Investigating payment coping mechanisms used for the treatment of uncomplicated malaria to different socio-economic groups in Nigeria.

Background: Given the enormous economic burden of malaria in Nigeria and in sub-Saharan Africa, it is important to determine how different population groups cope with payment for malaria treatment. This paper provides new information about the differences in household coping mechanisms for expenditures on malaria treatment.Methods: The study was undertaken in two communities in Southeast Nigeria. A total of 200 exit interviews were conducted with patients and their care givers after consultation and treatment for malaria. The methods that were used to cope with payments for malaria treatment expenditures were determined. The coping mechanisms were disaggregated by socio- economic status (SES).Results: The average expenditure to treat malaria was $22.9, which was all incurred through out-of- pocket payments. Some households used more than one coping method but none reported using health insurance. It was found that use of household savings (79.5%) followed by reduction in other household expenses (22.5%) were the most common coping methods. The reduction of other household expenses was significantly more prevalent with the average (Q4) SES group (p<0.05).Conclusion: People used different coping strategies to take care of their malaria expenditures, which are mostly paid outof- pocket. The average socio-economic household had to forego other basic household expenditures in order to cope with malaria illness; otherwise there were no other significant differences in the coping mechanisms across the different SES groups. This could be indicative of the catastrophic nature of malaria treatment expenditures. Interventions that will reduce the burden of malaria expenditures on all households, within the context of Universal Health Coverage are needed so as to decrease the economic burden of malaria on households.Key words: malaria, coping, household, expenditures, payments, socio-economic statu

What co-morbidities do people with malaria have and what are their patterns of health seeking in Nigeria?

Background: This study assessed the comorbidities associated with malaria and patterns of health seeking in southeast Nigeria.Materials and Methods: The survey was undertaken in Enugu state, Southeast Nigeria. Data were collected from 500 householders, 200 in-patient and outpatient exit surveys and data abstraction from 125 inpatient and outpatient records.Results: A total of 307 (64.2%) households had an episode of malaria within 1 month of the interview. The most common malaria comorbidities were upper respiratory tract infection and diarrhea. Most patients first sought treatment from patent medicine vendors. The average monthly cost of treating the comorbidities was 270 Naira (1.75 USD) and 601 Naira (3.89 USD) for outpatient department and inpatient department respectively.Conclusion: The economic burden of malaria is compounded by  comorbidities and inappropriate health seeking behavior. Interventions to control malaria are required to also control common comorbidities.Key words: Co.morbidity, costs, health.seeking pattern, malari

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

Health policy and systems research and analysis in Nigeria: examining health policymakers' and researchers' capacity assets, needs and perspectives in south-east Nigeria.

BACKGROUND: Health policy and systems research and analysis (HPSR+A) has been noted as central to health systems strengthening, yet the capacity for HPSR+A is limited in low- and middle-income countries. Building the capacity of African institutions, rather than relying on training provided in northern countries, is a more sustainable way of building the field in the continent. Recognising that there is insufficient information on African capacity to produce and use HPSR+A to inform interventions in capacity development, the Consortium for Health Policy and Systems Analysis in Africa (2011-2015) conducted a study with the aim to assess the capacity needs of its African partner institutions, including Nigeria, for HPSR+A. This paper provides new knowledge on health policy and systems research assets and needs of different stakeholders, and their perspectives on HPSR+A in Nigeria. METHODS: This was a cross-sectional study conducted in the Enugu state, south-east Nigeria. It involved reviews and content analysis of relevant documents and interviews with organizations' academic staff, policymakers and HPSR+A practitioners. The College of Medicine, University of Nigeria, Enugu campus (COMUNEC), was used as the case study and the HPSR+A capacity needs were assessed at the individual, unit and organizational levels. The HPSR+A capacity needs of the policy and research networks were also assessed. RESULTS: For academicians, lack of awareness of the HPSR+A field and funding were identified as barriers to strengthening HPSR+A in Nigeria. Policymakers were not aware of the availability of research findings that could inform the policies they make nor where they could find them; they also appeared unwilling to go through the rigors of reading extensive research reports. CONCLUSION: There is a growing interest in HPSR+A as well as a demand for its teaching and, indeed, opportunities for building the field through research and teaching abound. However, there is a need to incorporate HPSR+A teaching and research at an early stage in student training. The need for capacity building for HPSR+A and teaching includes capacity building for human resources, provision and availability of academic materials and skills development on HPSR+A as well as for teaching. Suggested development concerns course accreditation, development of short courses, development and inclusion of HPSR+A teaching and research-specific training modules in school curricula for young researchers, training of young researchers and improving competence of existing researchers. Finally, we could leverage on existing administrative and financial governance mechanisms when establishing HPSR+A field building initiatives, including staff and organizational capacity developments and course development in HPSR+A

