Seye AbimbolaNational Primary Health Care Development Agency, Abuja Nigeria
32.80· MBChB, MPhil, PhD
Skills and Expertise
Research Items (62)
With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency.
- Jul 2018
This study aimed to examine the factors associated with healthcare-seeking behaviour of Nigeria's older adult population. Data were retrieved from the Nigeria General Household Survey (GHS - year 2013) database, representative at the national level. Bivariate analysis and Poisson regression were performed. Among 3587 adults aged 50 years and over, 850 reported having been sick in the previous four weeks, and 53% of those had consulted a health practitioner in that period. Those consulting were more likely to be women (PR = 1.30, 95% CI [1.1-1.15]), older than 65 (PR = 1.25, 95% CI [1.1-1.5]), and unemployed (PR = 1.24, 95% CI [1.0-1.4]), whereas lack of education (PR = 0.73, 95% CI [0.6 0-0.8]), low household income (PR = 0.72, 95% CI [0.5-0.9]) and living in the South East (PR = 0.59 95% CI [0.4-0.7]) and in the South South zones (PR = 0.60 95% CI [0.4-0.7]) were associated with lower consultation rates. Our results suggest that improving older adults' healthcare-seeking behaviour in Nigeria will require the lifting of financial barriers and improvements to education. More studies are needed to better understand geographic differences and the low consultation rate by men.
Efforts to strengthen health systems require the engagement of diverse, multidisciplinary stakeholder networks. Networks provide a forum for experimentation and knowledge creation, information exchange and the spread of good ideas and practice. They might be useful in addressing complex issues or ‘wicked’ problems, the solutions to which go beyond the control and scope of any one agency. Innovation platforms are proposed as a novel type of network because of their diverse stakeholder composition and focus on problem solving within complex systems. Thus, they have potential applicability to health systems strengthening initiatives, even though they have been predominantly applied in the international agricultural development sector. In this paper, we compare and contrast the concept of innovation platforms with other types of networks that can be used in efforts to strengthen primary healthcare systems, such as communities of practice, practice-based research networks and quality improvement collaboratives. We reflect on our ongoing research programme that applies innovation platform concepts to drive large-scale quality improvement in primary healthcare for Aboriginal and Torres Strait Islander Australians and outline our plans for evaluation. Lessons from our experience will find resonance with others working on similar initiatives in global health.
Background: Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades – including 13 wars during 1990–2015 – than any other part of the world, and this has had an adverse effect on health systems in the region. Objective: To understand the best health system practices in five SSA countries that experienced wars during 1990–2015, and yet managed to achieve a maternal mortality reduction – equal to or greater than 50% during the same period – according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). Maternal mortality is a death of a woman during pregnancy, or within 42 days after childbirth – measured as maternal mortality ratio (MMR) per 100,000 live births. Design: We conducted a selective literature review based on a framework that drew upon the World Health Organisation’s (WHO) six health system building blocks. We searched seven databases, Google Scholar as well as conducting a manual search of sources in articles’ reference lists – restricting our search to articles published in English. We searched for terms related to maternal healthcare, the WHO six health system building blocks, and names of the five countries. Results: Our study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms. Conclusion: Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars. Our findings provide insight from five war-affected SSA countries which could inform policy. However, since few studies have been conducted concerning this topic, our findings require further research to inform policy, and to help countries rebuild and maintain their health systems resilience.
Despite growing support for integration of frontline services, a lack of information about the pre-conditions necessary to integrate such services hampers the ability of policy makers and implementers to assess how feasible or worthwhile integration may be, especially in low- and middle-income countries (LMICs). We adopted a modified systematic review with aspects of realist review, including quantitative and qualitative studies that incorporated assessment of health system preparedness for and capacity to implement integrated services. We searched Medline via Ovid, Web of Science and the Cochrane library using terms adapted from Dudley and Garner's systematic review on integration in LMICs. From an initial list of 10 550 articles, 206 were selected for full-text review by two reviewers who independently reviewed articles and inductively extracted and synthesized themes related to health system preparedness. We identified five 'context' related categories and four health system 'capability' themes. The contextual enabling and constraining factors for frontline service integration were: (1) the organizational framework of frontline services, (2) health care worker preparedness, (3) community and client preparedness, (4) upstream logistics and (5) policy and governance issues. The intersecting health system capabilities identified were the need for: (1) sufficiently functional frontline health services, (2) sufficiently trained and motivated health care workers, (3) availability of technical tools and equipment suitable to facilitate integrated frontline services and (4) appropriately devolved authority and decision-making processes to enable frontline managers and staff to adapt integration to local circumstances. Moving beyond claims that integration is defined differently by different programs and thus unsuitable for comparison, this review demonstrates that synthesis is possible. It presents a common set of contextual factors and health system capabilities necessary for successful service integration which may be considered indicators of preparedness and could form the basis for an 'integration preparedness tool'.
