Development of oral health policy in Nigeria: an analysis of the role of context, actors and policy process

Abstract Background: In Nigeria, there is a high burden of oral health diseases, poor coordination of health services and human resources for delivery of oral health services. Previous attempts to develop an Oral Health Policy (OHP) to decrease the oral disease burden failed. However, a policy was eventually developed in November 2012. This paper explores the role of contextual factors, actors and the policy process in the development of the OHP and possible reasons why the current approved OHP succeeded. Methods: The study was undertaken across Nigeria; information gathered through document reviews and in-depth interviews with five groups of purposively selected respondents. Analysis of the policy development process was guided by the policy triangle framework, examining context, policy process and actors involved in the policy development. Results: The foremost enabling factor was the yearning among policy actors for a policy, having had four failed attempts. Other factors were the presence of a democratically elected government, a framework for health sector reform instituted by the Federal Ministry of Health (FMOH). The approved OHP went through all stages required for policy development unlike the previous attempts. Three groups of actors played crucial roles in the process, namely academics/researchers, development partners and policy makers. They either had decision making powers or influenced policy through funding or technical ability to generate credible research evidence, all sharing a common interest in developing the OHP. Although evidence was used to inform the development of the policy, the complex interactions between the context and actors facilitated its approval. Conclusions: The OHP development succeeded through a complex inter-relationship of context, process and actors, clearly illustrating that none of these factors could have, in isolation, catalyzed the policy development. Availability of evidence is necessary but not sufficient for developing policies in this area. Wider socio-political contexts in which actors develop policy can facilitate and/or constrain actors’ roles and interests as well as policy process. These must be taken into consideration at stages of policy development in order to produce policies that will strengthen the health system, especially in low and middle-income countries, where policy processes and influences can be often less than transparent

De-constructing a complex programme using a logic map: Realist Evaluation of Maternal and Child Health in Nigeria

Community health workers (CHW) programmes are inherently complex and their outcome is mediated by how interventions are implemented, the availability and quality of local health services, preferences of service users and the context of the health system. In March 2015, the University of Leeds was awarded a 5-year MRC grant to use a realist evaluation framework and mixed methods design to assess the extent to which and under what circumstances, a novel CHW programme in Nigeria, promotes equitable access to quality services and improves maternal and child health outcomes. As background to the evaluation, the Government of Nigeria launched a social protection initiative (SURE-P) in 2012, to invest revenues from fuel subsidy reduction for improving the lives of its most vulnerable populations. The SURE-P programme comprises of supply and demand components. The first aims to broaden access to quality maternal health services and improve MCH outcomes through recruiting CHWs, improving infrastructure development and increasing availability of supplies and medicines. The second aims to increase utilization of health services during pregnancy and at birth through the use of a conditional cash transfer (CCT) programme. CCTs are given to pregnant women who register at a primary health care (PHC) centre, where they get health check-ups while pregnant, deliver at a health facility, and take their baby for the first series of vaccinations. The methodology for evaluation involves three steps: 1) initial programme theory development, 2) theory validation and 3) refining theory and developing lessons learned. This paper aims to report the process of using ‘logic map’ as a tool for developing the initial programme theory for SURE-P programme. To achieve this, we have used the logic map to graphically deconstruct our group’s (i.e. researchers, policymakers and implementers) current thinking of how SURE-P programme should work in the context of Nigeria by illustrating complex relations between stakeholders, context, implementation process, outputs and outcomes of SURE-P interventions. The logic map will also serve as a focal point for discussions about data collection and programme evaluation by displaying when, where, and how we will obtain information most needed to manage the SURE-P programme and determine its effectiveness

A Multi-Site Knowledge Attitude and Practice Survey of Ebola Virus Disease in Nigeria

Background The 2014 Ebola Virus Disease (EVD) outbreak was characterised by fear, misconceptions and irrational behaviours. We conducted a knowledge attitude and practice survey of EVD in Nigeria to inform implementation of effective control measures. Methods Between July 30th and September 30th 2014, we undertook a cross sectional study on knowledge, attitude and practice (KAP) of Ebola Virus Disease (EVD) among adults of the general population and healthcare workers (HCW) in three states of Nigeria, namely Bayelsa, Cross River and Kano states. Demographic information and data on KAP were obtained using a self-administered standardized questionnaire. The percentage KAP scores were categorised as good and poor. Independent predictors of good knowledge of EVD were ascertained using a binary logistic regression model. Results Out of 1035 study participants with median age of 32 years, 648 (62.6%) were males, 846 (81.7%) had tertiary education and 441 (42.6%) were HCW. There were 218, 239 and 578 respondents from Bayelsa, Cross River and Kano states respectively. The overall median percentage KAP scores and interquartile ranges (IQR) were 79.46% (15.07%), 95.0% (33.33%) and 49.95% (37.50%) respectively. Out of the 1035 respondents, 470 (45.4%), 544(52.56%) and 252 (24.35%) had good KAP of EVD defined using 80%, 90% and 70% score cut-offs respectively. Independent predictors of good knowledge of EVD were being a HCW (Odds Ratio-OR-2.89, 95% Confidence interval-CI of 1.41–5.90), reporting ‘moderate to high fear of EVD’ (OR-2.15, 95% CI-(1.47–3.13) and ‘willingness to modify habit’ (OR-1.68, 95% CI-1.23–2.30). Conclusion Our results reveal suboptimal EVD-related knowledge, attitude and practice among adults in Nigeria. To effectively control future outbreaks of EVD in Nigeria, there is a need to implement public sensitization programmes that improve understanding of EVD and address EVD-related myths and misconceptions, especially among the general population

‘Flattening’ one curve: what about ‘raising the line’ on the other? COVID-19 and palliative care in low-income and middle-income countries

The death toll from the coronavirus 2019 (COVID-19) pandemic has exposed the public to the reality of death and dying, raising awareness of the fragility of one’s mortality. It has revealed to many care professionals and policymakers the need for integrated, comprehensive care provision across public health and medical services, including palliative and end-of-life care. With large disparities in the capacity of health systems globally prior to the pandemic, inequity in the response to COVID-19-related palliative care needs was inevitable across low-, middle- and high-income countries. Importantly, the immediacy of the dialogue around COVID-19 response preparedness has largely muted calls around the need to enhance palliative care service provision in low- and-middle-income countries (LMICs), and the longer-term development necessary to inform future disease outbreaks specifically and the needs of the dying generally