Sexual and reproductive health information needs; an inquiry from the lens of in-school adolescents in Ebonyi State, Southeast Nigeria.

BACKGROUND: It is important to understand the sexual and reproductive health (SRH) needs of adolescents from the adolescents themselves to address their needs properly. Hence, this paper provides new knowledge on the information needs on SRH among adolescent boys and girls in selected secondary schools in Ebonyi state, southeast Nigeria. METHOD: A comparative assessment was conducted among adolescent boys and girls in public secondary schools that received a specific school-based SRH intervention (group A) and those that did not receive the intervention (group B). These schools were spread across six urban and rural local government areas in Ebonyi state, southeast Nigeria. A structured interviewer-administered questionnaire was used to collect data from 514 adolescents aged 13 to 18 on their stated needs for SRH information and services. Categorical variables were compared using the Chi-square test, and predictors were determined using logistic regression analysis. The statistical significance was determined at p < 0.05. RESULT: Majority of the adolescents (82% of intervention group and 92% of non-intervention group) identified puberty and pubertal changes as perceived SRH information need for adolescents (χ2 = 7.94; p-value = 0.01). Adolescents who received SRH intervention have 3.13 (p < 0.001) times the odds of perceiving the need for adolescents to be provided with SRH information than adolescents who did not receive SRH intervention. The odds of perceiving the need for adolescents to be provided with SRH information for adolescents who reside in urban communities are 0.31 (p < 0.001) times the odds for adolescents who resides in rural communities. That is, the perception odds are higher adolescents who reside in rural communities. Multivariate regression of specific SRH information showed the location of residence as a strong predictor of adolescents' perceived need for information on 'puberty and pubertal changes' (OR = 0.30; p = 0.001), 'safe sex and sexual relations' (OR = 0.33; p < 0.001) and 'prevention of pregnancy and use of contraceptives' (OR = 0.28; p < 0.001). Adolescents in senior secondary school have 2.21 (p = 0.002) times the odds of perceiving the need for adolescents to be provided with specific SRH information than adolescents who are in junior secondary school. CONCLUSION: Adolescents' age, location of residence, and study group were found to be strong predictors of SRH information needs. This suggests the need for in-school adolescents to be provided with substantial and continuous SRH information for healthy living and making informed SRH choices. In developing SRH interventions that will achieve optimal effectiveness in the lives of adolescents in school, different demographic factors should be considered for context-specific and appropriate strategies.

Analysis of the availability, effectiveness and equity of deployment of resources in the health system response to COVID-19 in Nigeria.

BACKGROUND: Coronavirus disease 2019 (COVID-19) exposed weaknesses in the health systems of countries such as Nigeria, which affected the effectiveness of the health system response to the pandemic. This paper provides new knowledge on the level of the availability, effectiveness and equity of resources in response to COVID-19 in Nigeria. This is valuable information for improving the delivery of countermeasures against future pandemics. METHODS: The study was conducted at the federal level and in two states in Nigeria. The states were Lagos in the southwest and Enugu in the southeast. In-depth interviews were undertaken with 34 key informants. NVivo version 12 software was used for coding and thematic analysis. RESULTS: There were inadequate, inequitable and suboptimal resources (human, financial, equipment and materials) for the response. In some of the countermeasures, only people that were employed in the formal sector benefitted from the distribution of welfare materials and financial packages; the informal sector, which constitutes the majority of the poor population in Nigeria, was excluded. CONCLUSIONS: Inequity and suboptimal availability of resources to control COVID-19 led to reduced effectiveness of the health system response to the disease in Nigeria. Such negative factors must be mitigated in future responses to pandemics in the country.

Analysing the progress in service delivery towards achieving universal health coverage in Nigeria: a scoping review.