Introduction Community health workers (CHWs) are increasingly being tasked to prevent and manage cardiovascular disease (CVD) and its risk factors in underserved populations in low-income and middle-income countries (LMICs); however, little is known about the required training necessary for them to accomplish their role. This review aimed to evaluate the training of CHWs for the prevention and management of CVD and its risk factors in LMICs. Methods A search strategy was developed in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and five electronic databases (Medline, Global Health, ERIC, EMBASE and CINAHL) were searched to identify peer-reviewed studies published until December 2016 on the training of CHWs for prevention or control of CVD and its risk factors in LMICs. Study characteristics were extracted using a Microsoft Excel spreadsheet and quality assessed using Effective Public Health Practice Project’s Quality Assessment Tool. The search, data extraction and quality assessment were performed independently by two researchers. Results The search generated 928 articles of which 8 were included in the review. One study was a randomised controlled trial, while the remaining were before–after intervention studies. The training methods included classroom lectures, interactive lessons, e-learning and online support and group discussions or a mix of two or more. All the studies showed improved knowledge level post-training, and two studies demonstrated knowledge retention 6 months after the intervention. Conclusion The results of the eight included studies suggest that CHWs can be trained effectively for CVD prevention and management. However, the effectiveness of CHW trainings would likely vary depending on context given the differences between studies (eg, CHW demographics, settings and training programmes) and the weak quality of six of the eight studies. Well-conducted mixed-methods studies are needed to provide reliable evidence about the effectiveness and cost-effectiveness of training programmes for CHWs.
- Jul 2017
It is important that researchers who study health system governance have a set of collective under-standings of the meanings of governance, which can then inform the methods used in research. We present an institutional framing and definition of health system governance; that is, governance refers to making, changing, monitoring and enforcing the rules that govern the demand and supply of health services. This pervasive, relational view of governance is to be preferred to approaches that focus primarily on structures of governments and health care organizations, because health system governance involves communities and service users, and because governments in many low-and middle-income countries tend to under-govern. Therefore, the study of health system governance requires institutional analysis; an approach that focuses not only on structures, but also on the rules (both formal and informal) governing demand and supply relations. Using this 'structure–relations' lens, and based on our field experience, we discuss how this focus could be applied to the three approaches to framing and studying health system governance that we identified in the literature. In order of decreasing focus on structures ('hardware') and increasing focus on relations ('software'), they are: (1) the government-centred approach, which focuses on the role of governments, above or to the exclusion of non-government health system actors; (2) the building-block approach, which focuses on the internal workings of health care organizations , and treats governance as one of the several building blocks of organizations; and (3) the institutional approach, which focuses on how the rules governing social and economic interactions are made, changed, monitored and enforced. Notably, either or both qualitative and quantitative methods may be used by researchers in efforts to incorporate the analysis of how rules determine relations among health system actors into these three approaches to health system governance.
- May 2017
While food insecurity is a well-known cause of under-nutrition and stunting, in recent decades it has also been linked with obesity. Understanding and thus minimising the risk factors for obesity in low- and middle-income country contexts, which often lack the health system capacity to treat the consequent obesity-related illnesses, is crucial. This study adopted realist review methodology because it enabled us to analyse and organise the evidence from low- and middle-income countries into a coherent scheme. By comparing this evidence to existing theory on food security and nutrition, we aimed to provide a richer understanding of the nuances and the socio-demographic nature of the food insecurity-obesity relationship. The review generated 13 peer-reviewed articles which studied the relationship between food insecurity and overweight/obesity in low- and middle-income countries. Affordability of high-energy, processed foods was identified as a main mechanism, which determined whether or not food insecurity leads to obesity in low- and middle-income countries. Other mechanisms identified were: quantity and diversity of food consumed; spatial-temporal access to nutritious food; inter-personal food choice and distribution; and non-dietary behaviours. Despite the limited empirical evidence available, our review presents meaningful and policy-relevant insights into the food insecurity-obesity relationship in from low- and middle-income countries. Interventions to address the food insecurity-obesity link need to address diet quality, and demand a broad understanding across a variety of experiences.
