A health technology assessment of COVID-19 vaccination for Nigerian decision-makers: Identifying stakeholders and pathways to support evidence uptake.

BACKGROUND: Nigeria commenced rollout of vaccination for coronavirus disease 2019 (COVID-19) in March 2021 as part of the national public health response to the pandemic. Findings from appropriately contextualized cost-effectiveness analyses (CEA) as part of a wider process involving health technology assessment (HTA) approaches have been important in informing decision-making in this area. In this paper we outline the processes that were followed to identify COVID-19 vaccine stakeholders involved in the selection, approval, funding, procurement and rollout of vaccines in Nigeria, and describe the process routes we identified to support uptake of HTA-related information for evidence-informed policy in Nigeria. METHODS: Our approach to engaging with policy-makers and other stakeholders as part of an HTA of COVID vaccination in Nigeria consisted of three steps, namely: (i) informal discussions with key stakeholders; (ii) stakeholder mapping, analysis and engagement; and (iii) communication and dissemination strategies for the HTA-relevant evidence produced. The analysis of the stakeholder mapping uses the power/interest grid framework. RESULTS: The informal discussion with key stakeholders generated six initial policy questions. Further discussions with policy-makers yielded three suitable policy questions for analysis: which COVID-19 vaccines should be bought; what is the optimal mode of delivery of these vaccines; and what are the cost and cost-effectiveness of vaccinating people highlighted in Nigeria's phase 2 vaccine rollout prioritized by the government, especially the inclusion of those aged between 18 and 49 years. The stakeholder mapping exercise highlighted the range of organizations and groups within Nigeria that could use the information from this HTA to guide decision-making. These stakeholders included both public/government, private and international organizations The dissemination plan developed included disseminating the full HTA results to key stakeholders; production of policy briefs; and presentation at different national and international conferences and peer-reviewed publications. CONCLUSIONS: HTA processes that involve stakeholder engagement will help ensure important policy questions are taken into account when designing any HTA including any underpinning evidence generation. Further guidance about stakeholder engagement throughout HTA is required, especially for those with low interest in vaccine procurement and use.

Economic and social determinants of health care utilization during the first wave of COVID-19 pandemic among adults in Ghana: a population-based cross-sectional study.

BACKGROUND: The COVID-19 pandemic had socioeconomic effects in Africa. This study assessed the social and economic determinants of healthcare utilization during the first wave of COVID-19 among adults in Ghana. METHODS: Information about individuals residing in Ghana was derived from a survey conducted across multiple countries, aiming to evaluate the impact of the COVID-19 pandemic on the mental health and overall well-being of adults aged 18 and above. The dependent variable for the study was healthcare utilization (categorized as low or high). The independent variables were economic (such as financial loss, job loss, diminished wages, investment/retirement setbacks, and non-refunded travel cancellations) and social (including food scarcity, loss of financial support sources, housing instability, challenges affording food, clothing, shelter, electricity, utilities, and increased caregiving responsibilities for partners) determinants of health. A multinomial logistic regression was conducted to identify factors associated with healthcare utilization after adjusting for confounders (age, gender, access to medical insurance, COVID-19 status, educational background, employment, and marital status of the participants). RESULTS: The analysis included 364 responses. Individuals who encountered a loss of financial support (AOR: 9.58; 95% CI: 3.44-26.73; p < 0.001), a decrease or loss of wages (AOR: 7.44, 95% CI: 3.05-18.16, p < 0.001), experienced investment or retirement setbacks (AOR: 10.69, 95% CI: 2.60-43.88, p = 0.001), and expressed concerns about potential food shortages (AOR: 6.85, 95% CI: 2.49-18.84, p < 0.001) exhibited significantly higher odds of low healthcare utilization during the initial phase of the pandemic. Contrastingly, participants facing challenges in paying for basic needs demonstrated lower odds of low healthcare utilization compared to those who found it easy to cover basic expenses (AOR: 0.19, 95% CI: 0.06-0.67, p = 0.001). CONCLUSION: Economic and social factors were associated with low healthcare utilization in Ghana during the first wave of the pandemic. Investment or retirement loss and financial support loss during the pandemic had the largest effect on healthcare utilization. Further research is needed to understand the connection between concerns about food shortages, welfare losses during pandemics and healthcare utilization during pandemics in Ghana.

