Epidemiological insights into neonatal deaths: The role of cooking fuel pollution in Colombia.

PURPOSE: Household air pollution is one of the leading causes of death and disease globally. Emerging evidence of elevated risk of neonatal death has been reported in Africa and South Asia. However, evidence on the extent of the problem in Latin America is limited despite the persistent use of highly polluting cooking fuels. We assessed whether the use of high-polluting household cooking fuels increases the risk of neonatal death compared to low-polluting fuels in Colombia. METHODS: We used cross-sectional data from the 2005-2015 Colombian Demographic Health Survey and performed a survey-featured multivariate logistic regression. We selected adjustment covariates based on a causal diagram, addressed missing data through multiple imputation, and conducted several sensitivity analysis, such as propensity score matching. RESULT: We found evidence suggesting an increased risk of neonatal death in households using high-polluting fuels (OR: 1.48; 95% CI: 0.91, 2.39). The sensitivity analyses were consistent with the main analysis. CONCLUSION: We observed increased odds of neonatal death associated with using high-polluting household cooking fuels compared to low-polluting fuels, although this association was not statistically significant. This study contributes evidence to a region where the issue is not yet a priority and should be included in national-level discussions and interventions that impact cooking fuel use patterns.

Did the health care vaccine mandate work? An evaluation of the impact of the COVID-19 vaccine mandate on vaccine uptake and infection risk in a large cohort of Canadian health care workers.

BACKGROUND: We aimed to evaluate the impact of health care vaccine mandates on vaccine uptake and infection risk in a cohort of Canadian health care workers (HCWs). METHODS: We conduct interrupted time series analysis through a regression discontinuity in time approach to estimate the immediate and delayed impact of the mandate. Multilevel mixed effect modeling fitted with restricted maximum likelihood was used to estimate impact on infection risk. RESULTS: The immediate and sustained effects of the mandate was a 0.19% (P < .05) and a 0.012% (P < .05) increase in the daily proportion of unvaccinated HCWs getting their first dose, respectively. An additional 623 (95% confidence interval: 613-667) HCWs received first doses compared to the predicted uptake absent the mandate. Adjusted test positivity declined by 0.053% (95% confidence interval: 0.035%, 0.069) for every additional day the mandate was in effect. DISCUSSION: Our results indicate that the mandate was associated with significant increases in vaccine uptake and infection risk reduction in the cohort. CONCLUSIONS: Given the benefit that vaccination could bring to HCWs, understanding strategies to enhance uptake is crucial for bolstering health system resilience, but steps must be taken to avert approaches that sacrifice trust, foster animosity, or exacerbate staffing constraints for short-term results.

Are COVID-19 vaccination mandates for healthcare workers effective? A systematic review of the impact of mandates on increasing vaccination, alleviating staff shortages and decreasing staff illness.

INTRODUCTION: The rapid development of COVID-19 vaccines is a cornerstone in the global effort to combat the pandemic. Healthcare workers (HCWs), being at the forefront of the pandemic response, have been the focus of vaccine mandate policies. This review aims to evaluate the impacts of COVID-19 vaccine mandates among HCWs, a critical step in understanding the broader implications of such policies in healthcare settings. OBJECTIVE: The review seeks to synthesize available literature to contribute to greater understanding of the outcomes associated with COVID-19 vaccine mandates for HCWs including vaccine uptake, infection rates, and staffing. METHODS: A systematic search of relevant literature published from March 2020 to September 2023 was conducted. The Newcastle-Ottawa scale was employed for quality assessment of the included articles. A total of 4,779 publications were identified, with 15 studies meeting the inclusion criteria for the review. A narrative synthesis approach was used to analyze these studies. RESULTS: COVID-19 vaccine mandates for HCWs were broadly successful in increasing vaccine uptake in most settings. Although the penalties imposed on unvaccinated HCWs did not lead to major disruption of health services, less well-resourced areas may have been more impacted. Furthermore, there is insufficient literature on the impact of the vaccine mandate on reducing SARS-CoV-2 infection among HCWs. CONCLUSION: COVID-19 vaccine mandates for HCWs have significant implications for public health policy and healthcare management. The findings underscore the need for tailored approaches in mandate policies, considering the specific contexts of healthcare settings and the diverse populations of HCWs. While mandates have shown potential in increasing vaccine uptake with minimal impacts to staffing, more work is needed to investigate the impacts of mandates across various contexts. In addition to these impacts, future research should focus on long-term effects and implications on broader public health strategies.