Background Policy making, translation and implementation in politically and administratively decentralized systems can be challenging. Beyond the mere sub-national acceptance of national initiatives, adherence to policy implementation processes is often poor, particularly in low and middle-income countries. In this study, we explore the implementation fidelity of integrated PHC governance policy in Nigeria’s decentralized governance system and its implications on closing implementation gaps with respect to other top-down health policies and initiatives. Methods Having engaged policy makers, we identified 9 core components of the policy (Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Structure, and Office Establishment). We evaluated the level and pattern of implementation at state level as compared to the national guidelines using a scorecard approach. ResultsContrary to national government’s assessment of level of compliance, we found that sub-national governments exercised significant discretion with respect to the implementation of core components of the policy. Whereas 35 and 32% of states fully met national criteria for the structural domains of “Office Establishment” and Legislation” respectively, no state was fully compliant to “Human Resource Management” and “Funding” requirements, which are more indicative of functionality. The pattern of implementation suggests that, rather than implementing to improve outcomes, state governments may be more interested in executing low hanging fruits in order to access national incentives. Conclusions Our study highlights the importance of evaluating implementation fidelity in providing evidence of implementation gaps towards improving policy execution, particularly in decentralized health systems. This approach will help national policy makers identify more effective ways of supporting lower tiers of governance towards improvement of health systems and outcomes.
- Feb 2017
Responsibility for immunisation in Nigeria is decentralised to sub-national governments. So far, they have failed to achieve optimal coverage for their populations. We evaluated a pilot intervention implemented between 2013 and 2014 to redesign a vaccine supply chain management system in Kano, Nigeria. The intervention included financing immunisation services from a designated pool of government and donor funds, a visibility tool to track vaccine stock, and a private vendor engaged to deliver vaccines directly to health facilities. The number of local government areas within the state with adequate vaccine stock increased from 21% to 98% after 10 months. To understand how the intervention achieved this outcome, we analysed immunisation coverage for the period and interviewed 18 respondents across different levels of government. We found that the intervention worked by improving ownership and accountability for immunisation by sub-national governments and their capacity for generating resources and management (of data and the supply chain). While the intervention focused on improving immunisation coverage, we identified gaps in the demand for services. Efforts to improve immunisation coverage and vaccine supply systems should streamline decentralised structures, empower sub-national governments with financial and technical capacity, and promote strategies to improve the demand and use of services.
In 6 months, WHO will have a new Director General, who will likely start off by promising and identifying areas for reforms. One intent of such reforms will likely be to improve efficiency within the organisation. The commentary by Negin and Dhillon sought to provide one example of how WHO could improve efficiency—outsourcing functions for which WHO may not have a comparative advantage. The article received much …
- Dec 2016
Background The federal government of Nigeria started the Midwives Service Scheme in 2009 to address the scarcity of skilled health workers in rural communities by temporarily redistributing midwives from urban to rural communities. The scheme was designed as a collaboration among federal, state and local governments. Six years on, this study examines the contextual factors that account for the differences in performance of the scheme in Benue and Kogi, two contiguous states in central Nigeria. Methods We obtained qualitative data through 14 in-depth interviews and 2 focus group discussions: 14 government officials at the federal, state and local government levels were interviewed to explore their perceptions on the design, implementation and sustainability of the Midwives Service Scheme. In addition, mothers in rural communities participated in 2 focus group discussions (one in each state) to elicit their views on Midwives Service Scheme services. The qualitative data were analysed for themes. ResultsThe inability of the federal government to substantially influence the health care agenda of sub-national governments was a significant impediment to the achievement of the objectives of the Midwives Service Scheme. Participants identified differences in government prioritisation of primary health care between Benue and Kogi as relevant to maternal and child health outcomes in those states: Kogi was far more supportive of the Midwives Service Scheme and primary health care more broadly. High user fees in Benue was a significant barrier to the uptake of available maternal and child health services. Conclusion Differential levels of political support and prioritisation, alongside financial barriers, contribute substantially to the uptake of maternal and child health services. For collaborative health sector strategies to gain sufficient traction, where federating units determine their health care priorities, they must be accompanied by strong and enforceable commitment by sub-national governments.
One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a " make-or-buy " decision. The " make " decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm—informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses.
Background: The federal government of Nigeria started the Midwives Service Scheme in 2009 to address the scarcity of skilled health workers in rural communities by temporarily redistributing midwives from urban to rural communities. The scheme was designed as a collaboration among federal, state and local governments. Six years on, this study examines the contextual factors that account for the differences in performance of the scheme in Benue and Kogi, two contiguous states in central Nigeria. Methods: We obtained qualitative data through 14 in-depth interviews and 2 focus group discussions: 14 government officials at the federal, state and local government levels were interviewed to explore their perceptions on the design, implementation and sustainability of the Midwives Service Scheme. In addition, mothers in rural communities participated in 2 focus group discussions (one in each state) to elicit their views on Midwives Service Scheme services. The qualitative data were analysed for themes. Results: The inability of the federal government to substantially influence the health care agenda of sub-national governments was a significant impediment to the achievement of the objectives of the Midwives Service Scheme. Participants identified differences in government prioritisation of primary health care between Benue and Kogi as relevant to maternal and child health outcomes in those states: Kogi was far more supportive of the Midwives Service Scheme and primary health care more broadly. High user fees in Benue was a significant barrier to the uptake of available maternal and child health services. Conclusion: Differential levels of political support and prioritisation, alongside financial barriers, contribute substantially to the uptake of maternal and child health services. For collaborative health sector strategies to gain sufficient traction, where federating units determine their health care priorities, they must be accompanied by strong and enforceable commitment by sub-national governments.