BACKGROUND: Attainment of universal health coverage (UHC) requires optimal utilization of health services. Poor coverage and inequitable access to healthcare could hinder improvement in service delivery towards UHC. The study analyzed the progress in service delivery coverage and equity in access to care within the Nigerian health systems based on the tracer indicators of the WHO framework for monitoring UHC. METHODS: We searched the literature in databases: PubMed, Scopus, Directory of Open Access Journals, Google Scholar, Science Direct and websites of relevant health Ministries, Agencies, and Organizations between March to December 2022. Search terms were identified in four broader themes: Service delivery coverage, equity, UHC and Nigeria. Data were collected through a review of 37 published articles (19 peer-reviewed articles and 8 grey documents). We synthesized the findings in thematic areas using the WHO framework for monitoring UHC. RESULTS: The findings show a slow improvement in service delivery coverage across the UHC tracer indicators; reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access. With regards to equity in access to care across the tracer indicators, there has been a great disparity in the utilization of healthcare services among rural dwellers, lower educational level individuals and those with poor socio-economic status over 20 years. However, there was remarkable progress in the ownership and use of long-lasting insecticide-treated nets among rural and lowest-wealth quantile households than their urban counterpart. CONCLUSION: There is poor coverage and persistent inequitable access to care among the tracer indicators for monitoring progress in service delivery. Attaining UHC requires concerted efforts and investment of more resources in service delivery to address inequitable access to care and sustainable service coverage for improved health outcomes.

What, how and who: Cost-effectiveness analyses of COVID-19 vaccination to inform key policies in Nigeria.

While safe and efficacious COVID-19 vaccines have achieved high coverage in high-income settings, roll-out remains slow in sub-Saharan Africa. By April 2022, Nigeria, a country of over 200 million people, had only distributed 34 million doses. To ensure the optimal use of health resources, cost-effectiveness analyses can inform key policy questions in the health technology assessment process. We carried out several cost-effectiveness analyses exploring different COVID-19 vaccination scenarios in Nigeria. In consultation with Nigerian stakeholders, we addressed three key questions: what vaccines to buy, how to deliver them and what age groups to target. We combined an epidemiological model of virus transmission parameterised with Nigeria specific data with a costing model that incorporated local resource use assumptions and prices, both for vaccine delivery as well as costs associated with care and treatment of COVID-19. Scenarios of vaccination were compared with no vaccination. Incremental cost-effectiveness ratios were estimated in terms of costs per disability-adjusted life years averted and compared to commonly used cost-effectiveness ratios. Viral vector vaccines are cost-effective (or cost saving), particularly when targeting older adults. Despite higher efficacy, vaccines employing mRNA technologies are less cost-effective due to high current dose prices. The method of delivery of vaccines makes little difference to the cost-effectiveness of the vaccine. COVID-19 vaccines can be highly effective and cost-effective (as well as cost-saving), although an important determinant of the latter is the price per dose and the age groups prioritised for vaccination. From a health system perspective, viral vector vaccines may represent most cost-effective choices for Nigeria, although this may change with price negotiation.

Ensuring Safety of Patients in Complex Health Systems: A Focus on Primary Healthcare Service Relations in Nigeria.

Patient-centered healthcare is a goal for all health systems. However, given the inherent complexities of the health system as one with many nonlinear and dynamic components, the safety of patients could be affected. Therefore, there is the need to study these complexities to manage them toward optimal service delivery. The present study is a qualitative inquiry into the complexities of primary healthcare (PHC) in Nigeria and effects on patients' safety across four PHC facilities in Enugu state in southeast Nigeria. It utilizes a framework that draws on the components of interprofessional collaboration, inclusive of health financing and health workforce satisfaction, to understand the complex PHC system and patient safety. The study findings show that the PHC system in the study area performs suboptimally on the three counts, which implies poor management of the complexities of the system such that patients are highly susceptible to harm. Making a commitment to addressing the shortcomings present in each of the three components will help to decomplexify PHC in line with the World Health Organization agenda of achieving resilient and strong health systems. Importantly, optimizing the psychosocial space in Nigeria's PHC by employing qualified social workers and other psychosocial professionals is crucial for patient safety and a range of psychosocial activities that can enhance job satisfaction of health workers.

