Population assessment of health system performance in 16 countries.

Objective: To demonstrate how the new internationally comparable instrument, the People's Voice Survey, can be used to contribute the perspective of the population in assessing health system performance in countries of all levels of income. Methods: We surveyed representative samples of populations in 16 low-, middle- and high-income countries on health-care utilization, experience and confidence during 2022-2023. We summarized and visualized data corresponding to the key domains of the World Health Organization universal health coverage framework for health system performance assessment. We examined correlation with per capita health spending by calculating Pearson coefficients, and within-country income-based inequities using the slope index of inequality. Findings: In the domain of care effectiveness, we found major gaps in health screenings and endorsement of public primary care. Only one in three respondents reported very good user experience during health visits, with lower proportions in low-income countries. Access to health care was rated highest of all domains; however, only half of the populations felt secure that they could access and afford high-quality care if they became ill. Populations rated the quality of private health systems higher than that of public health systems in most countries. Only half of respondents felt involved in decision-making (less in high-income countries). Within countries, we found statistically significant pro-rich inequalities across many indicators. Conclusion: Populations can provide vital information about the real-world function of health systems, complementing other system performance metrics. Population-wide surveys such as the People's Voice Survey should become part of regular health system performance assessments.

Containment of Ebola and Polio in Low-Resource Settings Using Principles and Practices of Emergency Operations Centers in Public Health.

Emergency Operations Centers (EOCs) have been credited with driving the recent successes achieved in the Nigeria polio eradication program. EOC concept was also applied to the Ebola virus disease outbreak and is applicable to a range of other public health emergencies. This article outlines the structure and functionality of a typical EOC in addressing public health emergencies in low-resource settings. It ascribes the successful polio and Ebola responses in Nigeria to several factors including political commitment, population willingness to engage, accountability, and operational and strategic changes made by the effective use of an EOC and Incident Management System. In countries such as Nigeria where the central or federal government does not directly hold states accountable, the EOC provides a means to improve performance and use data to hold health workers accountable by using innovative technologies such as geographic position systems, dashboards, and scorecards.

Predictive spatial risk model of poliovirus to aid prioritization and hasten eradication in Nigeria.

BACKGROUND: One of the challenges facing the Global Polio Eradication Initiative is efficiently directing limited resources, such as specially trained personnel, community outreach activities, and satellite vaccinator tracking, to the most at-risk areas to maximize the impact of interventions. A validated predictive model of wild poliovirus circulation would greatly inform prioritization efforts by accurately forecasting areas at greatest risk, thus enabling the greatest effect of program interventions. METHODS: Using Nigerian acute flaccid paralysis surveillance data from 2004-2013, we developed a spatial hierarchical Poisson hurdle model fitted within a Bayesian framework to study historical polio caseload patterns and forecast future circulation of type 1 and 3 wild poliovirus within districts in Nigeria. A Bayesian temporal smoothing model was applied to address data sparsity underlying estimates of covariates at the district level. RESULTS: We find that calculated vaccine-derived population immunity is significantly negatively associated with the probability and number of wild poliovirus case(s) within a district. Recent case information is significantly positively associated with probability of a case, but not the number of cases. We used lagged indicators and coefficients from the fitted models to forecast reported cases in the subsequent six-month periods. Over the past three years, the average predictive ability is 86 ± 2% and 85 ± 4% for wild poliovirus type 1 and 3, respectively. Interestingly, the predictive accuracy of historical transmission patterns alone is equivalent (86 ± 2% and 84 ± 4% for type 1 and 3, respectively). We calculate uncertainty in risk ranking to inform assessments of changes in rank between time periods. CONCLUSIONS: The model developed in this study successfully predicts districts at risk for future wild poliovirus cases in Nigeria. The highest predicted district risk was 12.8 WPV1 cases in 2006, while the lowest district risk was 0.001 WPV1 cases in 2013. Model results have been used to direct the allocation of many different interventions, including political and religious advocacy visits. This modeling approach could be applied to other vaccine preventable diseases for use in other control and elimination programs.

Conditional cash transfer schemes in Nigeria: potential gains for maternal and child health service uptake in a national pilot programme.