Background Development Assistance for Health (DAH) in Nigeria has been on the increase since the advent of civilian democracy in 1999 after decades of military rule. Although Nigeria is not a donor-dependent country, donor agencies in the last decade have made significant investments in efforts to reform Nigerian health sector for improved service delivery and health outcomes. This paper attempts to track the trend of DAH over time, understand the aid instruments, the coordinating and accountability mechanisms among others. The information would help in improving aid alignment as Nigeria transits into the SDG era as a low-medium income country. Methods To understand the pattern of DAH in Nigeria, relevant data was extracted from the database of Organization for Economic Cooperation and Development (OECD)’s Development Assistance Committee (DAC). We also reviewed published literature and reports by Institute for Health Metrics and Evaluation (IHME) and International Health Partnership (IHP+), Nigeria’s Ministry of Budget and National Planning as well as the National Health Accounts. We also reviewed donor aid related policies and reports to further understand the coordination and accountability mechanisms for DAH in Nigeria. Results The results show that although donor funding constitute a small percentage of total health expenditure in Nigeria, DAH increased significantly over the past decade, running into millions of dollars. Funding and technical assistance from donor agencies were targeted at population health interventions especially disease programmes like HIV/AIDS, Tuberculosis and Malaria. Although we did not explore the political economy of DAH, it was observed that certain regions in Nigeria benefitted more from donor assistance. The geographic consideration may have been influenced by disease burden and socio-economic indices. Traditional bilateral donors like United States and Britain are major players in addition to multilateral donors, with Canada, Japan, France, South Korea, China, Norway active in the health sector as well. In recent times, international Foundations like Bill and Melinda Gates have become major players with the increasing roles of local philanthropies and foundations. Overall, donor coordination role by the government is weak, thus affecting aid alignment. Conclusion There is need to strengthen institutional mechanisms for coordinating DAH in Nigeria, as the country grapples with the realities of contracting fiscal space and reduced funding for the health sector. Pool funding mechanisms and strong accountability mechanisms might help to improve donor alignment and channeling of resources towards achieving UHC and health related SDGs in Nigeria.
- Sep 2016
Background: Decentralised governance of health care has been widely adopted globally over the past three decades. But despite being implemented as a management strategy across many health systems, its impact on health equity is yet unclear. Objective: To conduct a systematic literature review of the implications of decentralised governance of health care on equity in health, health care and health financing. Methods: A systematic search of CINAHL, EconLit, Embase, MEDLINE, PsycINFO, PubMed, Scopus, and Cochrane database of systematic reviews was conducted. Articles that met the inclusion criteria examined entire health systems and the relationship between implementing decentralised governance and health-related equity. The quality of reporting of the included studies was assessed using a 10-point quality rating tool. Results: Out of 808 articles identified, 9 met the inclusion criteria. The included studies were mostly explorative and used a range of quantitative techniques to analyse the relationship between variables of interest. The review found that depending on context, decentralisation could either lead to equity gains or exacerbate inequities. The impact of decentralisation on inequities in health and health care depends on pre-existing socio-economic disparities and financial barriers to access. While decentralisation can lead to inequities in health financing between sub-national jurisdictions, this is minimised with substantial central government transfers and cross subsidisation. Conclusion: The implications of decentralised governance of health systems on health-related equity are varied and depend on pre-existing socio-economic and organisational context, the form of decentralisation implemented and the complementary mechanisms implemented alongside decentralisation.
The posting and transfer of health workers and managers receives little policy and research attention in global health. In Nigeria, there is no national policy on posting and transfer in the health sector. We sought to examine how the posting and transfer of frontline primary health care (PHC) workers is conducted in four states (Lagos, Benue, Nasarawa and Kaduna) across Nigeria, where public sector PHC facilities are usually the only form of formal health care service providers available in many communities. We conducted in-depth interviews with PHC workers and managers, and group discussions with community health committee members. The results revealed three mechanisms by which PHC managers conduct posting and transfer: (1) periodically moving PHC workers around as a routine exercise aimed at enhancing their professional experience and preventing them from being corrupted; (2) as a tool for improving health service delivery by assigning high-performing PHC workers to PHC facilities perceived to be in need, or posting PHC workers nearer their place of residence; and (3) as a response to requests for punishment or favour from PHC workers, political office holders, global health agencies and community health committees. Given that posting and transfer is conducted by discretion, with multiple influences and sometimes competing interests, we identified practices that may lead to unfair treatment and inequities in the distribution of PHC workers. The posting and transfer of PHC workers therefore requires policy measures to codify what is right about existing informal practices and to avert their negative potential. © 2016 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.