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

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

Assessing the impacts of COVID-19 vaccination programme's timing and speed on health benefits, cost-effectiveness, and relative affordability in 27 African countries.

BACKGROUND: The COVID-19 vaccine supply shortage in 2021 constrained roll-out efforts in Africa while populations experienced waves of epidemics. As supply improves, a key question is whether vaccination remains an impactful and cost-effective strategy given changes in the timing of implementation. METHODS: We assessed the impact of vaccination programme timing using an epidemiological and economic model. We fitted an age-specific dynamic transmission model to reported COVID-19 deaths in 27 African countries to approximate existing immunity resulting from infection before substantial vaccine roll-out. We then projected health outcomes (from symptomatic cases to overall disability-adjusted life years (DALYs) averted) for different programme start dates (01 January to 01 December 2021, n = 12) and roll-out rates (slow, medium, fast; 275, 826, and 2066 doses/million population-day, respectively) for viral vector and mRNA vaccines by the end of 2022. Roll-out rates used were derived from observed uptake trajectories in this region. Vaccination programmes were assumed to prioritise those above 60 years before other adults. We collected data on vaccine delivery costs, calculated incremental cost-effectiveness ratios (ICERs) compared to no vaccine use, and compared these ICERs to GDP per capita. We additionally calculated a relative affordability measure of vaccination programmes to assess potential nonmarginal budget impacts. RESULTS: Vaccination programmes with early start dates yielded the most health benefits and lowest ICERs compared to those with late starts. While producing the most health benefits, fast vaccine roll-out did not always result in the lowest ICERs. The highest marginal effectiveness within vaccination programmes was found among older adults. High country income groups, high proportions of populations over 60 years or non-susceptible at the start of vaccination programmes are associated with low ICERs relative to GDP per capita. Most vaccination programmes with small ICERs relative to GDP per capita were also relatively affordable. CONCLUSION: Although ICERs increased significantly as vaccination programmes were delayed, programmes starting late in 2021 may still generate low ICERs and manageable affordability measures. Looking forward, lower vaccine purchasing costs and vaccines with improved efficacies can help increase the economic value of COVID-19 vaccination programmes.

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.

Stakeholders' Perspectives on the Unmet Needs and Health Priorities of the Urban Poor in South-East Nigeria.

Relatively little is known about readiness of urban health systems to address health needs of the poor. This study explored stakeholders' perception of health needs and strategies for improving health of the urban poor using qualitative analysis. Focus group discussions (n = 5) were held with 26 stakeholders drawn from two Nigerian states during a workshop. Urban areas are characterised by double burden of diseases. Poor housing, lack of basic amenities, poverty, and poor access to information are determinants of health of the urban poor. Shortage of health workers, stock-out of medicines, high cost of care, lack of clinical practice guidelines, and dual practice constrain access to primary health services. An overarching strategy, that prioritises community-driven urban planning, health-in-all policies, structured linkages between informal and formal providers, financial protection schemes, and strengthening of primary health care system, is required to address health needs of the urban poor.

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.

SARS CoV-2 Seroprevalence in Selected States of High and Low Disease Burden in Nigeria.

Importance: The global impact of COVID-19 has led to an increased need to continuously assess disease surveillance tools. The utility of SARS-CoV-2 serologic tools in determining immunity levels across different age groups and locations in helping to quickly assess the burden of COVID-19 with significant health policy implications is unknown. Objective: To determine the prevalence of SARS-CoV-2 antibodies with respect to the age group and sex of participants. Design, Setting, and Participants: A cross-sectional survey of 4904 individuals across 12 states with high and low COVID-19 disease burden in Nigeria was carried out between June 29 and August 21, 2021. Main Outcomes and Measures: Enzyme-linked immunosorbent assay was used for the detection of specific SARS-CoV-2 immunoglobulin G and immunoglobulin M antibodies, such as the nucleocapsid protein-NCP and spike protein S1. Interviewer-administered questionnaires provided information on participants' history of disease and associated risk factors. Results: A total of 4904 individuals participated in the study (3033 were female [61.8%]; mean [SD] age, 26.7 [6.51] years). A high seroprevalence of SARS-CoV-2 (78.9%) was obtained. Seropositivity was consistent across the states surveyed, ranging from 69.8% in Lagos to 87.7% in Borno. There was no association between sex and seropositivity (female, 2414 [79.6%]; male, 1456 [77.8%]; P = .61); however, an association was noted between age and seropositivity, with the peak prevalence observed in participants aged 15 to 19 years (616 [83.6%]; P = .001). Similarly, loss of appetite (751 [82.3%]; P = .04) and smell (309 [84.4%]; P = .01) were associated with seropositivity. Conclusions and Relevance: In this cross-sectional study, a high SARS-CoV-2 seroprevalence was obtained among the study population during the low level of vaccination at the time of the survey. Thus, there is a need for both an efficacy and antibody neutralization test study to ascertain the efficacy of the antibody detected and the potential for herd immunity in Nigeria.