Strategic Health Purchasing in Nigeria: Exploring the Evidence on Health System and Service Delivery Improvements.

Well-functioning purchasing arrangements allocate pooled funds to health providers, and are expected to deliver efficient, effective, quality, equitable and responsive health services and advance progress toward universal health coverage (UHC). This paper explores how improvements in purchasing functions in three Nigerian schemes-the Formal Sector Social Health Insurance Program (FSSHIP), the Saving One Million Lives Program for Results (SOML PforR), and Enugu State's Free Maternal and Child Health Program (FMCHP)-may have contributed to better resource allocation, incentives for performance, greater accountability and improved service delivery. The paper uses a case-study approach, with data analyzed using the Strategic Health Purchasing Progress Tracking Framework. Data were collected through review of program documents and published research articles, and semi-structured interviews of 33 key informant interviews. Findings were triangulated within each case study across the multiple sources of information. Improvements in benefits specification and provider payment contributed to some service delivery improvements in all three schemes: higher satisfaction with the quality of care in FSSHIP; increased use of insecticide-treated nets; greater prevention of mother-to-child HIV transmission; expanded pentavalent-3 coverage in SOML PforR; and greater service utilization in FMCHP. Resource allocation to public health facilities was enhanced and lines of accountability were better defined. These scheme-level improvements have not translated to system change, because of the small amount of funding flowing through these schemes and the high level of health financing fragmentation. The institutionalization of strategic purchasing in Nigeria to advance UHC will require raising awareness among decision makers, strengthening purchasing agencies' capacity, and reducing fragmentation.

Stakeholders' perceptions of adolescents' sexual and reproductive health needs in Southeast Nigeria: a qualitative study.

OBJECTIVES: This study explored the perceptions of adult stakeholders on adolescents sexual and reproductive health (SRH) needs, variations of perceived needs by different social stratifiers and adolescent's perceived interventions to address these needs. This will provide evidence that could be useful for policy and programme reviews for improving access and use of services in to meet the SRH needs of adolescents. DESIGN: A qualitative cross-sectional study was conducted in Ebonyi state, Southeast, Nigeria. Data were analysed using thematic framework and content analysis approaches. SETTING AND PARTICIPANTS: This qualitative study was conducted in six selected local government areas in Ebonyi state, Nigeria. The study participants comprised of adult stakeholders including community leaders, adolescent boys and girls aged 13-18 years. Adolescents were purposively selected from schools, skill acquisition centres and workplaces. A total of 77 in-depth interviews, 6 (with community leaders) and 12 (with adolescents) focus group discussions were conducted using pretested question guides. RESULTS: Adolescent SRH needs were perceived to be unique and special due to their vulnerability, fragility and predisposition to explore new experiences. Recurring adolescent SRH needs were: SRH education and counselling; access to contraceptive services and information. These needs were perceived to vary based on sex, schooling and marital status. Adolescent girls were perceived to have more psychological needs, and more prone to negative health outcomes. Out-of-school adolescents were described as more vulnerable, less controlled, less supervised and more prone to sexual abuse. Unmarried adolescents were perceived more vulnerable to sexual exploitation and risks, while married were perceived to have more maternal health service needs. CONCLUSIONS: Perceptions of adolescents' SRH needs converge among stakeholders (including adolescents) and are thought to vary by gender, schooling and marital status. This calls for well-designed gender-responsive interventions that also take into consideration other social stratifiers and adolescent's perceived SRH intervention strategies.

Stakeholders' perspectives and willingness to institutionalize linkages between the formal health system and informal healthcare providers in urban slums in southeast, Nigeria.