Vaccination, time lost from work, and COVID-19 infections: a Canadian healthcare worker retrospective cohort study.

The COVID-19 pandemic highlighted hurdles for healthcare delivery and personnel globally. Vaccination has been an important tool for preventing severe illness and death in healthcare workers (HCWs) as well as the public at large. However, vaccination has resulted in some HCWs requiring time off work post-vaccination to recover from adverse events. We aimed to understand which HCWs needed to take time off work post-vaccination, for which vaccine types and sequence, and how post-vaccination absence impacted uptake of booster doses in a cohort of 26,267 Canadian HCWs. By March 31, 2022, more than 98% had received at least two doses of the approved COVID-19 vaccines, following a two-dose mandate. We found that recent vaccination and longer intervals between doses were associated with significantly higher odds of time-loss, whereas being a medical resident and receiving the BNT162b2 vaccine were associated with lower odds. A history of lab-confirmed SARS-CoV-2 infection was associated with lower odds of receiving a booster dose compared with no documented infection, aOR 0.61 (95% CI: 0.55, 0.68). Similarly, taking sick time following the first or second dose was associated with lower odds of receiving a booster dose, aOR 0.83 (95% CI: 0.75, 0.90). As SARS-CoV-2 becomes endemic, the number and timing of additional doses for HCWs requires consideration of prevention of illness as well as service disruption from post-vaccination time-loss. Care should be taken to ensure adequate staffing if many HCWs are being vaccinated, especially for coverage for those who are more likely to need time off to recover.

Protecting healthcare workers during a pandemic: what can a WHO collaborating centre research partnership contribute?

Objectives: To ascertain whether and how working as a partnership of two World Health Organization collaborating centres (WHOCCs), based respectively in the Global North and Global South, can add insights on "what works to protect healthcare workers (HCWs) during a pandemic, in what contexts, using what mechanism, to achieve what outcome". Methods: A realist synthesis of seven projects in this research program was carried out to characterize context (C) (including researcher positionality), mechanism (M) (including service relationships) and outcome (O) in each project. An assessment was then conducted of the role of the WHOCC partnership in each study and overall. Results: The research found that lower-resourced countries with higher economic disparity, including South Africa, incurred greater occupational health risk and had less acceptable measures to protect HCWs at the onset of the COVID-19 pandemic than higher-income more-equal counterpart countries. It showed that rigorously adopting occupational health measures can indeed protect the healthcare workforce; training and preventive initiatives can reduce workplace stress; information systems are valued; and HCWs most at-risk (including care aides in the Canadian setting) can be readily identified to trigger adoption of protective actions. The C-M-O analysis showed that various ways of working through a WHOCC partnership not only enabled knowledge sharing, but allowed for triangulating results and, ultimately, initiatives for worker protection. Conclusions: The value of an international partnership on a North-South axis especially lies in providing contextualized global evidence regarding protecting HCWs as a pandemic emerges, particularly with bi-directional cross-jurisdiction participation by researchers working with practitioners.

Masking strategy to protect healthcare workers from COVID-19: An umbrella meta-analysis.