Strategic Health Purchasing in Nigeria: Investigating Governance and Institutional Capacities within Federal Tax-Funded Health Schemes and the Formal Sector Social Health Insurance Programme.

For Nigeria to make progress on its commitment to universal health coverage, additional public funding will be required. But more resources alone will not be enough. Government health spending must be more efficient and effective, through more strategic purchasing-a critical policy tool. Studies on health purchasing in Nigeria's health financing schemes are limited, however. This study examines the purchasing arrangements in schemes funded by the federal budget and in the Formal Sector Social Health Insurance Programme (FSSHIP) within the National Health Insurance Scheme. We adopted a qualitative, descriptive case-study approach and collected data through document reviews and key informant interviews based on the Strategic Health Purchasing Progress Tracking Framework. Our analysis used a thematic framework approach. Our findings reveal that legal frameworks and governance structures for strategic purchasing are in place for both schemes. Steps toward strategic purchasing are more advanced in FSSHIP, particularly in the design of benefit packages, accreditation and monitoring of health maintenance organizations (HMOs) and providers, and provider payment mechanisms. The limited share of health funding flowing through these mechanisms, and further fragmentation of that funding, impede strategic purchasing. Strategic purchasing is also hampered by weak regulation and monitoring of providers and purchasers, delays in provider payment, and corrupt practices by HMOs. Improving strategic purchasing in Nigeria will require a concerted effort to reduce fragmentation of health spending, significant investment in human resources, technical know-how, and information systems of purchasing institutions, and actions to improve the accountability of all actors in the system.

COVID-19, economic problems, and family relationships in eight Middle East and North African countries.

Objective: The aim was to assess the reported family relationships during the COVID-19 pandemic and the association between these relationships and individual, interpersonal, and country-level income in eight Middle East and North Africa (MENA) countries. Background: COVID-19 causes fear of infection, loss of loved ones, and economic problems that may affect family relationships. Methods: Data were collected from eight MENA countries using an online survey (July-August 2020). The dependent variable was change in family relationship during COVID-19, and the independent variables were individual, interpersonal, and country-level factors represented by sociodemographic factors, COVID-19 status, financial impact (whether participants lost or had reduced wages) and country income. Multilevel logistic regression analysis was conducted. Results: There were 1854 responses, mean (SD) age of 30.6 (9.9) years, 65.8% were female, 3.4% tested COVID-19 positive, and 20.8% reported lost/reduced wages. Family relationships were more likely to improve or remain unchanged (84.3%) for participants who had a history of COVID-19 (adjusted odds ratio [AOR] = 3.54, 95% confidence interval [CI]: [1.25, 10.01]). However, family relationships were more likely to not improve for those who knew someone who died of COVID-19 (AOR = 0.76, 95% CI [0.58, 0.99]) and those with lost/reduced wages (AOR = 0.69, 95% CI [0.52, 0.94]). Conclusion: Family relationship improved or remained unchanged for those who tested positive for COVID-19 and did not improve for those who lost wages or lost someone due to COVID-19. Implications: Policy makers should develop strategies to provide social and financial support to employees to reduce the losses and adverse social impact caused by the pandemic.

Examining healthcare purchasing arrangements for strategic purchasing in Nigeria: a case study of the Imo state healthcare system.

