Malaria treatment perceptions, practices and influences on provider behaviour: comparing hospitals and non-hospitals in south-east Nigeria

<p>Abstract</p> <p>Background</p> <p>People seek treatment for malaria from a wide range of providers ranging from itinerant drug sellers to hospitals. However, there are lots of problems with treatment provision. Hence, factors influencing treatment provision in hospitals and non-hospitals require further investigation in order to remedy the situation.</p> <p>Objectives</p> <p>To examine the knowledge, pattern of treatment provision and factors influencing the behaviour of hospitals and non-hospitals in the treatment of malaria, so as to identify loci for interventions to improve treatment of the disease.</p> <p>Methods</p> <p>A pre-tested structured questionnaire was used to collect data from 225 providers from hospitals and non-hospitals about their malaria treatment practices and factors that influence their provision of malaria treatment services in south-east Nigeria. The data from hospitals and other providers were compared for systematic differences.</p> <p>Results</p> <p>73.5% of hospitals used microscopy to diagnose malaria and only 34.5.1% of non-hospitals did (p < 0.05). Majority of the respondents considered ability to pay bills (35.2%), already existing relationship (9.4%) and body mechanism (35.2%) of the patient before they provided malaria treatment services. Pressure from wholesalers to providers to repay the cost of supplied drugs was the major influence of the type of drugs provided to patients.</p> <p>Conclusion</p> <p>There are many challenges to appropriate provision of malaria treatment services, although challenges are less in hospitals compared to other types of non-hospitals. Improving proper diagnosis of malaria and improving the knowledge of providers about malaria are interventions that could be used to improve malaria treatment provision.</p

Willingness to pay for rapid diagnostic tests for the diagnosis and treatment of malaria in southeast Nigeria: ex post and ex ante

<p>Abstract</p> <p>Background</p> <p>The introduction of rapid diagnostic tests (RDTs) has improved the diagnosis and treatment of malaria. However, any successful control of malaria will depend on socio-economic factors that influence its management in the community. Willingness to pay (WTP) is important because consumer responses to prices will influence utilization of services and revenues collected. Also the consumer's attitude can influence monetary valuation with respect to different conditions ex post and ex ante.</p> <p>Methods</p> <p>WTP for RDT for Malaria was assessed by the contingent valuation method using a bidding game approach in rural and urban communities in southeast Nigeria. The ex post WTP was assessed at the health centers on 618 patients immediately following diagnosis of malaria with RDT and the ex ante WTP was assessed by household interviews on 1020 householders with a prior history of malaria.</p> <p>Results</p> <p>For the ex ante WTP, 51% of the respondents in urban and 24.7% in rural areas were willing to pay for RDT. The mean WTP (235.49 naira) in urban is higher than WTP (182.05 Naira) in rural areas. For the ex post WTP, 89 and 90.7% of the respondents in urban and rural areas respectively were WTP. The mean WTP (372.30 naira) in urban is also higher than (296.28 naira) in rural areas. For the ex post scenario, the lower two Social Economic Status (SES) quartiles were more willing to pay and the mean WTP is higher than the higher two SES while in the ex ante scenario, the higher two SES quartiles were more WTP and with a higher WTP than the lower two SES quartile. Ex ante and ex post WTP were directly dependent on costs.</p> <p>Conclusion</p> <p>The ex post WTP is higher than the ex ante WTP and both are greater than the current cost of RDTs. Urban dwellers were more willing to pay than the rural dwellers. The mean WTP should be considered when designing suitable financial strategies for making RDTs available to communities.</p

Exploring actors roles in formulation of the human resources for health policy in Nigeria

BACKGROUND: Most policies in Nigeria are deliberate choices based on political mechanism, oversight, and lack of appropriate information. However in recent times there has been a global shift towards evidence based policy making. Thus Actors' views on evidence and their role in policy development appear critical to the use of evidence.OBJECTIVE: This study aimed to examine how actors' perception, roles and levels of power influenced Human Resources for Health policy development in Nigeria.METHOD: The research was conducted using a case study approach. Systematic reviews of relevant policy documents and reports, in-depth interviews of twelve respondents comprising government policymakers, academia, civil society organizations, health-workers and development partners were done. Interviews were analysed using NVivo 10 software for qualitative analysis.FINDINGS: Most respondents perceived evidence to be factual and concrete to support a given decision. The government policymakers wielded a high level of power and spearheaded the policy process. Development partners were major decision makers because they had financial and technical power. Civil society groups had the power of advocacy and generated evidence. The academia had medium power level of power and also generated evidence.CONCLUSION: The actors' with the highest level of power greatly influenced policy use and type of evidence used in formulating the Human Resources for Health policy. Stakeholders with coercive, financial or group power influenced the type of evidence finally used in formulating the Human Resources for Health policy.KEY WORDS: Human Resource for Health; Health policy making; Role of actors in policy makin

Leadership experiences and practices of South African health managers: what is the influence of gender? -a qualitative, exploratory study

Background The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women’s full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being ‘left behind’ in terms of career development and progression into senior health leadership positions. Methods Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments. Results Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the ‘first’ to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture. Conclusion This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play

Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria.