Nigeria faces challenges that delay progress toward the attainment of the national government's declared goal of universal health coverage (UHC). One such challenge is system-wide inequities resulting from lack of financial protection for the health care needs of the vast majority of Nigerians. Only a small proportion of Nigerians have prepaid health care. In this paper, we draw on existing evidence to suggest steps toward reforming health care financing in Nigeria to achieve UHC through social health insurance. This article sets out to demonstrate that a viable path to UHC through expanding social health insurance exists in Nigeria. We argue that encouraging the states which are semi-autonomous federating units to setup and manage their own insurance schemes presents a unique opportunity for rapidly scaling up prepaid coverage for Nigerians. We show that Nigeria's federal structure which prescribes a sharing of responsibilities for health care among the three tiers of government presents serious challenges for significantly extending social insurance to uncovered groups. We recommend that rather than allowing this governance structure to impair progress toward UHC, it should be leveraged to accelerate the process by supporting the states to establish and manage their own insurance funds while encouraging integration with the National Health Insurance Scheme.
- Dec 2015
International scholarships for higher education are a large component of foreign aid in many high-income countries, including Australia. The aims for Australian scholarships awarded to African students are to achieve development in Africa and advance the influence of Australia. However, well-articulated theories of change that define how scholarships are linked to these and other outcomes are not available in the literature. In order to address this gap, the authors explore the perspectives of Australian-funded Master's-level alumni from Kenya, Uganda and Mozambique on the implementation process before, during and after their scholarship award, and the outcomes of the scholarships. The authors found that Australian scholarships to Africans have the potential to spread Australian influence, and that returnee scholars, by virtue of their study in Australia, gain the capacity to become agents for development in their country. The process of choosing scholarship awardees, the local circumstances in each country on return, and support and mentoring networks after return can influence the achievement of these outcomes. Investments in international scholarships should be directed to develop additional skills and facilitate networks in order to further prepare the returnee scholars to influence development in their country and perpetuate Australian influence.
Background: The available data on routine immunization in Nigeria show a disparity in coverage between Northern and Southern Nigeria, with the former performing worse. The effect of socio-cultural differences on health-seeking behaviour has been identified in the literature as the main cause of the disparity. Our study analyses the role of supply-side determinants, particularly access to services, in causing these disparities. Methods: Using routine government data, we compared supply-side determinants of access in two Northern states with two Southern states. The states were identified using criteria-based purposive selection such that the comparisons were made between a low-coverage state in the South and a low-coverage state in the North as well as between a high-coverage state in the South and a high-coverage state in the North. Results: Human resources and commodities at routine immunization service delivery points were generally insufficient for service delivery in both geographical regions. While disparities were evident between individual states irrespective of regional location, compared to the South, residents in Northern Nigeria were more likely to have vaccination service delivery points located within a 5km radius of their settlements. Conclusion: Our findings suggest that regional supply-side disparities are not apparent, reinforcing the earlier reported socio-cultural explanations for disparities in routine immunization service uptake between Northern and Southern Nigeria. Nonetheless, improving routine immunisation coverage services require that there are available human resources and that health facilities are equitably distributed.
Health systems are complex and health policies are political. While grand policies are set by politicians, the detailed implementation strategies which influence the shape and impact of these policies are delegated to technical personnel. This is an underappreciated opportunity for optimising health systems. We propose that selective 'breeding' through successive evaluations of and selection among implementation strategies is a metaphor that health system thinkers can use to improve health care. Similar to Darwinian evolution, the acceptance and accumulation of successful choices and the detection and discarding of unsuccessful ones would improve health systems in small and uncontroversial ways, over time. The effects of better implementation choices would be synergistic and cumulative, accumulating large impact (and lessons) from small changes. Just as with evolution of species, this means that even slight improvements over usual outcomes makes these numerous small choices as important a focus for system improvement as the overarching policy itself. Several alternative implementation approaches can be compared under real-world conditions in prospective head-to-head experimental and non-experimental explorations to understand whether and to what extent a strategy works and what works for whom, how, and under what circumstances in different locations. As in breeding or evolution, the best variants would spread to become the new, proven superior, implementation strategies for that policy in those settings. Evolution does not produce a new species whole, in a single transaction. Instead it gathers new parts and powers over time as different combinations are tested through competition with one another, to survive and spread or become extinct. Without necessarily changing or challenging grand policies, extending this idea to health systems innovation can facilitate thinking around how local, small - but cumulative - improvements in implementation potentially contribute to a pattern of successive adaptation spreading within its viable niche and ultimately providing locally-derived, long-term improvements in health systems.