BACKGROUND: The burden of severe disease and death due to SARS-CoV-2 (COVID-19) pandemic among healthcare workers (HCWs) worldwide has been substantial. Masking is a critical control measure to effectively protect HCWs from respiratory infectious diseases, yet for COVID-19, masking policies have varied considerably across jurisdictions. As Omicron variants began to be predominant, the value of switching from a permissive approach based on a point of care risk assessment (PCRA) to a rigid masking policy needed to be assessed. METHODS: A literature search was conducted in MEDLINE (Ovid platform), Cochrane Library, Web of Science (Ovid platform), and PubMed to June 2022. An umbrella review of meta-analyses investigating protective effects of N95 or equivalent respirators and medical masks was then conducted. Data extraction, evidence synthesis and appraisal were duplicated. RESULTS: While the results of Forest plots slightly favoured N95 or equivalent respirators over medical masks, eight of the ten meta-analyses included in the umbrella review were appraised as having very low certainty and the other two as having low certainty. CONCLUSION: The literature appraisal, in conjunction with risk assessment of the Omicron variant, side-effects and acceptability to HCWs, along with the precautionary principle, supported maintaining the current policy guided by PCRA rather than adopting a more rigid approach. Well-designed prospective multi-centre trials, with systematic attention to the diversity of healthcare settings, risk levels and equity concerns are needed to support future masking policies.

Protecting healthcare workers during a pandemic: what can a WHO collaborating centre research partnership contribute? / Protección de los trabajadores de salud durante una pandemia: ¿qué puede aportar una alianza para la investigación entre centros colaboradores de la OMS? / Proteção dos trabalhadores da saúde em uma pandemia: qual seria a contribuição de uma parceria de pesquisa entre centros colaboradores da OMS?

ABSTRACT Objectives. To ascertain whether and how working as a partnership of two World Health Organization collaborating centres (WHOCCs), based respectively in the Global North and Global South, can add insights on "what works to protect healthcare workers (HCWs) during a pandemic, in what contexts, using what mechanism, to achieve what outcome". Methods. A realist synthesis of seven projects in this research program was carried out to characterize context (C) (including researcher positionality), mechanism (M) (including service relationships) and outcome (O) in each project. An assessment was then conducted of the role of the WHOCC partnership in each study and overall. Results. The research found that lower-resourced countries with higher economic disparity, including South Africa, incurred greater occupational health risk and had less acceptable measures to protect HCWs at the onset of the COVID-19 pandemic than higher-income more-equal counterpart countries. It showed that rigorously adopting occupational health measures can indeed protect the healthcare workforce; training and preventive initiatives can reduce workplace stress; information systems are valued; and HCWs most at-risk (including care aides in the Canadian setting) can be readily identified to trigger adoption of protective actions. The C-M-O analysis showed that various ways of working through a WHOCC partnership not only enabled knowledge sharing, but allowed for triangulating results and, ultimately, initiatives for worker protection. Conclusions. The value of an international partnership on a North-South axis especially lies in providing contextualized global evidence regarding protecting HCWs as a pandemic emerges, particularly with bi-directional cross-jurisdiction participation by researchers working with practitioners.