BACKGROUND: The low demand for maternal and child health services is a significant factor in Nigeria's high maternal death rate. This paper explores demand and supply-side determinants at the primary healthcare level, highlighting factors affecting provision and utilization. METHODS: This qualitative study was undertaken in Anambra state, southeast Nigeria. Anambra state was purposively chosen because a maternal and child health programme had just been implemented in the state. The three-delay model was used to analyze supply and demand factors that affect MCH services and improve access to care for pregnant women/mothers and newborns/infants. RESULT: The findings show that there were problems with both the demand and supply aspects of the programme and both were interlinked. For service users, their delays were connected to the constraints on the supply side. On the demand side, the delays include poor conditions of the facilities, the roads to the facilities are inaccessible, and equipment were lacking in the facilities. These delayed the utilisation of facilities. On the supply side, the delays include the absence of security (fence, security guard), poor citing of the facilities, inadequate accommodation, no emergency transport for referrals, and lack of trained staff to man equipment. These delayed the provision of services. CONCLUSION: Our findings show that there were problems with both the demand and supply aspects of the programme, and both were interlinked. For service users, their delays were connected to the constraints on the supply side

Examining appropriate diagnosis and treatment of malaria: availability and use of rapid diagnostic tests and artemisinin-based combination therapy in public and private health facilities in south east Nigeria

<p>Abstract</p> <p>Background</p> <p>Rapid diagnostic tests (RDTs) and Artemisinin-based combination therapy (ACT) have been widely advocated by government and the international community as cost-effective tools for diagnosis and treatment of malaria. ACTs are now the first line treatment drug for malaria in Nigeria and RDTs have been introduced by the government to bridge the existing gaps in proper diagnosis. However, it is not known how readily available these RDTs and ACTs are in public and private health facilities and whether health workers are actually using them. Hence, this study investigated the levels of availability and use of RDTs and ACTs in these facilities.</p> <p>Methods</p> <p>The study was undertaken in Enugu state, southeast Nigeria in March 2009. Data was collected from heads of 74 public and private health facilities on the availability and use of RDTs and ACTs. Also, the availability of RDTs and the types of ACTs that were available in the facilities were documented.</p> <p>Results</p> <p>Only 31.1% of the health facilities used RDTs to diagnose malaria. The majority used the syndromic approach. However, 61.1% of healthcare providers were aware of RDTs. RDTs were available in 53.3% of the facilities. Public health facilities and health facilities in the urban areas were using RDTs more and these were mainly bought from pharmacy shops and supplied by NGOs. The main reasons given for non use are unreliability of RDTs, supply issues, costs, preference for other methods of diagnosis and providers' ignorance. ACTs were the drug of choice for most public health facilities and the drugs were readily available in these facilities.</p> <p>Conclusion</p> <p>Although many providers were knowledgeable about RDTs, not many facilities used it. ACTS were readily available and used in public but not private health facilities. However, the reported use of ACTs with limited proper diagnosis implies that there could be high incidence of inappropriate case management of malaria which can also increase the economic burden of illnesses. Government and donors should ensure constant availability of RDTs in both public and private facilities, so that every treatment with ACTs is accompanied with proper diagnosis.</p

Role and use of evidence in policymaking: an analysis of case studies from the health sector in Nigeria.

Background Health policymaking is a complex process and analysing the role of evidence is still an evolving area in many low- and middle-income countries. Where evidence is used, it is greatly affected by cognitive and institutional features of the policy process. This paper examines the role of different types of evidence in health policy development in Nigeria. Methods The role of evidence was compared between three case studies representing different health policies, namely the (1) integrated maternal neonatal and child health strategy (IMNCH); (2) oral health (OH) policy; and (3) human resource for health (HRH) policy. The data was collected using document reviews and 31 in-depth interviews with key policy actors. Framework Approach was used to analyse the data, aided by NVivo 10 software. Results Most respondents perceived evidence to be factual and concrete to support a decision. Evidence was used more if it was perceived to be context-specific, accessible and timely. Low-cost high-impact evidence, such as the Lancet series, was reported to have been used in drafting the IMNCH policy. In the OH and HRH policies, informal evidence such as experts’ experiences and opinions, were reported to have been useful in the policy drafting stage. Both formal and informal evidence were mentioned in the HRH and OH policies, while the development of the IMNCH was revealed to have been informed mainly by more formal evidence. Overall, respondents suggested that formal evidence, such as survey reports and research publications, were most useful in the agenda-setting stage to identify the need for the policy and thus initiating the policy development process. International and local evidence were used to establish the need for a policy and develop policy, and less to develop policy implementation options. Conclusion Recognition of the value of different evidence types, combined with structures for generating and using evidence, are likely to enhance evidence-informed health policy development in Nigeria and other similar contexts

The economic burden of malaria on households and the health system in Enugu State southeast Nigeria.

BACKGROUND: Malaria is the number one public health problem in Nigeria, responsible for about 30% of deaths in under-fives and 25% of deaths in infants and 11% maternal mortality. This study estimated the economic burden of malaria in Nigeria using the cost of illness approach. METHODS: A cross-sectional study was undertaken in two malaria holo-endemic communities in Nigeria, involving both community and hospital based surveys. A random sample of 500 households was interviewed using interviewer administered questionnaire. In addition, 125 exit interviews for inpatient department stays (IPD) and outpatient department visits (OPD) were conducted and these were complemented with data abstraction from 125 patient records. RESULTS: From the household survey, over half of the households (57.6%) had an episode of malaria within one month to the date of the interview. The average household expenditure per case was 12.57US$and 23.20US$ for OPD and IPD respectively. Indirect consumer costs of treatment were higher than direct consumer medical costs. From a health system perspective, the recurrent provider costs per case was 30.42 US$and 48.02 US$ for OPD and IPD while non recurrent provider costs were 133.07US$and 1857.15US$ for OPD and IPD. The mode of payment was mainly through out-of-pocket spending (OOPS). CONCLUSION: Private expenditure on treatment of malaria constitutes a high economic burden to households and to the health system. Removal of user fees and interventions that will decrease the use of OOPS for treatment of malaria will significantly decrease the economic burden of malaria to both households and the health system