Since the mid-1980s, the national health policy in Nigeria has sought to inspire community engagement in primary health care by bringing communities into partnership with service providers through community health committees. Using a realist approach to understand how and under what circumstances the committees function, we explored 581 meeting minutes from 129 committees across four states in Nigeria (Lagos, Benue, Nasarawa and Kaduna). We found that community health committees provide opportunities for improving the demand and supply of health care in their community. Committees demonstrate five modes of functioning: through meetings (as 'village square'), reaching out within their community (as 'community connectors'), lobbying governments for support (as 'government botherers'), inducing and augmenting government support (as 'back-up government') and taking control of health care in their community (as 'general overseers'). In performing these functions, community health committees operate within and through the existing social, cultural and religious structures of their community, thereby providing an opportunity for the health facility with which they are linked to be responsive to the needs and values of the community. But due to power asymmetries, committees have limited capacity to influence health facilities for improved performance, and governments for improved health service provision. This is perhaps because national guidelines are not clear on their accountability functions; they are not aware of the minimum standards of services to expect; and they have a limited sense of legitimacy in their relations with sub-national governments because they are established as the consequence of a national policy. Committees therefore tend to promote collective action for self-support more than collective action for demanding accountability. To function optimally, community health committees require national government or non-government organization mentoring and support; they need to be enshrined in law to bolster their sense of legitimacy; and they also require financial support to subsidise their operation costs especially in geographically large communities. © The Author 2015. Published by Oxford University Press.
In Nigeria, the shortage of health workers is worst at the primary health care (PHC) level, especially in rural communities. And the responsibility for PHC - usually the only form of formal health service available in rural communities - is shared among the three tiers of government (federal, state, and local governments). In addition, the responsibility for community engagement in PHC is delegated to community health committees. This study examines how the decentralisation of health system governance influences retention of health workers in rural communities in Nigeria from the perspective of health managers, health workers, and people living in rural communities. The study adopted a qualitative approach, and data were collected using semi-structured in-depth interviews and focus group discussions. The multi-stakeholder data were analysed for themes related to health system decentralisation. The results showed that decentralisation influences the retention of rural health workers in two ways: 1) The salary of PHC workers is often delayed and irregular as a result of delays in transfer of funds from the national to sub-national governments and because one tier of government can blame failure on another tier of government. Further, the primary responsibility for PHC is often left to the weakest tier of government (local governments). And the result is that rural PHC workers are attracted to working at levels of care where salaries are higher and more regular - in secondary care (run by state governments) and tertiary care (run by the federal government), which are also usually in urban areas. 2) Through community health committees, rural communities influence the retention of health workers by working to increase the uptake of PHC services. Community efforts to retain health workers also include providing social, financial, and accommodation support to health workers. To encourage health workers to stay, communities also take the initiative to co-finance and co-manage PHC services in order to ensure that PHC facilities are functional. In Nigeria and other low- and middle-income countries with decentralised health systems, intervention to increase the retention of health workers in rural communities should seek to reform and strengthen governance mechanisms, using both top-down and bottom-up strategies to improve the remuneration and support for health workers in rural communities.
Knowledge that older people are vulnerable to develop tuberculosis is rarely considered in developing country settings. According to 2010 Global Burden of Disease estimates, the majority of tuberculosis-related deaths occurred among people older than 50; most in those aged 65 and above. Older people also contribute a large proportion of Disability-Adjusted Life Years (DALYs); 51% of tuberculosis DALYs occurred in patients aged 50 years and older in East Asia. Tuberculosis age distributions in Africa have been severely skewed by the human immunodeficiency virus (HIV) epidemic, but emerging data suggest increasing disease burdens among older people. Older adults are more likely to develop extra-pulmonary and atypical forms of disease that are often harder to diagnose than conventional sputum smear-positive pulmonary tuberculosis. Their care is complicated by more frequent drug-related adverse events and increased co-morbidity, which may prove difficult to manage in regions where health resources are already constrained. Health systems will have to confront the challenge of an ageing global population and the integrated services required to address their health needs. Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.
Health care costs incurred prior to the appropriate patient-provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.
Although there is evidence that non-government health system actors can individually or collectively develop practical strategies to address primary health care (PHC) challenges in the community, existing frameworks for analysing health system governance largely focus on the role of governments, and do not sufficiently account for the broad range of contribution to PHC governance. This is important because of the tendency for weak governments in low- and middle-income countries (LMICs). We present a multi-level governance framework for use as a thinking guide in analysing PHC governance in LMICs. This framework has previously been used to analyse the governance of common-pool resources such as community fisheries and irrigation systems. We apply the framework to PHC because, like common-pool resources, PHC facilities in LMICs tend to be commonly owned by the community such that individual and collective action is often required to avoid the 'tragedy of the commons'-destruction and degradation of the resource resulting from lack of concern for its continuous supply. In the multi-level framework, PHC governance is conceptualized at three levels, depending on who influences the supply and demand of PHC services in a community and how: operational governance (individuals and providers within the local health market), collective governance (community coalitions) and constitutional governance (governments at different levels and other distant but influential actors). Using the example of PHC governance in Nigeria, we illustrate how the multi-level governance framework offers a people-centred lens on the governance of PHC in LMICs, with a focus on relations among health system actors within and between levels of governance. We demonstrate the potential impact of health system actors functioning at different levels of governance on PHC delivery, and how governance failure at one level can be assuaged by governance at another level.