RESUMEN Objetivos. Determinar si la asociación de dos centros colaboradores de la Organización Mundial de la Salud, ubicados uno en el hemisferio norte y el otro en el hemisferio sur, puede aportar información sobre "qué es necesario para proteger a los trabajadores de salud durante una pandemia, en qué contextos, con qué mecanismos, con el objetivo de lograr qué resultados". Métodos. Se realizó una síntesis realista de siete proyectos en este programa de investigación para caracterizar el contexto (C) (incluida la posición del investigador), el mecanismo (M) (incluidas las relaciones de servicio) y el resultado (R) en cada proyecto. A continuación, se realizó una evaluación del papel que desempeñó la alianza de centros colaboradores de la OMS en términos generales y en cada estudio. Resultados. En la investigación se encontró que los países de escasos recursos con mayor disparidad económica, como Sudáfrica, incurrieron en un mayor riesgo para la salud ocupacional y tenían medidas menos aceptables para proteger a los trabajadores de salud al inicio de la pandemia de COVID-19 que los países homólogos de mayores ingresos y mayor equidad. Se de mostró que la adopción rigurosa de medidas de salud ocupacional puede proteger al personal de salud; la capacitación y las iniciativas preventivas pueden reducir el estrés en el lugar de trabajo; los sistemas de información se consideran valiosos; y los trabajadores de salud de mayor riesgo (como los asistentes de atención en el entorno canadiense) pueden identificarse con facilidad para la adopción de medidas de protección. El análisis de C-M-R mostró que las diferentes formas de trabajar por medio de una alianza de centros colaboradores de la OMS no solo facilitaron el intercambio de conocimientos, sino que además permitieron triangular los resultados y, en última instancia, las iniciativas para la protección de los trabajadores. Conclusiones. El valor de una alianza internacional radica especialmente en proporcionar evidencia mundial contextualizada sobre la protección de los trabajadores de salud cuando surge una situación de pandemia, particularmente con la participación bidireccional entre distintas jurisdicciones de investigadores que trabajan con el personal de salud.

RESUMO Objetivo. Determinar se, e como, o trabalho em parceria entre dois centros colaboradores da Organização Mundial da Saúde (OMS), localizados no Norte e no Sul global, pode contribuir com conhecimento sobre "o que é eficaz para proteger os trabalhadores da saúde em uma pandemia, em que contextos, com que mecanismos e para obter quais resultados". Métodos. Foi realizada uma síntese realista de sete projetos de pesquisa do programa da OMS para determinar o contexto (C) (incluindo a posicionalidade dos pesquisadores), o mecanismo (M) (incluindo as relações entre os serviços) e o resultado (O, do inglês outcome) de cada projeto e avaliar o papel da parceria entre os centros colaboradores em cada estudo e em geral. Resultados. Este estudo demonstrou que, nos países de baixa renda com maior desigualdade econômica (por exemplo, na África do Sul), o risco à saúde ocupacional foi maior e as medidas adotadas para proteger os trabalhadores da saúde na pandemia de COVID-19 foram menos adequadas em comparação ao observado em países comparáveis de alta renda com menor desigualdade. Verificou-se que a adoção rigorosa de medidas de saúde ocupacional efetivamente protege os trabalhadores da saúde, e que iniciativas de prevenção e capacitação dos profissionais reduzem o estresse no trabalho. Também se reconhece a importância dos sistemas de informação e que o pessoal com maior risco de exposição ao vírus (incluindo os cuidadores auxiliares, no caso do Canadá) pode ser prontamente identificado para que sejam adotadas medidas de proteção. A análise do tipo C-M-O indicou que as diferentes formas de trabalho em parceria entre os centros colaboradores possibilitaram não apenas dividir conhecimentos, mas também compartilhar resultados e, sobretudo, iniciativas para a proteção dos trabalhadores da saúde. Conclusões. A parceria internacional no eixo Norte-Sul é particularmente importante para obter evidências globais contextualizadas relativas à proteção dos trabalhadores da saúde em uma situação de pandemia, com a participação bidirecional entre foros de pesquisadores que trabalham com o pessoal da saúde.

Healthcare clinic and pharmacy chains in Kenya and Nigeria: A qualitative exploration of the opportunities and risks they present for healthcare regulatory systems.

BACKGROUND: Regulating fragmented healthcare markets is a major challenge in low- and middle-income countries. Although a recent transformation towards consolidation could improve regulatory efficiency, there are concerns over risks to client safety and market functioning. We investigated market consolidation through the emergence of clinic and pharmacy chains in Kenya and Nigeria and explored resultant regulatory opportunities and risks. METHODS: The study was conducted in Nairobi Kenya and Abuja Nigeria. Data were collected through document reviews and 26 interviews with chain operators, professional associations and regulators between September and December 2018. A thematic analysis was conducted. RESULTS: We characterised two broad types of chains: organic chains that started as single business locations and expanded gradually, and investor-driven chains that expanded rapidly following external capital injection. In both countries, chains and independents were regulated similarly, with regulators failing to both capitalize on opportunities and guard against risks. For instance, chains' brand visibility and centralised management systems made them easier to regulate and more suitable for self-regulation. On the other hand, chains were perceived to pose the risks of market dominance, commercialisation of healthcare, and regulatory capture. CONCLUSION: As healthcare chains expand, regulators should build on opportunities presented and guard against emerging risks.