BACKGROUND: Strategic healthcare purchasing (SHP), as a critical function of health financing, enhances the optimal attainment of health system goals through the efficient use of financial resources. Countries committed to universal health coverage (UHC) have made progress towards strategic purchasing through relevant reforms in their healthcare financing systems. This study examined the purchasing arrangements and practices in the Imo state healthcare system to track progress towards SHP committed to UHC. METHODS: A critical review and analysis of healthcare financing schemes in Imo state, south-eastern Nigeria, was undertaken to assess their purchasing practices based on a descriptive qualitative case study approach. Relevant documents were collected and reviewed including in-depth interviews with stakeholders. Information was collected on external factors and governance, purchasing practices and other capacities of the state's health financing schemes. The analytical framework was guided by comparing purchasing practices of the financing schemes with the ideal strategic purchasing actions (SPAs) developed by RESYST (Resilient and Responsive Health Systems), based on the three pairs of principal-agent relationships. RESULTS: Healthcare purchasing in the state is dominated by the State Ministry of Health (SMOH) using a general tax-based and public health system, making government revenue a major source of funding and provision of healthcare services. However, purchasing of health services is passive and the stewardship role of government is significantly weak, characterized by substantial insufficient budgetary allocations, inadequate infrastructure and poor accountability. However, the health benefit package significantly reflects the needs of the population. As an integrated system, there is no purchaser-provider split. Provider selection, monitoring and payment processes do not promote quality and efficiency of service delivery. There is very limited institutional and technical capacity for SHP. However, the state recently established the Imo State Health Insurance Agency (IMSHIA), a social agency whose structure and organization support SHP functions, including benefit packages, provider selection processes, appropriate provider payment mechanisms and regulatory controls. CONCLUSION: Healthcare purchasing in Imo state remains mostly passive, with very limited strategic purchasing arrangements. The main challenges stem from the entrenched institutional mechanism of passive purchasing in the government's health budgets that are derived from general tax revenue, lack of purchaser-provider split, and poor provider payment and performance monitoring mechanisms. The establishment of the social insurance agency represents an opportunity for boosting SHP in the state for enhanced progress towards UHC. Building capacity and awareness of the benefits of SHP among policy-makers and programme managers will improve the efficiency and equity of health purchasing in the state.

Health-related quality of life and associated factors among Onchocerciasis patients in southeast Nigeria: A cross-sectional comparative study.

INTRODUCTION: Onchocerciasis, a neglected tropical disease of public health importance, causes chronic morbidity and severe disability that may impact on health-related quality of life (HRQoL) of the infected people. This study assessed the HRQoL and associated factors among onchocerciasis patients in southeast Nigeria. METHODS: This was a community-based cross-sectional comparative study. Using a multistage sampling technique, 340 onchocerciasis patients were selected and matched for age and gender with the healthy population in the same neighbourhood. The respondents were interviewed using the short-form-36 (SF-36) questionnaire to determine their HRQoL. WHO Disability Assessment Schedule 2.0 tool (WHODAS 2.0) was used to assess disability in persons with onchocerciasis. Means were compared with independent student t-test while Chi-square test was used to compare proportions. Also, correlation analysis and logistic regression were used in the analyses. RESULTS: A significantly lower proportion of people living with onchocerciasis had a good quality of life when compared with the healthy subjects (69.4% vs 93.5%, p<0.001). Also, an inverse relationship was seen between disability and quality of life in the onchocerciasis group (r = -0.647, p<0.001). Predictors of poor quality of life among respondents with onchocerciasis were: respondents aged ≥48 years (AOR = 2.5, 95% CI: 1.4-5.0), those with some disability associated with onchocerciasis (AOR = 3.33, 95%CI: 1.4-5.0) and respondents who perceived themselves as a burden to people (AOR = 10, 95%CI: 2.5-20). CONCLUSION: Onchocerciasis impacted negatively on HRQoL of persons with onchocerciasis when compared with the healthy population. The quality of life of persons affected with onchocerciasis reduces with increasing disability. There is the need to increase community awareness on onchocerciasis to ensure early diagnosis and prompt treatment as this will reduce disability among those affected with the disease thus enhancing their HRQoL.

Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation.