What makes advocacy work? Stakeholders’ voices and insights from prioritisation of maternal and child health programme in Nigeria

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

Exploring mechanisms that explain how coalition groups are formed and how they work to sustain political priority for maternal and child health in Nigeria using the advocacy coalition framework

Background: The unacceptably high rate of maternal and child mortality in Nigeria prompted the government to introduce a free maternal and child health (MCH) programme, which was stopped abruptly following a change in government. This triggered increased advocacy for sustaining MCH as a political priority in the country and led to the formation of advocacy coalitions. This study set out to explain the process involved in the formation of advocacy coalition groups and how they work to bring about sustained political prioritization for MCH in Nigeria. It will contribute to the understanding of the Nigerian MCH sector subsystem and will be beneficial to health policy advocates and public health researchers in Nigeria. Methods: This study employed a qualitative case study approach. Data were collected using a pretested interview guide to conduct 22 in-depth interviews, while advocacy events were reviewed pro forma. The document review was analysed using the manual content analysis method, while qualitative data audiotapes were transcribed verbatim, anonymized, double-coded in MS Word using colour-coded highlights and analysed using manual thematic and framework analysis guided by the advocacy coalition framework (ACF). The ACF was used to identify the policy subsystem including the actors, their belief, coordination and resources, as well as the effects of advocacy groups on policy change. Ethics and consent approval were obtained for the study. Results: The policy subsystem identified the actors and characterized the coalitions, and described their group formation processes and resources/strategies for engagement. The perceived deep core belief driving the MCH agenda is the right of an individual to health. The effects of advocacy groups on policy change were identified, along with the factors that enabled effectiveness, as well as constraints to coalition formation. External factors and triggers of coalition formation were identified to include high maternal mortality and withdrawal of the free MCH programme, while the contextual issues were the health system issues and the socioeconomic factors affecting the country. Conclusion: Our findings add to an increasing body of evidence that the use of ACF is beneficial in exploring how advocacy coalitions are formed and in identifying the effects of advocacy groups on policy change

The challenge of bridging the gap between researchers and policy makers: experiences of a Health Policy Research Group in engaging policy makers to support evidence informed policy making in Nigeria

Background: Getting research into policy and practice (GRIPP) is a process of going from research evidence to decisions and action. To integrate research findings into the policy making process and to communicate research findings to policymakers is a key challenge world-wide. This paper reports the experiences of a research group in a Nigerian university when seeking to ‘do’ GRIPP, and the important features and challenges of this process within the African context. Methods: In-depth interviews were conducted with nine purposively selected policy makers in various organizations and six researchers from the universities and research institute in a Nigerian who had been involved in 15 selected joint studies/projects with Health Policy Research Group (HPRG). The interviews explored their understanding and experience of the methods and processes used by the HPRG to generate research questions and research results; their involvement in the process and whether the methods were perceived as effective in relation to influencing policy and practice and factors that influenced the uptake of research results. Results: The results are represented in a model with the four GRIPP strategies found: i) stakeholders’ request for evidence to support the use of certain strategies or to scale up health interventions; ii) policymakers and stakeholders seeking evidence from researchers; iii) involving stakeholders in designing research objectives and throughout the research process; and iv) facilitating policy maker-researcher engagement in finding best ways of using research findings to influence policy and practice and to actively disseminate research findings to relevant stakeholders and policymakers. The challenges to research utilization in health policy found were to address the capacity of policy makers to demand and to uptake research, the communication gap between researchers, donors and policymakers, the management of the political process of GRIPP, the lack of willingness of some policy makers to use research, the limited research funding and the resistance to change. Conclusions: Country based Health Policy and Systems Research groups can influence domestic policy makers if appropriate strategies are employed. The model presented gives some direction to potential strategies for getting research into policy and practice in the health care sector in Nigeria and elsewhere

Was the Maternal Health Cash Transfer Programme in Nigeria Sustainable and Cost-Effective?