that, despite achievements in top down political engagement at the national and sub-national levels, va ccine refusal and scant information on the importance and availability of oral poliovirus vaccine (OPV) at the community level continue to impede poliomyelitis eradication eﬀ orts in northern Nigeria. However, in addition to contextual factors that account for vaccine refusal,
Seye Abimbola and colleagues provide a view from Nigeria, Pakistan, and Afghanistan on global efforts to eradicate polio in those countries. Please see later in the article for the Editors' Summary
Studies on costs incurred by patients for tuberculosis (TB) care are limited as these costs are reported as averages, and the economic impact of the costs is estimated based on average patient/household incomes. Average expenditures do not represent the poor because they spend less on treatment compared to other economic groups. Thus, the extent to which TB expenditures risk sending households into, or further into, poverty and its determinants, is unknown. We assessed the incidence and determinants of household catastrophic payments for TB care in rural Nigeria. Data used were obtained from a survey of 452 pulmonary TB patients sampled from three rural health facilities in Ebonyi State, Nigeria. Using household direct costs and income data, we analyzed the incidence of household catastrophic payments using, as thresholds, the traditional >10% of household income and the >=40% of non-food income, as recommended by the World Health Organization. We used logistic regression analysis to identify the determinants of catastrophic payments. Average direct household costs for TB were US$157 or 14% of average annual incomes. The incidence catastrophic payment was 44%; with 69% and 15% of the poorest and richest household income-quartiles experiencing catastrophic activity, respectively. Independent determinants of catastrophic payments were: age >40 years (adjusted odds ratio [aOR] 3.9; 95% confidence interval [CI], 2.0, 7.8), male gender (aOR 3.0; CI 1.8, 5.2), urban residence (aOR 3.8; CI 1.9, 7.7), formal education (aOR 4.7; CI 2.5, 8.9), care at a private facility (aOR 2.9; 1.5, 5.9), poor household (aOR 6.7; CI 3.7, 12), household where the patient is the primary earner (aOR 3.8; CI 2.2, 6.6]), and HIV co-infection (aOR 3.1; CI 1.7, 5.6). Current cost-lowering strategies are not enough to prevent households from incurring catastrophic out-of-pocket payments for TB care. Financial and social protection interventions are needed for identified at-risk groups, and community-level interventions may reduce inefficiencies in the care-seeking pathway. These observations should inform post-2015 TB strategies and influence policy-making on health services that are meant to be free of charge.
It is necessary to select a range of consistently identified prognostic factors from exploratory studies to include in multivariate models of confirmatory studies. We illustrate a systematic approach to selecting consistently identified prognostic factors using the example of predictors of remission in newly diagnosed epilepsy. Medline and Embase were searched for reports of cohort studies enrolling at least 100 people with epilepsy within 1 year of diagnosis, and followed up for at least 1 year. We included studies that identified predictors of remission after adjusting for confounders using multivariate regression analysis. To identify consistent predictors a chart was designed to list the variables considered for inclusion in each model and those retained in more than one model from different cohorts were deemed to be consistent. Remission off medication was less likely if there was more than one seizure between 6 and 12 months on medication and if there was comorbid intellectual disability in childhood onset epilepsy. The likelihood of remission on or off medication reduces with mixed seizure types at onset, intellectual disability, symptomatic aetiology, and also with increasing number of seizures before diagnosis or in the first 6 months after diagnosis. A greater number of seizures before diagnosis and early in treatment, intellectual disability, and symptomatic aetiology are consistent predictors of less likelihood of remission. This suggests that early identification, diagnosis of epilepsy, and seizure control should be the primary aim of medical intervention, and that these predictors should be included in future confirmatory studies of prognostic factors of remission in newly diagnosed epilepsy.
DK and JVL have been engaged in establishing a new society for health systems research (Health Systems Global) since its idea phase, over a year ago. MPK has actively participated in the discussions leading to the translation of this concept into reality. This paper outlines some of the thinking that has gone into the initial interim design of the society and includes our hopes for how the society will develop.
