaluation design through a mixed quantitative and qualitative methods case study approach. The programme theory (PT) was developed from three substantive social theories (power politics, media influence communication theory, and the three-streams theory of agenda-setting), data and programme design documentation, and subsequently tested. We report information from 22 key informant interviews including national and State policy and law makers, policy implementers, CSOs, Development partners, NGOs, health professional groups, and media practitioners and review of relevant documents on advocacy events post-SURE-P. RESULTS Key advocacy organizations and individuals including health professional groups, the media, civil society organizations, powerful individuals, and policymakers were involved in advocacy activities. The nature of their engagement included organizing workshops, symposiums, town hall meetings, individual meetings, press conferences, demonstrations, and engagements with media. Effective advocacy mechanism involved alliance brokering to increase influence, the media supporting and engaging in advocacy, and the use of champions, influencers, and spouses (Leadership and Elite Gendered Power Dynamics). The key contextual influences which determined the effectiveness of advocacy measures for MCH included the political cycle, availability of evidence on the issue, networking with powerful and interested champions, and alliance building in advocacy. All these enhanced the entrenchment of MCH on the political and financial agenda at the State and Federal levels. CONCLUSIONS Our result suggest that advocacy can be a useful tool to bring together different forces by allowing expression of voices and ensuring accountability of different actors including policymakers. In the context of poor health outcomes, interest from policymakers and politicians in MCH, combined with advocacy from key policy actors armed with evidence, can improve prioritization and sustained implementation of MCH services.
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Affiliation(s)
- Benjamin Uzochukwu
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Chioma Onyedinma
- Department of Community Medicine, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria
| | - Chinyere Okeke
- Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Obinna Onwujekwe
- Department of Health Administration and Management College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Ana Manzano
- School of Sociology & Social Policy, University of Leeds, Leeds, UK
| | - Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
| | - Enyi Etiaba
- Department of Health Administration and Management College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Nkoli Ezuma
- Health Policy Research Group (HPRG), College of Medicine, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Worsley Building, Clarendon Way, Leeds, UK
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Eze P, Ezenduka C, Obikeze E, Ogbuabor D, Arize I, Ezenwaka U, Onwujekwe O. Examining the distribution of benefits of a free Maternal and Child Health programme in Enugu State, Nigeria: a benefit incidence analysis. Trop Med Int Health 2020; 25:1522-1533. [PMID: 32910555 DOI: 10.1111/tmi.13486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the population groups that benefit from a Free Maternal and Child Health (FMCH) programme in Enugu State, South-east Nigeria, so as to understand the equity effects of the programme. METHOD A community-based survey was conducted in rural and urban local government areas (LGAs) to aid the benefit incidence analysis (BIA) of the FMCH. Data were elicited from 584 randomly selected women of childbearing age. Data on their level of utilisation of FMCH services and their out-of-pocket expenditures on various FMCH services that they utilised were elicited. Benefits of the FMCH were valued using the unit cost of providing services while the net benefit was calculated by subtracting OOP expenditures made for services from the value of benefits. Costs were calculated in local currency (Naira (₦)) and converted to US Dollars. The net benefits were disaggregated by urban-rural locations and socio-economic status (SES). Concentration indices were computed to provide the level of SES inequity in BIA of FMCH. RESULTS The total gross benefit incidence was ₦2.681 million ($7660). The gross benefit that was consumed by the urban dwellers was ₦1.581 million ($4517.1), while the rural dwellers consumed gross benefits worth ₦1.1 million ($3608.20). However, OOP expenditure for the supposedly FMCH was ₦6 527 580 (US$18 650.2) in the urban area, while it was ₦3, 194, 706 (US$ 9127.7) among rural dwellers. There was negative benefit incidence for the FMCH because the OOP exceeded the gross benefits at the point of use of services. There was no statistically significant difference in the benefit incidence and OOP expenditure between the urban and rural dwellers and across socio-economic groups. CONCLUSION The distribution of the gross benefits of the FMCH programme indicates that it may not have achieved the desired aim of enhanced access particularly to the low-income population. Crucially, the high level of OOP erased whatever societal gain the FMCH was developed to provide. Hence, there is a need to review its implementation and re-strategise to reduce OOP and achieve greater access for improved effectiveness of the programme.