BACKGROUND: The widely available informal healthcare providers (IHPs) present opportunities to improve access to appropriate essential health services in underserved urban areas in many low- and middle-income countries (LMICs). However, they are not formally linked to the formal health system. This study was conducted to explore the perspectives of key stakeholders about institutionalizing linkages between the formal health systems and IHPs, as a strategy for improving access to appropriate healthcare services in Nigeria. METHODS: Data was collected from key stakeholders in the formal and informal health systems, whose functions cover the major slums in Enugu and Onitsha cities in southeast Nigeria. Key informant interviews (n = 43) were conducted using semi-structured interview guides among representatives from the formal and informal health sectors. Interview transcripts were read severally, and using thematic content analysis, recurrent themes were identified and used for a narrative synthesis. RESULTS: Although the dominant view among respondents is that formalization of linkages between IHPs and the formal health system will likely create synergy and quality improvement in health service delivery, anxieties and defensive pessimism were equally expressed. On the one hand, formal sector respondents are pessimistic about limited skills, poor quality of care, questionable recognition, and the enormous challenges of managing a pluralistic health system. Conversely, the informal sector pessimists expressed uncertainty about the outcomes of a government-led supervision and the potential negative impact on their practice. Some of the proposed strategies for institutionalizing linkages between the two health sub-systems include: sensitizing relevant policymakers and gatekeepers to the necessity of pluralistic healthcare; mapping and documenting of informal providers and respective service their areas for registration and accreditation, among others. Perceived threats to institutionalizing these linkages include: weak supervision and monitoring of informal providers by the State Ministry of Health due to lack of funds for logistics; poor data reporting and late referrals from informal providers; lack of referral feedback from formal to informal providers, among others. CONCLUSIONS: Opportunities and constraints to institutionalize linkages between the formal health system and IHPs exist in Nigeria. However, there is a need to design an inclusive system that ensures tolerance, dignity, and mutual learning for all stakeholders in the country and in other LMICs.

Strengthening equitable health systems in West Africa: The regional project on governance research for equity in health systems.

The West African Health Organization (WAHO) supported an innovative regional initiative that contributes to building effective decision making, community and researcher partnerships to strengthen equitable health systems and influence local programmes and policies. Four projects were funded in Nigeria, Sierra Leone, Burkina Faso and Senegal, supported by a Regional Advisory Committee of experts and local Steering Committees. Based on a framework drawn from WAHO objectives, we reviewed documents, conducted 56 project stakeholder interviews and undertook thematic analysis. A diverse range of stakeholders perceived that the projects were in line with national priorities, were well managed and were equitably implemented. The projects generated evidence that could increase access to and improve quality maternal health services. Sustainable partnerships were formed and stakeholder and research team capacity were strengthened. Our study provides insight into project implementation in West Africa, bearing in mind context-specific issues.

Did an Intervention Programme Aimed at Strengthening the Maternal and Child Health Services in Nigeria Improve the Completeness of Routine Health Data Within the Health Management Information System?

BACKGROUND: During 2012-2015, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme, a health system strengthening (HSS) programme with a Maternal and Child Health component (Subsidy Reinvestment and Empowerment Programme [SURE-P]/MCH), which was monitored using the Health Management Information Systems (HMIS) data reporting tools. Good quality data is essential for health policy and planning decisions yet, little is known on whether and how broad health systems strengthening programmes affect quality of data. This paper explores the effects of the SURE-P/MCH on completeness of MCH data in the National HMIS. METHODS: This mixed-methods study was undertaken in Anambra state, southeast Nigeria. A standardized proforma was used to collect facility-level data from the facility registers on MCH services to assess the completeness of data from 2 interventions and one control clusters. The facility data was collected to cover before, during, and after the SURE-P intervention activities. Qualitative in-depth interviews were conducted with purposefully-identified health facility workers to identify their views and experiences of changes in data quality throughout the above 3 periods. RESULTS: Quantitative analysis of the facility data showed that data completeness improved substantially, starting before SURE-P and continuing during SURE-P but across all clusters (ie, including the control). Also health workers felt data completeness were improved during the SURE-P, but declined with the cessation of the programme. We also found that challenges to data completeness are dependent on many variables including a high burden on providers for data collection, many variables to be filled in the data collection tools, and lack of health worker incentives. CONCLUSION: Quantitative analysis showed improved data completeness and health workers believed the SURE-P/MCH had contributed to the improvement. The functioning of national HMIS are inevitably linked with other health systems components. While health systems strengthening programmes have a great potential for improved overall systems performance, a more granular understanding of their implications on the specific components such as the resultant quality of HMIS data, is needed.