Maternal, newborn, and child health indices in Nigeria vary widely across geopolitical zones and between urban and rural areas, mostly due to variations in the availability of skilled attendance at birth. To improve these indices, the Midwives Service Scheme (MSS) in Nigeria engaged newly graduated, unemployed, and retired midwives to work temporarily in rural areas. The midwives are posted for 1 year to selected primary care facilities linked through a cluster model in which four such facilities with the capacity to provide basic essential obstetric care are clustered around a secondary care facility with the capacity to provide comprehensive emergency obstetric care. The outcome of the MSS 1 year on has been an uneven improvement in maternal, newborn, and child health indices in the six geopolitical zones of Nigeria. Major challenges include retention, availability and training of midwives, and varying levels of commitment from state and local governments across the country, and despite the availability of skilled birth attendants at MSS facilities, women still deliver at home in some parts of the country.
The benefits of an interconnected world for health care remain untapped. As a result of the politics of inequality between rich and poor countries, one or a few health systems are set up as models. Every country, irrespective of political or economic status, should be open to learning from others to build relevant and cost-effective systems. To combat the current global challenge of chronic non-communicable diseases, poor countries have the advantage of flexible health systems that are veritable laboratories of health systems research. Not only can research conducted in these health systems help harness the potential of mobile communication technologies and informal health providers, it can also help rich country health systems adapt to meet the chronic disease challenge.
Remission while on anti-epileptic drug (AED) therapy and remission off AED are the only prognostic criteria defined by the International League against Epilepsy (ILAE), defining remission as 5 seizure-free years. Prognosis studies in epilepsy have investigated other prognostic categories using different designs and definitions. This systematic review explores factors that explain discrepancies in the proportion of patients reported with commonly studied prognostic categories in general epilepsy cohorts. Thirty publications (reporting 37 studies) were included. The outcome categories were classified as immediate remission (5 studies), remission off medication (7 studies), remission on or off medication (15 studies), intractability (9 studies) and no remission after relapse (1 study). The findings show the importance of qualifying estimates specifically by how they were defined in each study, study design, setting and patient population as these have implications for patient management and counselling. The ILAE should define the outcome measures and terminology to which researchers should be required to adhere in subsequent updates of their guidelines on research related to remission and intractability.
- Feb 2011
To expand the evidence base on the prevalence of non-communicable disease (NCD) risk factors in rural Africa, in particular among older adults aged 50 and older. Cross-sectional study in three rural sites in Malawi, Rwanda and Tanzania. One person was interviewed from each of 665 households selected through a stratified random sampling procedure across the three sites. The questionnaire included socio-demographic characteristics, smoking and alcohol intake as well as a food frequency questionnaire. Smoking rates among older men and women were higher than among adults under 50. While only 2.3% of women under 50 were current smokers, 21.0% of older women smoked (P<0.0001). Among men, 19.0% of men under 50 smoked versus 36.6% of older men (P=0.001). Alcohol consumption among older women aged 50 and older (45.0%) was more common (P=0.005) than among women under 50 (27.6%). Examining a set of five risk factors, more men aged 50 and older (49.5%) had two or more risk factors than men under 50 (25.5%) (P<0.0001). Similarly, 52.0% of women aged 50 and older had two or more risk factors, versus 24.1% of women under 50 (P<0.0001). Contrary to what is seen in developed country settings, this study reveals high rates of smoking and alcohol consumption among men and women aged 50 years and older in rural Africa that puts them at risk of NCDs. The health of older adults in rural Africa has been neglected, and these findings highlight the importance of reaching out to older adults with messaging regarding diet, smoking, alcohol use and general health.
The former US president Bill Clinton has brokered a deal to provide cheaper antiretroviral drugs for people with HIV in developing countries. The agreement was reached between the William J Clinton Foundation, a charity set up to foster health security and economic empowerment worldwide, and two Indian manufacturers of generic drugs, Cipla and Matrix. The reduced prices will be available in 66 developing countries in Africa, Asia, Latin America, and the Caribbean. “Seven million people in the developing world are in need of treatment for HIV/AIDS,” said Mr Clinton. “We are trying to meet that need with the best medicine available today and at prices that low and middle income countries can afford.” Under the deal, the first line combination of tenofovir, lamivudine, and efavirenz, taken as a single daily dose, will cost $340 (£170; €250) per patient each year. This is a reduction of 45% in low income countries and 67% in many middle income countries. The deal was made possible by funding from UNITAID, an international drug purchasing organisation. Established in 2006 by France, Brazil, Chile, Norway, and the United Kingdom, UNITAID raises funds from a levy on airline ticket sales to support health care in developing countries. It will provide the Clinton Foundation's HIV and AIDS initiative with more than $100m to buy second line drugs for 27 countries throughout 2008. Philippe Douste-Blazy, the French foreign minister and chairman of the UNITAID board, said, “Every person living with HIV deserves access to the most effective medicines, and UNITAID aims to ensure that these are affordable for all developing countries.” About 750 000 people worldwide are currently receiving drugs to treat AIDS through the Clinton Foundation.