Traditional birth attendant-assisted versus unassisted births: a comparison of neonatal deaths in Nigeria, 2008-2018.

PURPOSE: to directly compare the risk of neonatal death between traditional birth attendant (TBA)-assisted and unassisted deliveries in Nigeria. METHODS: Using data on live births from the 2008, 2013, and 2018 Nigeria Demographic and Health Surveys, this cross-sectional study compared risk of neonatal death for TBA-assisted versus unassisted births. We used survey-featured logistic regression to estimate the odds of neonatal death. Survey year-stratified and propensity score-matched (PSM) estimates were obtained. Multivariate imputation by chained equation (MICE) for missing data was conducted. RESULTS: A total of 28, 922 births were included. Regression and PSM analysis of pooled data showed that unassisted births had lower odds of neonatal death compared to TBA-assisted births, (aOR 0.81, 95% CI: 0.65,1.00) and (aOR 0.80, 95% CI: 0.64,1.00), respectively. Regression analysis by survey year yielded non-significant higher odds of neonatal death for TBA-assisted births. Pooled estimates from MICE showed non-significant higher odds of death for TBA-assisted births. CONCLUSIONS: These findings indicate that birth care by TBAs do not necessarily lead to better neonatal survival. Jurisdictions seeking to allow continued operation of TBAs need to consider measures such as training, supervision, and regulation to ensure the safety of newborns.

The direct and indirect impact of COVID-19 pandemic on maternal and child health services in Africa: a scoping review.

INTRODUCTION: The novel coronavirus disease 2019 (COVID-19) continues to disrupt the availability and utilization of routine and emergency health care services, with differing impacts in jurisdictions across the world. In this scoping review, we set out to synthesize documentation of the direct and indirect effect of the pandemic, and national responses to it, on maternal, newborn and child health (MNCH) in Africa. METHODS: A scoping review was conducted to provide an overview of the most significant impacts identified up to March 15, 2022. We searched MEDLINE, Embase, HealthSTAR, Web of Science, PubMed, and Scopus electronic databases. We included peer reviewed literature that discussed maternal and child health in Africa during the COVID-19 pandemic, published from January 2020 to March 2022, and written in English. Papers that did not focus on the African region or an African country were excluded. A data-charting form was developed by the two reviewers to determine which themes to extract, and narrative descriptions were written about the extracted thematic areas. RESULTS: Four-hundred and seventy-eight articles were identified through our literature search and 27 were deemed appropriate for analysis. We identified three overarching themes: delayed or decreased care, disruption in service provision and utilization and mitigation strategies or recommendations. Our results show that minor consideration was given to preserving and promoting health service access and utilization for mothers and children, especially in historically underserved areas in Africa. CONCLUSIONS: Reviewed literature illuminates the need for continued prioritization of maternity services, immunization, and reproductive health services. This prioritization was not given the much-needed attention during the COVID-19 pandemic yet is necessary to shield the continent's most vulnerable population segments from the shocks of current and future global health emergencies.

COVID-19 vaccine hesitancy in Africa: a scoping review.