An assessment of Nigeria's health systems response to COVID-19.

Objectives: This study aims to understand and report on selected health system interventions considered nationally and sub-nationally of particular significance both in terms of COVID-19 responses and in strengthening the health system for the future. Design: A review of published and grey literature, including journals, news/ media and official documents, was conducted from 1st December 2019 to 31st December 2020. The reviewers read and extracted relevant data using FACTIVA in a uniform data extraction template. Responses that related to service delivery were captured. Setting: The assessment considered responses at the national and two state levels: Lagos and Enugu, representing the epicentre and a low COVID-19 burden centre. Inclusion criteria: Documents and news that mentioned COVID-19 response, particularly service delivery aspects, were included in this review. Results: The identified interventions were mostly technical support targeted at health workers: including training of about 17,000 health workers, supervising and engaging more health workers, upgrading laboratories and building new ones to improve screening and diagnosis, and motivation of health workforce with incentives. Furthermore, the influx of philanthropic contributions improved the data and information systems supply of medicines, medical products and non-pharmaceutical protective materials through local production. The presence of political will and the government's efforts in health system's response to COVID-19 facilitated these interventions. Conclusions: Interventions of state and non-state actors have strengthened the health systems to some extent. However, more needs to be done to sustain these gains and make the health system resilient to absorb unprecedented shocks. Funding: IDRC Canada Grant # 109479-001.

Supporting strategic health purchasing: a case study of annual health budgets from general tax revenue and social health insurance in Abia state, Nigeria.

BACKGROUND: Tracking general trends in strategic purchasing of health financing mechanisms will highlight where country demands may exist for technical support and where progress in being made that offer opportunities for regional learning. Health services in Abia State, Nigeria are funded from general tax-revenues (GTR), and a new state social health insurance scheme (SSHIS) is proposed to overcome the failings of the GTR and expand coverage of services. This study examined purchasing functions within the GTR and the proposed SSHIS to determine if the failings in GTR have been overcome, identify factors that shape health purchasing at sub-national levels, and provide lessons for other states in Nigeria pursuing a similar intervention. METHODS: Data was collected through document review and key informant interviews. Government documents were retrieved electronically from the websites of different organizations. Hard copies of paper-only files were retrieved from relevant government agencies and departments. Interviews were conducted with seven key personnel of the State Ministry of Health and State Health Insurance Agency. Thematic analysis of data was based on a strategic health purchasing progress tracking framework which delves into the governance arrangements and information architecture needed for purchasing to work well; and the core purchasing decisions of what to buy; who to buy from; and how to buy. RESULTS: There are differences in the purchasing arrangements of the two schemes. Purchaser-provider split does not exist for the GTR, unlike in the proposed SSHIS. There are no data systems for monitoring provider performance in the GTR-funded system, unlike in the SSHIS. Whereas GTR is based on a historical budgeting system, the SSHIS proposes to use a defined benefit package, which ensures value-for-money, as the basis for resource allocation. The GTR lacks private sector engagement, provider accreditation and contracting arrangements while the SSHIS will accredit and engage private providers through selective contracting. Likewise, provider payment is not linked to performance or adherence to established standards in the GTR, whereas provider payment will be linked to performance in the SSHIS. CONCLUSIONS: The State Social Health Insurance has been designed to overcome many of the limitations of the budgetary allocation to health. This study provides insights into the enabling and constraining factors that can be used to develop interventions intended to strengthen the strategic health purchasing in the study area, and lessons for the other Nigeria states with similar characteristics and approaches.

Food Security Status and Factors Affecting Household Food Security in Enugu State, Nigeria.