BACKGROUND: This paper describes use of a Conditional Cash Transfer (CCT) programme to encourage use of critical MNCH services among rural women in Nigeria. METHODS: The CCT programme was first implemented as a pilot in 37 primary health care facilities (PHCs), in nine Nigerian states. The programme entitles women using these facilities up to N5,000 (approximately US$30) if they attend antenatal care (ANC), skilled delivery, and postnatal care. There are 88 other PHCs from these nine states included in this study, which implemented a standard package of supply upgrades without the CCT. Data on monthly service uptake throughout the continuum of care was collected at 124 facilities during quarterly monitoring visits. An interrupted time series using segmented linear regression was applied to estimate separately the effects of the CCT programme and supply package on service uptake. RESULTS: From April 2013-March 2014, 20,133 women enrolled in the CCT. Sixty-four percent of beneficiaries returned at least once after registration, and 80% of women delivering with skilled attendance returned after delivery. The CCT intervention is associated with a statistically significant increase in the monthly number of women attending four or more ANC visits (increase of 15.12 visits per 100,000 catchment population, p < 0.01; 95% confidence interval 7.38 to 22.85), despite a negative level effect immediately after the intervention began (-45.53/100,000 catchment population; p < 0.05; 95% CI -82.71 to -8.36). A statistically significant increase was also observed in the monthly number of women receiving two or more Tetanus toxoid doses during pregnancy (21.65/100,000 catchment population; p < 0.01; 95% CI 9.23 to 34.08). Changes for other outcomes with the CCT intervention (number of women attending first ANC visit; number of deliveries with skilled attendance; number of neonates receiving OPV at birth) were not found to be statistically significant. CONCLUSIONS: The results show that the CCT intervention is capable of significant effects on service uptake, although results for several outcomes of interest were inconclusive. Key lessons learnt from the pilot phase of implementation include a need to track beneficiary retention throughout the continuum of care as closely as possible, and avert loss to follow-up.

Implications of a circulating vaccine-derived poliovirus in Nigeria.

BACKGROUND: The largest recorded outbreak of a circulating vaccine-derived poliovirus (cVDPV), detected in Nigeria, provides a unique opportunity to analyze the pathogenicity of the virus, the clinical severity of the disease, and the effectiveness of control measures for cVDPVs as compared with wild-type poliovirus (WPV). METHODS: We identified cases of acute flaccid paralysis associated with fecal excretion of type 2 cVDPV, type 1 WPV, or type 3 WPV reported in Nigeria through routine surveillance from January 1, 2005, through June 30, 2009. The clinical characteristics of these cases, the clinical attack rates for each virus, and the effectiveness of oral polio vaccines in preventing paralysis from each virus were compared. RESULTS: No significant differences were found in the clinical severity of paralysis among the 278 cases of type 2 cVDPV, the 2323 cases of type 1 WPV, and the 1059 cases of type 3 WPV. The estimated average annual clinical attack rates of type 1 WPV, type 2 cVDPV, and type 3 WPV per 100,000 susceptible children under 5 years of age were 6.8 (95% confidence interval [CI], 5.9 to 7.7), 2.7 (95% CI, 1.9 to 3.6), and 4.0 (95% CI, 3.4 to 4.7), respectively. The estimated effectiveness of trivalent oral polio vaccine against paralysis from type 2 cVDPV was 38% (95% CI, 15 to 54%) per dose, which was substantially higher than that against paralysis from type 1 WPV (13%; 95% CI, 8 to 18%), or type 3 WPV (20%; 95% CI, 12 to 26%). The more frequent use of serotype 1 and serotype 3 monovalent oral polio vaccines has resulted in improvements in vaccine-induced population immunity against these serotypes and in declines in immunity to type 2 cVDPV. CONCLUSIONS: The attack rate and severity of disease associated with the recent cVDPV identified in Nigeria are similar to those associated with WPV. International planning for the management of the risk of WPV, both before and after eradication, must include scenarios in which equally virulent and pathogenic cVDPVs could emerge.

Community health workers for universal health-care coverage: from fragmentation to synergy.

