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

Exploring health providers' and community perceptions and experiences with malaria tests in South-East Nigeria: a critical step towards appropriate treatment.

BACKGROUND: The adoption of ACT as the first line treatment for uncomplicated malaria in Nigeria has concentrated attention on the role of testing in appropriate malaria treatment. There are calls at both national and global level for malaria treatment to be based on test result, but it is still unclear how testing can be incorporated into treatment-seeking and practices of health providers. This study explored community members and health providers' perceptions and experiences with malaria tests in south east Nigeria. METHODS: The study was conducted in urban and rural areas of Enugu state in south-eastern Nigeria. A total of 18 focus group discussions with 179 community members including sub-groups of primary caregivers, adult men and adult women aged 15 years and above. Twenty-six (26) In-depth interviews were held with public and private health providers involved in prescribing medicines at public and private health facilities in the study area. RESULTS: Both providers and community members were familiar with malaria tests and identified malaria tests as an important step to distinguish malaria from other illnesses with similar symptoms and as a means of delivering appropriate treatment. However, the logic of test-directed treatment was undermined by cost of test and a lack of testing facilities but above all concerns over the reliability of negative test results, with community members and providers observing inconsistencies between results and symptoms, and providers attributing inaccurate results to incompetencies of technicians. Recognition of malaria symptoms was deemed most important in determining the use of antimalarial drugs rather than the result of a malaria test. CONCLUSION: The results highlight important areas of intervention to promote appropriate malaria treatment. If tests are to play a role in patient management, demand and supply side interventions are needed to change people's attitude towards malaria test results