INTRODUCTION: In Nigeria, high inflation rates, increasing consumer price index, insurgency, and displacement of households have negatively affected household income expenditures on food resulting in food insecurity. This study aimed at determining the food security status and factors affecting this among households in Enugu state, Nigeria. METHODS: A descriptive cross-sectional study of 800 households in Enugu state, Nigeria. RESULTS: As many as 61.1% of households in Enugu State were found to be food-insecure. The factors influencing food security status were wealth index, belonging to a cooperative society, lack of money to buy food items, and the number of accessible marketplaces. Various coping strategies included skipping meals (77%), reducing quantity of meals (92.6%), purchasing less preferred meals (72.3%) and borrowing food and money (31.3%). CONCLUSION: The prevalence of food-insecure households was high, mostly due to poverty, not belonging to a cooperative society, and few accessible marketplaces. There is a need for economic and political stability that is supportive of households.

Exploring mechanisms that explain how coalition groups are formed and how they work to sustain political priority for maternal and child health in Nigeria using the advocacy coalition framework.

BACKGROUND: The unacceptably high rate of maternal and child mortality in Nigeria prompted the government to introduce a free maternal and child health (MCH) programme, which was stopped abruptly following a change in government. This triggered increased advocacy for sustaining MCH as a political priority in the country and led to the formation of advocacy coalitions. This study set out to explain the process involved in the formation of advocacy coalition groups and how they work to bring about sustained political prioritization for MCH in Nigeria. It will contribute to the understanding of the Nigerian MCH sector subsystem and will be beneficial to health policy advocates and public health researchers in Nigeria. METHODS: This study employed a qualitative case study approach. Data were collected using a pretested interview guide to conduct 22 in-depth interviews, while advocacy events were reviewed pro forma. The document review was analysed using the manual content analysis method, while qualitative data audiotapes were transcribed verbatim, anonymized, double-coded in MS Word using colour-coded highlights and analysed using manual thematic and framework analysis guided by the advocacy coalition framework (ACF). The ACF was used to identify the policy subsystem including the actors, their belief, coordination and resources, as well as the effects of advocacy groups on policy change. Ethics and consent approval were obtained for the study. RESULTS: The policy subsystem identified the actors and characterized the coalitions, and described their group formation processes and resources/strategies for engagement. The perceived deep core belief driving the MCH agenda is the right of an individual to health. The effects of advocacy groups on policy change were identified, along with the factors that enabled effectiveness, as well as constraints to coalition formation. External factors and triggers of coalition formation were identified to include high maternal mortality and withdrawal of the free MCH programme, while the contextual issues were the health system issues and the socioeconomic factors affecting the country. CONCLUSION: Our findings add to an increasing body of evidence that the use of ACF is beneficial in exploring how advocacy coalitions are formed and in identifying the effects of advocacy groups on policy change.

Oral health-seeking behavior among different population groups in Enugu Nigeria.

INTRODUCTION: This study investigates the oral health-seeking behaviour of households and its influence on demand for dental caries treatment services in Enugu state Nigeria. METHODS: A quantitative descriptive cross-sectional study was used to explore the oral health seeking pattern of 378 urban and 348 rural household respondents in Enugu state Nigeria. The study explored dental caries treatment-seeking, oral health behavior of respondents using the three dynamics of the Andersen and Newman health utilization model; predisposing, enabling and need factors. FINDINGS: Recommendations from community members (48.9%), severity of disease (22.1%), and cost of treatment (19.4%) all influenced where oral healthcare was first sought. Gender and type of occupation, influenced positive oral health-seeking behavior (p<0.05). The least poor socioeconomic status (SES) group, sought dental treatment in the private dental clinics, while the very poor and most poor SES groups used traditional healers, home treatment and patent medicine dealers more. Dental fillings and extractions were generally the most accessed treatment options for dental caries. The tendency for all the SES groups (especially the least poor), to choose tooth extraction more as a treatment option for dental caries was influenced by the oral health awareness level of respondents and the cost of dental fillings. (p<0.05). CONCLUSION: The findings suggest that interventions to create increased oral health awareness targeted at education on preventive strategies, appropriate time and place to seek oral health care and dental caries treatment, as well devising and implementing health financing options such as dental insurance would enable individuals to seek appropriate treatment for dental caries on time. In addition, it will reduce the proportion of people visiting unorthodox healthcare providers for their oral health problems or choosing cheaper but inappropriate treatment options.