To achieve universal health coverage, health systems will have to reach into every community, including the poorest and hardest to access. Since Alma-Ata, inconsistent support of community health workers (CHWs) and failure to integrate them into the health system have impeded full realization of their potential contribution in the context of primary health care. Scaling up and maintaining CHW programmes is fraught with a host of challenges: poor planning; multiple competing actors with little coordination; fragmented, disease-specific training; donor-driven management and funding; tenuous linkage with the health system; poor coordination, supervision and support, and under-recognition of CHWs' contribution. The current drive towards universal health coverage (UHC) presents an opportunity to enhance people's access to health services and their trust, demand and use of such services through CHWs. For their potential to be fully realized, however, CHWs will need to be better integrated into national health-care systems in terms of employment, supervision, support and career development. Partners at the global, national and district levels will have to harmonize and synchronize their engagement in CHW support while maintaining enough flexibility for programmes to innovate and respond to local needs. Strong leadership from the public sector will be needed to facilitate alignment with national policy frameworks and country-led coordination and to achieve synergies and accountability, universal coverage and sustainability. In moving towards UHC, much can be gained by investing in building CHWs' skills and supporting them as valued members of the health team. Stand-alone investments in CHWs are no shortcut to progress.

Pour parvenir à une couverture sanitaire universelle, les systèmes de santé devront étendre leur portée à toutes les communautés, y compris celles qui sont les plus pauvres et les plus difficiles d'accès. Depuis la Déclaration de Alma-Ata, le soutien inégal des agents sanitaires des collectivités et l'échec de leur intégration dans les systèmes de santé ont empêché la pleine réalisation de leur contribution potentielle dans le contexte des soins de santé primaires. Le développement et le maintien des programmes des agents sanitaires des collectivités se heurtent à une multitude de défis à relever: mauvaise planification; multitude d'acteurs concurrents avec peu de coordination; formation fragmentée et spécifique aux maladies; gestion et financement à l'initiative des donateurs; lien ténu avec le système de santé; coordination, supervision et soutien de mauvaise qualité, et sous-reconnaissance de la contribution des agents sanitaires des collectivités.La campagne actuelle vers une couverture sanitaire universelle offre une opportunité d'améliorer l'accès des personnes à des services de santé, ainsi que leur confiance, demande et utilisation de tels services par le biais des agents sanitaires des collectivités. Pour que leur potentiel puisse être pleinement réalisé, les agents sanitaires des collectivités devront toutefois être mieux intégrés dans les systèmes nationaux de soins de santé en termes d'embauche, de supervision, de soutien et d'évolution de carrière. Les partenaires au niveau du monde, du pays et du district devront harmoniser et synchroniser leurs engagements dans le soutien aux agents sanitaires des collectivités tout en maintenant suffisamment de flexibilité pour permettre aux programmes d'innover et de répondre aux besoins locaux. Un leadership fort du secteur public sera nécessaire pour faciliter l'alignement avec les cadres politiques nationaux et la coordination dirigée par le pays et pour réaliser des synergies et des responsabilités, la couverture universelle et la durabilité. En avançant vers la couverture sanitaire universelle, il y a beaucoup à gagner en investissant dans l'acquisition de compétences des agents sanitaires des collectivités et en les soutenant en tant que membres à part entière des équipes de santé. Les investissements autonomes au bénéfice des agents sanitaires des collectivités ne sont pas des raccourcis vers le progrès.

A fin de lograr la cobertura universal de la salud, los sistemas sanitarios deben llegar a todas las comunidades, incluidas las más pobres y de difícil acceso. Desde la conferencia de Alma-Ata, el apoyo inconstante de los trabajadores comunitarios de salud (TCS) y la falta de integración de estos en el sistema sanitario han impedido la plena realización de su contribución potencial en el contexto de la atención primaria de la salud. La ampliación y el mantenimiento de los programas de trabajadores comunitarios de salud suponen muchos desafíos: la mala planificación, los agentes múltiples que compiten con insuficiente coordinación, la fragmentación en los programas de capacitación orientados a combatir enfermedades específicas, la gestión y la financiación impulsadas por los donantes, la escasa unión con el sistema sanitario, la falta de coordinación, supervisión y apoyo, y la infravaloración de la contribución de los trabajadores comunitarios de la salud.El avance actual hacia la cobertura universal de la salud (CUS) ofrece una oportunidad para mejorar el acceso de la población a los servicios de salud, así como para aumentar la confianza, la demanda y el uso de dichos servicios a través de los trabajadores comunitarios de salud. Sin embargo, es necesario integrar mejor a los trabajadores comunitarios de salud, en términos de empleo, supervisión, apoyo y desarrollo profesional, en los sistemas nacionales sanitarios para aprovechar plenamente su potencial. Los socios a nivel mundial, nacional y local deben armonizar y sincronizar su compromiso a favor de los trabajadores comunitarios de salud, manteniendo la flexibilidad suficiente para que los programas tengan capacidad de innovación y respuesta frente a las necesidades locales. Se requiere un fuerte liderazgo por parte del sector público para facilitar la alineación con los marcos de las políticas nacionales y la coordinación dirigida por el país, y para lograr sinergias y la rendición de cuentas, la cobertura universal y la sostenibilidad. En la consecución de la cobertura universal de la salud, pueden obtenerse grandes beneficios si se invierte en el desarrollo de competencias de los trabajadores comunitarios de salud, y se les apoya como miembros valiosos del equipo sanitario. Por el contrario, las inversiones aisladas en trabajadores comunitarios de salud no son atajos hacia el progreso.

