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 contribution of decentralised nursing education to social responsibility in rural Arctic Norway

This study explores and analyses decentralised nursing education in Finnmark County, Northern Norway, from 1991 to 2018. The study may have relevance for educational policy discussions and strategic planning. Our research question has been how decentralised nursing education can contribute to social responsibility by educating nurses rurally. The data collection includes documentation of 15 decentralised classes. The decentralised nursing education programme has been completed in nine rural communities in Finnmark County over 28 years and has resulted in 191 graduated nurses. Educating nurses locally influences recruitment and stability. The location of the study site determines where the recruited students come from. In future decentralised programmes, study sites should be located close to regions with a shortage of nurses. This is especially true of the eastern part of Finnmark, where recruitment to regular on-campus programmes is lowest. Limiting decentralised nursing programmes to local applicants should be considered. By prioritising local applicants, we will fulfil the university's responsibility to place qualified nurses in all parts of Finnmark.

The experience of bedaquiline implementation at a decentralised clinic in South Africa

Multidrug-resistant tuberculosis (MDR-TB) is a serious public health problem, but the new drugs bedaquiline (BDQ) and delamanid offer hope to improve outcomes and minimise toxicity. In Khayelitsha, South Africa, patients are routinely started on BDQ in the out-patient setting. This report from the field describes BDQ use in the out-patient setting at the Nolungile Clinic. The clinic staff overall report a positive experience using the drug. Challenges have been based largely on the logistics of drug supply and delivery. BDQ can be started successfully in the out-patient setting, and can be a positive experience for both patients and providers. La tuberculose multirésistante (TB-MDR) est un problème de santé publique grave, mais les nouveaux médicaments que sont la bédaquiline (BDQ) et le délamanide apportent un espoir d'améliorer les résultats tout en réduisant la toxicité. A Khayelitsha, Afrique du Sud, les patients démarrent leur traitement par BDQ en consultation externe en routine. Ce rapport du terrain décrit l'utilisation de la BDQ à la consultation externe du dispensaire Nolungile. Dans l'ensemble, le personnel du centre de santé exprime une expérience positive du médicament. Les défis ont surtout été liés à la logistique de l'approvisionnement et de la distribution du médicament. La BDQ peut être mise en route avec succès dans le cadre d'une consultation externe et peut constituer une expérience positive pour les patients et les prestataires de soins. La tuberculosis multirresistente (TB-MDR) representa un grave problema de salud pública, pero la utilización de nuevos medicamentos como la bedaquilina (BDQ) y el delamanid ofrece perspectivas de mejores desenlaces terapéuticos y disminución de la toxicidad asociada. En Khayelitsha, Suráfrica, se inicia de manera sistemática el tratamiento ambulatorio con BDQ. En el presente informe del terreno, se describe la utilización de BDQ en tratamiento antituberculoso ambulatorio en el centro de atención Nolungile. En general, los miembros del personal del centro refirieron una experiencia positiva con la administración del medicamento. Las dificultades surgieron en gran parte con respecto a aspectos logísticos del suministro y la administración del medicamento. Es posible iniciar un tratamiento eficaz con BDQ en condiciones ambulatorias, y represente una experiencia positiva para los pacientes y los profesionales de salud.

Decentralised care for the management of child contacts of multidrug-resistant tuberculosis

SETTING

Cape Town, South Africa.

OBJECTIVE

To determine the number of multidrug-resistant tuberculosis (MDR-TB) child contacts routinely identified by health services, and whether a model of decentralised care improves access.

METHODS

All MDR-TB source cases registered in Cape Town from April 2010 to March 2011 were included. All child contacts assessed at hospital and outreach clinics were recorded from May 2010 to June 2011. Electronic probabilistic matching was used to match source cases with potential child contacts; the number of children accessing decentralised (Khayelitsha) and hospital-based care was compared.

RESULTS

Of 1221 MDR-TB source cases identified, 189 (15.5%) were registered in Khayelitsha; 31 (16.4%) had at least one child contact assessed. In contrast, 95 (9.2%) of the 1032 source cases diagnosed in the other Cape Town subdistricts (hospital-based care) had at least one child contact assessed (P = 0.003). Children in Khayelitsha were seen at a median of 71 days (interquartile range [IQR] 37-121 days) after source case diagnosis compared to 90 days (IQR 56-132 days) in other subdistricts (P = 0.15).

CONCLUSION

Although decentralised care led to an increased number of child contacts being evaluated, both models led to the assessment of a small number of potential child MDR-TB contacts, with considerable delay in assessment.