Socio-demographic and economic determinants of awareness and use of contraceptives among adolescents in Ebonyi State, South-east, Nigeria.

Understanding factors that explain levels of awareness and use of contraceptives among adolescents is a critical entry point for improving their sexual and reproductive health. This study assessed the demographic and socioeconomic determinants of awareness and use of contraceptives among adolescents in rural and urban communities in Ebonyi State, Nigeria. A cross-sectional household survey was conducted in three rural and urban communities in August, 2018. Modified cluster sampling technique was used to select eligible households. A total of 1045 adolescents (598 females and 447 males) were randomly selected from the households and interviewed using a pre-tested structured questionnaire. The mean age is 15.4years (15.3 - 15.5) and the median age is 15.5years. Univariate, bivariate and multivariate analysis were undertaken. Statistical significance was set at p-value of <0.05. Majority of respondents, 723 (68.9%), were aware of male condom. Place of residence predicts awareness of contraceptive pills (AOR 0.66, CI 0.48-0.91); schooling predicts awareness of male condoms (AOR 0.57; CI 0.32-0.99). Predictors of awareness of female condoms are place of residence (AOR 0.66, CI 0.47-0.93), gender (AOR 0.57, CI 0.32-0.99) and wealth index (AOR 1.16, CI 1.03-1.30). Demographic and socioeconomic characteristics of respondents did not predict contraceptive use in the last sex. Although awareness of contraceptives is high, utilization is low among sexually active adolescents. Hence, the need to promote access to and utilization of contraceptives through comprehensive contraceptive education to improve adolescents sexual and reproductive health.

Was the Maternal Health Cash Transfer Programme in Nigeria Sustainable and Cost-Effective?

Background: The Subsidy Reinvestment and Empowerment Programme (SURE-P), Maternal and Child Health (MCH) was introduced by the Nigerian government to increase the use of skilled maternal health services and reduce maternal mortality. The programme, funded out of a reduction in the fuel subsidy, was implemented between October 2012 and April 2015 and incorporated a conditional cash transfer to women to encourage use of facility based maternal services. We seek to assess the incremental cost effectiveness and long term impact of the conditional cash transfer element of the programme. Methods: An impact analysis and incremental cost-effectiveness analysis of conditional cash transfers (CCTs) is undertaken taking a health service perspective toward costs of the intervention. The study was undertaken in Anambra state, comparing areas that received only the investment in health services with areas that implemented the conditional cash transfer programme. An interrupted time series analysis of the programme outputs was undertaken. These were combined with a programme costing to determine the incremental cost per output. Findings: Maternal services provided to patients in conditional cash transfer areas accelerated rapidly from the middle of 2014 until after the programme in late 2015. The costs of providing services in each Primary Health Center facility was US $52,128 in the areas that only invested in health services compared to US $90,702 in facilities that also provided cash transfers. Much of the additional cost was in managing cash transfers. The incremental cost in the cash transfer areas was $572 for delivery care and $11 for antenatal care. If the programme was to be integrated as a regular service in the public health system, the cost of a delivery is estimated to fall to $389 and to $188 if 2015 levels of activity are assumed. Conclusion: Although the cost of CCTs as originally constituted as a vertical programme are relatively high compared to other similar programmes, these would fall substantially if integrated into the main health system. There is also evidence of sustained impact beyond the end of the funding suggesting that short term programmes can lead to a long-term change in patterns of health seeking behavior.

Does improving the skills of researchers and decision-makers in health policy and systems research lead to enhanced evidence-based decision making in Nigeria?-A short term evaluation.