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Affiliation(s)
- Philomena Eze
- Department of Nursing, Enugu State University Teaching Hospital, Enugu, Nigeria
| | - Charles Ezenduka
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Eric Obikeze
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Daniel Ogbuabor
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Ifeyinwa Arize
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Uchenna Ezenwaka
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Nsukka, Nigeria
| | - Obinna Onwujekwe
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Nsukka, Nigeria.,Health Policy Research Group, University of Nigeria, Nsukka, Nigeria
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Okoli C, Hajizadeh M, Rahman MM, Khanam R. Geographical and socioeconomic inequalities in the utilization of maternal healthcare services in Nigeria: 2003-2017. BMC Health Serv Res 2020; 20:849. [PMID: 32912213 PMCID: PMC7488161 DOI: 10.1186/s12913-020-05700-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/31/2020] [Indexed: 11/11/2022] Open
Abstract
Background Maternal mortality has remained a challenge in many low-income countries, especially in Africa and in Nigeria in particular. This study examines the geographical and socioeconomic inequalities in maternal healthcare utilization in Nigeria over the period between 2003 and 2017. Methods The study used four rounds of Nigeria Demographic Health Surveys (DHS, 2003, 2008, 2013, and 2018) for women aged 15–49 years old. The rate ratios and differences (RR and RD) were used to measure differences between urban and rural areas in terms of the utilization of the three maternal healthcare services including antenatal care (ANC), facility-based delivery (FBD), and skilled-birth attendance (SBA). The Theil index (T), between-group variance (BGV) were used to measure relative and absolute inequalities in the utilization of maternal healthcare across the six geopolitical zones in Nigeria. The relative and absolute concentration index (RC and AC) were used to measure education-and wealth-related inequalities in the utilization of maternal healthcare services. Results The RD shows that the gap in the utilization of FBD between urban and rural areas significantly increased by 0.3% per year over the study period. The Theil index suggests a decline in relative inequalities in ANC and FBD across the six geopolitical zones by 7, and 1.8% per year, respectively. The BGV results do not suggest any changes in absolute inequalities in ANC, FBD, and SBA utilization across the geopolitical zones over time. The results of the RC and the AC suggest a persistently higher concentration of maternal healthcare use among well-educated and wealthier mothers in Nigeria over the study period. Conclusion We found that the utilization of maternal healthcare is lower among poorer and less-educated women, as well as those living in rural areas and North West and North East geopolitical zones. Thus, the focus should be on implementing strategies that increase the uptake of maternal healthcare services among these groups.
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Affiliation(s)
- Chijioke Okoli
- School of Commerce, and Centre for Health Research, University of Southern Queensland, Toowoomba, QLD, 4350, Australia. .,Department of Health Administration and Management, Faculty of Health Sciences Technology, College of Medicine, University of Nigeria, Enugu Campus, Enugu, Enugu State, Nigeria.
