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

Does expanding fiscal space lead to improved funding of the health sector in developing countries?: lessons from Kenya, Lagos State (Nigeria) and South Africa

This article examines whether increased tax revenue in the three territories of Kenya, Lagos State (Nigeria) and South Africa was accompanied by improved resource allocation to their public health sectors, and explores the reasons underlying the observed trends.CW201

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

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

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

Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria.

BACKGROUND: The National Health Insurance Scheme (NHIS) in Nigeria was launched in 2005 as part of efforts by the federal government to achieve universal coverage using financial risk protection mechanisms. However, only 4% of the population, and mainly federal government employees, are currently covered by health insurance and this is primarily through the Formal Sector Social Health Insurance Programme (FSSHIP) of the NHIS. This study aimed to understand why different state (sub-national) governments decided whether or not to adopt the FSSHIP for their employees. METHODS: This study used a comparative case study approach. Data were collected through document reviews and 48 in-depth interviews with policy makers, programme managers, health providers, and civil servant leaders. RESULTS: Although the programme's benefits seemed acceptable to state policy makers and the intended beneficiaries (employees), the feasibility of employer contributions, concerns about transparency in the NHIS and the role of states in the FSSHIP, the roles of policy champions such as state governors and resistance by employees to making contributions, all influenced the decision of state governments on adoption. Overall, the power of state governments over state-level health reforms, attributed to the prevailing system of government that allows states to deliberate on certain national-level policies, enhanced by the NHIS legislation that made adoption voluntary, enabled states to adopt or not to adopt the program. CONCLUSIONS: The study demonstrates and supports observations that even when the content of a programme is generally acceptable, context, actor roles, and the wider implications of programme design on actor interests can explain decision on policy adoption. Policy implementers involved in scaling-up the NHIS programme need to consider the prevailing contextual factors, and effectively engage policy champions to overcome known challenges in order to encourage adoption by sub-national governments. Policy makers and implementers in countries scaling-up health insurance coverage should, early enough, develop strategies to overcome political challenges inherent in the path to scaling-up, to avoid delay or stunting of the process. They should also consider the potential pitfalls of reforms that first focus on civil servants, especially when the use of public funds potentially compromises coverage for other citizens

Gender Issues in the Prevention and Control of STIs and HIV/AIDS: Lessons from Awka and Agulu, Anambra State, Nigeria

The study examined perceptions, practices and norms underlying sexuality and gender relations that constrain the prevention and control of STIs and HIV/AIDS. It was carried out among the Igbo of Awka and Agulu in Anambra State of Nigeria. Both quantitative and qualitative methods were used for data collection. Findings indicate that cultural practices that encourage the establishment of sexual networks by men persist in the study communities. Some married women who are not able to achieve pregnancy with their husbands get involved in such networks to have children. Some parents who do not have male children encourage their unmarried daughters to have children out of wedlock so as to perpetuate the lineage. Inequality in gender relations and fear of repercussions constrain women from negotiating safe sex. Sexuality education is, therefore, necessary to improve the knowledge base, perceptions and sexual behaviours of the study communities. Women should be empowered to make informed decisions about sexuality and childbearing. Male responsibility in reproductive health should also be encouraged. (Afr J Reprod Health 2003; 7[2]: 89–99)RésuméQuestions de genre dans la prévention et la lutte contre les IST et le VIH/SIDA: lessons tirées d'Awka et d'Agulu, Etat d'Anambra, Nigeria. L'étude a examiné les perceptions, les pratiques et les normes qui sous-tendent la sexualité et les relations de genre qui limitent la prévention et la lutte contre les IST et le VIH/SIDA. L'étude a été menée auprès des Ibos d'Awka et d'Agulu dans l'Etat d'Anambra au Nigéria. Pour collecter les données, nous avons employé les méthodes quantitative et qualitative. Les résultats montrent que les pratiques culturelles qui encouragement l'établissement des réseaux sexuels par les hommes, demeurent toujours dans les communautés qui ont fait ‘objet de l'étude. Certaines femmes mariées qui n'arrivent pas à devenir enceintes de leurs maris, deviennent impliquées dans de tels réseaux pour avoir des enfants. Certains parents qui n'ont pas d'enfants de sexe masculin encouragent leurs filles célibataires d'avoir des enfants hors mariage afin de prolonger la lignée. L'inégalité dans les relations de genre et la peur des repercussions obligent les femmes à ne pas négocier la sexualité sans danger. L'éducation sexuelle est donc nécessaire pour améliorer la base de la connaissance, les perspectives et les comportements sexuels des communautés qui ont fait l'objet de l'étude. Il faut donner le pouvoir aux femmes qui leur permeltra de prendre des décisions en connaissance de cause sur la sexualité et l'accouchement. Il faut également encourager la responsabilisation de la part des hommes en matière de la santé reproductive. (Rev Afr Santé Reprod 2003; 7[2]: 89–99)Key Words: Gender, sexuality, STIs, HIV/AIDS, prevention, safe se