INTRODUCTION: Health care decision makers require capacity to demand and use research evidence for effective decision making. Capacity to undertake health policy and systems research (HPSR) and teaching is low in developing countries. Strengthening the capacity of producers and users of research is a more sustainable strategy for developing the field of HPSR in Africa, than relying on training in high-income countries. METHODS: Data were collected from 118 participants who had received the capacity building, using a pre-tested questionnaire. Respondents included health research scientists from institutions (producers) and decision makers (users) in the public health sector, in Anambra and Enugu states, southeast Nigeria. Data were collected on participants' progress with proposed group activities in their short- term goals; effects of these activities on evidence-informed decision making and constraints to implementing activities. Univariate analysis was done using SPSS version 16. FINDINGS: All prioritised activities were carried out. However, responses were low. Highest response for an activity amongst producers was 39.1%, and 44.4% for users. Some of the activities implemented positively influenced changes in practice; like modification of existing policies and programme plans. There was a wide range of responses between producers of evidence (0.0-39.1%) and users (2.7-44.4%) across both study states. Lack of authority to implement activities was the major constraint (42-9-100.0% across activities), followed by financial constraints (70.6%). CONCLUSION: Capacity building intervention improved skills of a critical mass of research scientists, policymakers and practitioners, towards evidence-based decision making. Participants committed to undertake proposed activities but faced a number of constraints. These need to be addressed, especially the decision space and authority, improving funding to implement activities that influence Getting Research into Policy & Practice (GRIPP). Being at different stages of planning and implementing proposed activities; participants require continuous technical and financial support to successfully implement activities and engage meaningfully within and across professional boundaries and roles, in order to achieve short-, medium- and long- term goals.

What makes advocacy work? Stakeholders' voices and insights from prioritisation of maternal and child health programme in Nigeria.

BACKGROUND: The Nigerian government introduced and implemented a health programme to improve maternal and child health (MCH) called Subsidy Reinvestment and Empowerment programme for MCH (SURE-P/MCH). It ran from 2012 and ended abruptly in 2015 and was followed by increased advocacy for sustaining the MCH (antenatal, delivery, postnatal and immunization) services as a policy priority. Advocacy is important in allowing social voice, facilitating prioritization, and bringing different forces/actors together. Therefore, the study set out to understand how advocacy works - through understanding what effective advocacy implementation processes comprise and what mechanisms are triggered by which contexts to produce the intended outcomes. METHODS: The study used a Realist Evaluation design through a mixed quantitative and qualitative methods case study approach. The programme theory (PT) was developed from three substantive social theories (power politics, media influence communication theory, and the three-streams theory of agenda-setting), data and programme design documentation, and subsequently tested. We report information from 22 key informant interviews including national and State policy and law makers, policy implementers, CSOs, Development partners, NGOs, health professional groups, and media practitioners and review of relevant documents on advocacy events post-SURE-P. RESULTS: Key advocacy organizations and individuals including health professional groups, the media, civil society organizations, powerful individuals, and policymakers were involved in advocacy activities. The nature of their engagement included organizing workshops, symposiums, town hall meetings, individual meetings, press conferences, demonstrations, and engagements with media. Effective advocacy mechanism involved alliance brokering to increase influence, the media supporting and engaging in advocacy, and the use of champions, influencers, and spouses (Leadership and Elite Gendered Power Dynamics). The key contextual influences which determined the effectiveness of advocacy measures for MCH included the political cycle, availability of evidence on the issue, networking with powerful and interested champions, and alliance building in advocacy. All these enhanced the entrenchment of MCH on the political and financial agenda at the State and Federal levels. CONCLUSIONS: Our result suggest that advocacy can be a useful tool to bring together different forces by allowing expression of voices and ensuring accountability of different actors including policymakers. In the context of poor health outcomes, interest from policymakers and politicians in MCH, combined with advocacy from key policy actors armed with evidence, can improve prioritization and sustained implementation of MCH services.