| | | | - Mohammad Mafizur Rahman
- School of Commerce, and Centre for Health Research, University of Southern Queensland, Toowoomba, QLD, 4350, Australia
| | - Rasheda Khanam
- School of Commerce, and Centre for Health Research, University of Southern Queensland, Toowoomba, QLD, 4350, Australia
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Policy context, coherence and disjuncture in the implementation of the Ideal Clinic Realisation and Maintenance programme in the Gauteng and Mpumalanga provinces of South Africa. Health Res Policy Syst 2020; 18:55. [PMID: 32493349 PMCID: PMC7268221 DOI: 10.1186/s12961-020-00567-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 05/04/2020] [Indexed: 11/11/2022] Open
Abstract
Background Universal health coverage is a key target of the Sustainable Development Goals and quality of care is fundamental to its attainment. In South Africa, the National Health Insurance (NHI) system is a major health financing reform towards universal health coverage. The Ideal Clinic Realisation and Maintenance (ICRM) programme aims to improve the quality of care at primary healthcare level in preparation for NHI system implementation. This study draws on Bressers’ Contextual Interaction Theory to explore the wider, structural and specific policy context of the ICRM programme and the influence of this context on policy actors’ motivation, cognition and perceived power. Methods This was a nested qualitative study, conducted in two NHI pilot districts in the Gauteng and Mpumalanga Provinces of South Africa. Following informed consent, we conducted in-depth interviews with key informants involved in the conceptualisation and implementation of the ICRM programme. The questions focused on ICRM policy context, rationale and philosophy, intergovernmental relationships, perceptions of roles and responsibilities in implementation, ICRM programme resourcing, and implementation progress, challenges and constraints. We used thematic analysis, informed by Bressers’ theory, to analyse the data. Results A total of 36 interviews were conducted with key informants from national, provincial and local government. The wider context of the ICRM programme implementation was the drive to improve the quality of care at primary healthcare level in preparation for NHI. However, the context was characterised by contestations about the roles and responsibilities of the three government spheres and weak intergovernmental relationships. Notwithstanding examples of strong local leadership, the disjuncture between two national quality of care initiatives and resource constraints influenced policy actors’ experiences and perceptions of the ICRM programme. They expressed frustrations about the lack of or diffuse accountability and their lack of involvement in decision-making, thus questioning the sustainability of the ICRM programme. Conclusions National health sector reforms should consider the context of policy implementation and potential impact on actors’ motivation, cognition and power. All relevant policy actors should be involved in policy design and implementation. A clear communication strategy and ongoing monitoring and evaluation are prerequisites for implementation success.
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Prevalence, Trends, and Drivers of the Utilization of Unskilled Birth Attendants during Democratic Governance in Nigeria from 1999 to 2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17010372. [PMID: 31935928 PMCID: PMC6981726 DOI: 10.3390/ijerph17010372] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 12/23/2019] [Accepted: 12/25/2019] [Indexed: 12/11/2022]
Abstract
Comprehensive epidemiological data on prevalence, trends, and determinants of the use of unskilled birth attendants (traditional birth attendants (TBAs) and other unskilled birth attendants) are essential to policy decision-makers and health practitioners, to guide efforts and resource allocation. This study investigated the prevalence, trends, and drivers of the utilization of unskilled birth attendants during democratic governance in Nigeria from 1999 to 2018. The study used the Nigeria Demographic and Health Surveys data for the years 1999 (n = 3552), 2003 (n = 6029), 2008 (n = 28,647), 2013 (n = 31,482), and 2018 (34,193). Multivariate multinomial logistic regression was used to investigate the association between socioeconomic, demographic, health-service, and community-level factors with the utilization of TBAs and other unskilled birth attendants in Nigeria. Between 1999 and 2018, the study showed that the prevalence of TBA-assisted delivery remained unchanged (20.7%; 95% CI: 18.0-23.7% in 1999 and 20.5%; 95% CI: 18.9-22.1% in 2018). The prevalence of other-unskilled-birth-attendant use declined significantly from 45.5% (95% CI: 41.1-49.7%) in 2003 to 36.2% (95% CI: 34.5-38.0%) in 2018. Higher parental education, maternal employment, belonging to rich households, higher maternal age (35-49 years), frequent antenatal care (ANC) (≥4) visits, the proximity of health facilities, and female autonomy in households were associated with lower odds of unskilled birth attendants' utilization. Rural residence, geopolitical region, lower maternal age (15-24 years), and higher birth interval (≥2 years) were associated with higher odds of unskilled-birth-attendant-assisted deliveries. Reducing births assisted by unskilled birth attendants in Nigeria would require prioritized and scaled-up maternal health efforts that target all women, especially those from low socioeconomic backgrounds, those who do not attend antenatal care, and/or those who reside in rural areas.
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Cerf ME. Health worker resourcing to meet universal health coverage in Africa. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2019. [DOI: 10.1080/20479700.2019.1693711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Marlon E. Cerf
- Grants, Innovation and Product Development, South African Medical Research Council, Cape Town, South Africa
- Biomedical Research and Innovation Platform, South African Medical Research Council, Cape Town, South Africa
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