BACKGROUND: Vaccination against the novel coronavirus is one of the most effective strategies for combating the global Coronavirus disease (COVID-19) pandemic. However, vaccine hesitancy has emerged as a major obstacle in several regions of the world, including Africa. The objective of this rapid review was to summarize the literature on COVID-19 vaccine hesitancy in Africa. METHODS: We searched Scopus, Web of Science, African Index Medicus, and OVID Medline for studies published from January 1, 2020, to March 8, 2022, examining acceptance or hesitancy towards the COVID-19 vaccine in Africa. Study characteristics and reasons for COVID-19 vaccine acceptance were extracted from the included articles. RESULTS: A total of 71 articles met the eligibility criteria and were included in the review. Majority (n = 25, 35%) of the studies were conducted in Ethiopia. Studies conducted in Botswana, Cameroun, Cote D'Ivoire, DR Congo, Ghana, Kenya, Morocco, Mozambique, Nigeria, Somalia, South Africa, Sudan, Togo, Uganda, Zambia, Zimbabwe were also included in the review. The vaccine acceptance rate ranged from 6.9 to 97.9%. The major reasons for vaccine hesitancy were concerns with vaccine safety and side effects, lack of trust for pharmaceutical industries and misinformation or conflicting information from the media. Factors associated with positive attitudes towards the vaccine included being male, having a higher level of education, and fear of contracting the virus. CONCLUSIONS: Our review demonstrated the contextualized and multifaceted reasons inhibiting or encouraging vaccine uptake in African countries. This evidence is key to operationalizing interventions based on facts as opposed to assumptions. Our paper provided important considerations for addressing the challenge of COVID-19 vaccine hesitancy and blunting the impact of the pandemic in Africa.

A Mixed-Methods Study of Risk Factors and Experiences of Health Care Workers Tested for the Novel Coronavirus in Canada.

OBJECTIVE: The aims of this study were to investigate occupational and non-work-related risk factors of coronavirus disease 2019 among health care workers (HCWs) in Vancouver Coastal Health, British Columbia, Canada, and to examine how HCWs described their experiences. METHODS: This was a matched case-control study using data from online and phone questionnaires with optional open-ended questions completed by HCWs who sought severe acute respiratory syndrome coronavirus 2 testing between March 2020 and March 2021. Conditional logistic regression and thematic analysis were utilized. RESULTS: Providing direct care to coronavirus disease 2019 patients during the intermediate cohort period (adjusted odds ratio, 1.90; 95% confidence interval, 1.04 to 3.46) and community exposure to a known case in the late cohort period (adjusted odds ratio, 3.595%; confidence interval, 1.86 to 6.83) were associated with higher infection odds. Suboptimal communication, mental stress, and situations perceived as unsafe were common sources of dissatisfaction. CONCLUSIONS: Varying levels of risk between occupational groups call for wider targeting of infection prevention measures. Strategies for mitigating community exposure and supporting HCW resilience are required.

The experience of a regional network of health policy and systems actors in translating evidence into policy and action in West Africa.

Objectives: To identify strategies and interventions to strengthen the generation and use of research evidence in health policy and practice decision-making and implementation in the West African sub-region (knowledge translation). Design: The study design was cross-sectional. Data sources were from a desk review, West African Network of Emerging Leaders (WANEL) member brainstorming, and group discussion outputs from WANEL members and session participants' discussions and reflections during an organised session at the 2019 African Health Economics and Policy Association meeting in Accra. Results: Strategies and interventions identified included developing a Community of Practice, a repository of health policy and systems research (HPSR) evidence, stakeholder mapping, and engagement for action, advocacy, and partnership. Approaches for improving evidence uptake beyond traditional knowledge translation activities included the use of cultural considerations in presenting research results and mentoring younger people, the presentation of results in the form of solutions to political problems for decision-makers, and the use of research results as advocacy tools by civil society organisations. Development of skills in stakeholder mapping, advocacy, effective presentation of research results, leadership skills, networking, and network analysis for researchers was also identified as important. Conclusions: To strengthen the generation and use of research evidence in health policy and practice decision-making in West Africa requires capacity building and multiple interventions targeted synergistically at researchers, decision-makers, and practitioners. Funding: Funding for the study was provided by the COMPCAHSS project (#108237) supported by IDRC.