Background: The Subsidy Reinvestment and Empowerment Programme (SURE-P), Maternal and Child Health (MCH) was introduced by the Nigerian government to increase the use of skilled maternal health services and reduce maternal mortality. The programme, funded out of a reduction in the fuel subsidy, was implemented between October 2012 and April 2015 and incorporated a conditional cash transfer to women to encourage use of facility based maternal services. We seek to assess the incremental cost effectiveness and long term impact of the conditional cash transfer element of the programme. Methods: An impact analysis and incremental cost-effectiveness analysis of conditional cash transfers (CCTs) is undertaken taking a health service perspective toward costs of the intervention. The study was undertaken in Anambra state, comparing areas that received only the investment in health services with areas that implemented the conditional cash transfer programme. An interrupted time series analysis of the programme outputs was undertaken. These were combined with a programme costing to determine the incremental cost per output. Findings: Maternal services provided to patients in conditional cash transfer areas accelerated rapidly from the middle of 2014 until after the programme in late 2015. The costs of providing services in each Primary Health Center facility was US $52,128 in the areas that only invested in health services compared to US$90,702 in facilities that also provided cash transfers. Much of the additional cost was in managing cash transfers. The incremental cost in the cash transfer areas was $572 for delivery care and$11 for antenatal care. If the programme was to be integrated as a regular service in the public health system, the cost of a delivery is estimated to fall to $389 and to$188 if 2015 levels of activity are assumed. Conclusion: Although the cost of CCTs as originally constituted as a vertical programme are relatively high compared to other similar programmes, these would fall substantially if integrated into the main health system. There is also evidence of sustained impact beyond the end of the funding suggesting that short term programmes can lead to a long-term change in patterns of health seeking behavior

Dealing with context in logic model development: Reflections from a realist evaluation of a community health worker programme in Nigeria

Logic models (LMs) have been used in programme evaluation for over four decades. Current debate questions the ability of logic modelling techniques to incorporate contextual factors into logic models. We share experience of developing a logic model within an ongoing realist evaluation which assesses the extent to which, and under what circumstances a community health workers (CHW) programme promotes access to maternity services in Nigeria. The article contributes to logic modelling debate by: i) reflecting on how other scholars captured context during LM development in theory-driven evaluations; and ii) explaining how we explored context during logic model development for realist evaluation of the CHW programme in Nigeria. Data collection methods that informed our logic model development included documents review, email discussions and teleconferences with programme stakeholders and a technical workshop with researchers to clarify programme goals and untangle relationships among programme elements. One of the most important findings is that, rather than being an end in itself, logic model development is an essential step for identifying initial hypotheses for tentative relevant contexts, mechanisms and outcomes (CMOs) and CMO configurations of how programmes produce change. The logic model also informed development of a methodology handbook that is guiding verification and consolidation of underlying programme theories

Reflections from using logic modelling as part of realist evaluation of a community health worker programme in Nigeria

Background: Community Health Workers (CHWs) are an essential component of resilient and responsive health systems, within which they are a bridge between the community and formal health service to increase access to services. Although evidence shows that CHW programmes are effective in improving maternal and child health (MCH), greater clarity is required to understand what makes CHW programmes work, for whom and under what circumstances. This presentation draws lessons from using logic mapping as a tool to de-construct a multi-intervention CHW programme in Nigeria, which aimed to increase access to quality maternity services and improve MCH outcomes. The presentation should be of interest to policymakers and researchers interested in innovative approaches for evaluating and/or strengthening health systems. Methods: A logic map (LM) is a graphic way of organizing and displaying information about a strategy, programme or policy. A coherent LM is a thread of evidence-based logic that integrates programme planning, implementation, evaluation and programme reporting. We used logic mapping as part of a realist evaluation framework, to assess whether the CHW programme in Nigeria worked, for whom and under what circumstances. The evaluation methodology involved 3 steps: initial programme theory development, theory validation and theory refinement. We share reflections on using logic mapping for the first evaluation step. To achieve this, we used logic mapping to graphically de-construct stakeholder’s (i.e. policymakers, implementers and researchers) thinking of how the programme should work, by illustrating interrelations between actors, context, implementation process, outputs and outcomes. Data for developing the LM was collected using documents review, email discussions and a technical workshop (for researchers and implementers), to untangle relationships between programme elements, and develop initial working theories. Results: Logic mapping enabled stakeholders to collaboratively describe and link desired outputs and impacts to actual activities, to confirm that activities contribute towards achieving measurable final outcomes. Discussion/conclusions: Logic mapping provided stakeholders with a shared language for, and an approach to strengthen learning at local levels, to build health system responsiveness. However, we experienced two challenges with using LMs. First, the LM depicted linear/simplified relationships between inputs, activities and outputs, or between outputs and outcomes whereas in reality, interrelationships between and among inputs, activities and outputs, or between outputs and outcomes are more complex. Second, it was difficult to represent all relationships among programme elements in a single two-dimensional LM. Consequently, a series of (or nested) LMs were required to depict various components within the multi-intervention programme