The midwives service scheme in Nigeria.

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.

Measles resurgence following a nationwide measles vaccination campaign in Nigeria, 2005-2008.

INTRODUCTION: From 1990 through 2008, routine immunization coverage of measles vaccine in Nigeria ranged from 35% to 70%. Nigeria conducted a nationwide measles vaccination campaign in 2 phases during 2005-2006 that targeted children aged 9 months to 14 years; in 2008, a nationwide follow-up campaign that targeted children aged 9 months to 4 years was conducted in 2 phases. Despite these efforts, measles cases continued to occur. METHODS: This is a descriptive study that reviewed the measles immunization coverage data from administrative, World Health Organization, United Nations Children's Fund, survey, and supplemental immunization activities data. Measles surveillance data were analyzed from case-based surveillance reports. RESULTS: Confirmed measles cases increased from 383 in 2006 to 2542 in 2007 and to 9510 in 2008. Of the confirmed cases in 2008, 717 (30%) occurred in children <2 years of age, 1145 (48%) in children 2-4 years of age, and 354 (14%) were in children 5-14 years of age. In 2008, the measles case fatality rate was 1.2%. CONCLUSIONS: Suboptimal routine coverage and the wide interval between the catch-up and follow-up campaigns likely led to an accumulation of children susceptible to measles.

Outbreak of type 2 vaccine-derived poliovirus in Nigeria: emergence and widespread circulation in an underimmunized population.

Wild poliovirus has remained endemic in northern Nigeria because of low coverage achieved in the routine immunization program and in supplementary immunization activities (SIAs). An outbreak of infection involving 315 cases of type 2 circulating vaccine-derived poliovirus (cVDPV2; >1% divergent from Sabin 2) occurred during July 2005-June 2010, a period when 23 of 34 SIAs used monovalent or bivalent oral poliovirus vaccine (OPV) lacking Sabin 2. In addition, 21 "pre-VDPV2" (0.5%-1.0% divergent) cases occurred during this period. Both cVDPV and pre-VDPV cases were clinically indistinguishable from cases due to wild poliovirus. The monthly incidence of cases increased sharply in early 2009, as more children aged without trivalent OPV SIAs. Cumulative state incidence of pre-VDPV2/cVDPV2 was correlated with low childhood immunization against poliovirus type 2 assessed by various means. Strengthened routine immunization programs in countries with suboptimal coverage and balanced use of OPV formulations in SIAs are necessary to minimize risks of VDPV emergence and circulation.

Human resources for maternal, newborn and child health: from measurement and planning to performance for improved health outcomes.

BACKGROUND: There is increasing attention, globally and in countries, to monitoring and addressing the health systems and human resources inputs, processes and outputs that impede or facilitate progress towards achieving the Millennium Development Goals for maternal and child health. We reviewed the situation of human resources for health (HRH) in 68 low- and middle-income countries that together account for over 95% of all maternal and child deaths. METHODS: We collected and analysed cross-nationally comparable data on HRH availability, distribution, roles and functions from new and existing sources, and information from country reviews of HRH interventions that are associated with positive impacts on health services delivery and population health outcomes. RESULTS: Findings from 68 countries demonstrate availability of doctors, nurses and midwives is positively correlated with coverage of skilled birth attendance. Most (78%) of the target countries face acute shortages of highly skilled health personnel, and large variations persist within and across countries in workforce distribution, skills mix and skills utilization. Too few countries appropriately plan for, authorize and support nurses, midwives and community health workers to deliver essential maternal, newborn and child health-care interventions that could save lives. CONCLUSIONS: Despite certain limitations of the data and findings, we identify some key areas where governments, international partners and other stakeholders can target efforts to ensure a sufficient, equitably distributed and efficiently utilized health workforce to achieve MDGs 4 and 5.