Infection control, occupational and public health measures including mRNA-based vaccination against SARS-CoV-2 infections to protect healthcare workers from variants of concern: A 14-month observational study using surveillance data.

BACKGROUND: We evaluated measures to protect healthcare workers (HCWs) in Vancouver, Canada, where variants of concern (VOC) went from <1% VOC in February 2021 to >92% in mid-May. Canada has amongst the longest periods between vaccine doses worldwide, despite Vancouver having the highest P.1 variant rate outside Brazil. METHODS: With surveillance data since the pandemic began, we tracked laboratory-confirmed SARS-CoV-2 infections, positivity rates, and vaccine uptake in all 25,558 HCWs in Vancouver Coastal Health, by occupation and subsector, and compared to the general population. Cox regression modelling adjusted for age and calendar-time calculated vaccine effectiveness (VE) against SARS-CoV-2 in fully vaccinated (≥ 7 days post-second dose), partially vaccinated infection (after 14 days) and unvaccinated HCWs; we also compared with unvaccinated community members of the same age-range. FINDINGS: Only 3.3% of our HCWs became infected, mirroring community rates, with peak positivity of 9.1%, compared to 11.8% in the community. As vaccine coverage increased, SARS-CoV-2 infections declined significantly in HCWs, despite a surge with predominantly VOC; unvaccinated HCWs had an infection rate of 1.3/10,000 person-days compared to 0.89 for HCWs post first dose, and 0.30 for fully vaccinated HCWs. VE compared to unvaccinated HCWs was 37.2% (95% CI: 16.6-52.7%) 14 days post-first dose, 79.2% (CI: 64.6-87.8%) 7 days post-second dose; one dose provided significant protection against infection until at least day 42. Compared with community infection rates, VE after one dose was 54.7% (CI: 44.8-62.9%); and 84.8% (CI: 75.2-90.7%) when fully vaccinated. INTERPRETATION: Rigorous droplet-contact precautions with N95s for aerosol-generating procedures are effective in preventing occupational infection in HCWs, with one dose of mRNA vaccination further reducing infection risk despite VOC and transmissibility concerns. Delaying second doses to allow more widespread vaccination against severe disease, with strict public health, occupational health and infection control measures, has been effective in protecting the healthcare workforce.

Data for decision making: using a dashboard to strengthen routine immunisation in Nigeria.

Availability of reliable data has for a long time been a challenge for health programmes in Nigeria. Routine immunisation (RI) data have always been characterised by conflicting coverage figures for the same vaccine across different routine data reporting platforms. Following the adoption of District Health Information System version 2 (DHIS2) as a national electronic data management platform, the DHIS2 RI Dashboard Project was initiated to address the absence of some RI-specific indicators on DHIS2. The project was also intended to improve visibility and monitoring of RI indicators as well as strengthen the broader national health management information system by promoting the use of routine data for decision making at all governance levels. This paper documents the process, challenges and lessons learnt in implementing the project in Nigeria. A multistakeholder technical working group developed an implementation framework with clear preimplementation; implementation and postimplementation activities. Beginning with a pilot in Kano state in 2014, the project has been scaled up countrywide. Nearly 34 000 health workers at all administrative levels were trained on RI data tools and DHIS2 use. The project contributed to the improvement in completeness of reports on DHIS2 from 53 % in first quarter 2014 to 81 % in second quarter 2017. The project faced challenges relating to primary healthcare governance structures at the subnational level, infrastructure and human resource capacity. Our experience highlights the need for early and sustained advocacy to stakeholders in a decentralised health system to promote ownership and sustainability of a centrally coordinated systems strengthening initiative.

The midwives service scheme: a qualitative comparison of contextual determinants of the performance of two states in central Nigeria.

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.

Operationalizing universal health coverage in Nigeria through social health insurance.

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.