BACKGROUND: Community health workers play an important role in linking communities with formal health service providers, thereby improving access to and utilization of health care. A novel cadre of community health workers known as village health workers (VHWs) were recruited to create demand for maternal health services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In this study, we investigated the role of contextual factors and underlying mechanisms motivating VHWs. METHODS: We used realist evaluation to understand the impact of a multi-intervention maternal and child health programme on VHW motivation using Anambra State as a case study. Initial working theories and logic maps were developed through literature review and stakeholder engagement; programme theories were developed and tested using focus group discussions and in-depth interviews with various stakeholder groups. Interview transcripts were analysed through an integrated approach of Context, Mechanism and Outcomes (CMO) categorisation and connecting, and matching of patterns of CMO configurations. Motivation theories were used to explain factors that influence VHW motivation. Explanatory configurations are reported in line with RAMESES reporting standards. RESULTS: The performance of VHWs in the SURE-P maternal and child health programme was linked to four main mechanisms of motivation: feelings of confidence, sense of identity or feeling of acceptance, feeling of happiness and hopefulness/expectation of valued outcome. These mechanisms were triggered by interactions of programme-specific contexts and resources such as training and supervision of VHWs by skilled health workers, provision of first aid kits and uniforms, and payments of a monthly stipend. The monthly payment was considered to be the most important motivational factor by VHWs. VHWs used a combination of innovative approaches to create demand for maternity services among pregnant women, and their performance was influenced by health system factors such as organisational capacity and culture, and societal factors such as relationship with the community and community support. CONCLUSION: This paper highlights important contextual factors and mechanisms for VHW motivation that can be applied to other interventions that seek to strengthen community engagement and demand creation in primary health care. Future research on how to sustain VHW motivation is also required.

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.

Factors Associated With Coverage of Health Insurance Among Women in Malawi.

Introduction: Access to healthcare for the vulnerable groups including women has long been a theme encouraged worldwide from the first general assembly on health to the current sustainable development goals. Despite many countries having a free public healthcare system, there are inequalities in access to care and significant out-of-pocket spending, pushing most women into poverty against the principles of universal health coverage. Coverage of Malawian women with health insurance is poor; thus, there is limited cushioning and high risk of poverty, as women bear costs of care as primary caregivers. There is need to explore determinants of coverage of health insurance among women in Malawi to inform health policy. Methodology: This study was quantitative in nature, using cross-sectional secondary data from the 2015 to 2016 Malawi Demographic and Health Survey involving women aged between 15 and 49 years. We assessed factors associated with insurance coverage by comparing women with and without insurance schemes using binary logistic regression. Analysis was done using STATA statistical package version 13. Results: The analysis included a total of 24,562 women with a mean age of 28 SD (9.3). Of these cases, 1.5% had health insurance. High education attainment, occupation, and wealth were significantly associated with health insurance ownership, with all having p-values of < 0.01. On the other hand, a woman's residence, marital status, and who heads a household were not associated with ownership of health insurance significantly. Conclusion: Education, occupation, and wealth have a key role in influencing a woman's choice in owning health insurance. This informs policymakers and health insurance providers on how best to approach women's health financing and factors to target in social security programs and health insurance products that speak to women's needs and capacity.

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.

Analysis of equity and social inclusiveness of national urban development policies and strategies through the lenses of health and nutrition.

INTRODUCTION: Rapid urbanization increases competition for scarce urban resources and underlines the need for policies that promote equitable access to resources. This study examined equity and social inclusion of urban development policies in Nigeria through the lenses of access to health and food/nutrition resources. METHOD: Desk review of 22 policy documents, strategies, and plans within the ambit of urban development was done. Documents were sourced from organizational websites and offices. Data were extracted by six independent reviewers using a uniform template designed to capture considerations of access to healthcare and food/nutrition resources within urban development policies/plans/strategies in Nigeria. Emerging themes on equity and social inclusion in access to health and food/nutirition resources were identified and analysed. RESULTS: Access to health and food/nutrition resources were explicit in eight (8) and twelve (12) policies/plans, respectively. Themes that reflect potential policy contributions to social inclusion and equitable access to health resources were: Provision of functional and improved health infrastructure; Primary Health Care strengthening for quality health service delivery; Provision of safety nets and social health insurance; Community participation and integration; and Public education and enlightenment. With respect to nutrition resources, emergent themes were: Provision of accessible and affordable land to farmers; Upscaling local food production, diversification and processing; Provision of safety nets; Private-sector participation; and Special considerations for vulnerable groups. CONCLUSION: There is sub-optimal consideration of access to health and nutrition resources in urban development policies in Nigeria. Equity and social inclusivity in access to health and nutrition resources should be underscored in future policies.

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.