Building social accountability to improve reproductive, maternal, newborn and child health in Nigeria.

BACKGROUND: Like many places in Nigeria, Niger, a predominantly rural and poor state in the north of the country, has high fertility, low contraceptive prevalence, and high maternal mortality. This paper presents a descriptive, contextualized case study of a social accountability campaign run by the nongovernmental organization White Ribbon Alliance Nigeria to strategically mobilize collective action to demand quality maternal health care and improve government responsiveness to those demands. We treat maternal health as a component of reproductive health, while recognizing it as a less contested area. METHODS: Data come from more than 40 interviews with relevant actors in Niger State in 2017 and 2018 during the initial phase of the campaign, and follow-up interviews with White Ribbon Alliance Nigeria staff in 2019 and 2021. Other data include White Ribbon Alliance Nigeria's monthly reports. We analyzed these data both deductively and inductively using qualitative techniques. RESULTS: During its first phase, the campaign used advocacy techniques to convince the previously reticent state government to engage with citizens, and worked to amplify citizen voice by hosting community dialogues and town halls, training a cadre of citizen journalists, and shoring up ward health development committees. Many of these efforts were unsustainable, however, so during the campaign's second phase, White Ribbon Alliance Nigeria worked to solidify state commitment to durable accountability structures intended to survive beyond the campaign's involvement. Key challenges have included a nontransparent state budget release process and the continued need for significant support from White Ribbon Alliance Nigeria. CONCLUSION: These findings reveal the significant time and resource inputs associated with implementing a strategic social accountability campaign, important compromises around the terminology used to describe "accountability," and the constraints on government responsiveness posed by unrealistic budgeting procedures. The campaign's contributions towards increased social accountability for maternal health should, however, also benefit accountability for reproductive health, as informed and empowered woman are better prepared to demand health services in any sector.

Community health workers and accountability: reflections from an international "think-in".

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a 'think in', held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger "accountability ecosystem." This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs' social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability.

International norms and the politics of sexuality education in Nigeria.

BACKGROUND: Proponents have promoted sexuality education as a means of empowering adolescents, yet it has been thwarted in many low and middle-income countries. Nigeria represents an exception. Despite social opposition, the government in 1999 unexpectedly approved sexuality education policy. Since then, implementation has advanced, although efficacy has differed across states. We draw on theory concerning international norm diffusion to understand Nigerian policy development. RESULTS: We find that a confluence of international and national norms and interests shaped policy outcomes, including concern over HIV/AIDS. A central dynamic was an alliance of domestic NGOs and international donors pressing the Nigerian government to act. CONCLUSIONS: We argue that theory on international norms can be applied to understand policy dynamics across a variety of health and population areas, finding value in approaches that integrate rather than juxtapose consideration of (1) international and national influences; (2) long and short-term perspectives on policy change; and (3) norms and interests.

Variable Implementation of Sexuality Education in Three Nigerian States.

In 2003, Nigeria adopted the Family Life and HIV Education (FLHE) sexuality education curriculum. Our analysis interrogates variation in sub-national implementation. We conducted 52 interviews with persons knowledgeable about the curriculum in three states-Kano, Lagos, and Niger-and reviewed publications on FLHE. In Kano, the socio-cultural context impeded implementation, but the persistence of innovative local champions resulted in some success. In Lagos, the cosmopolitan context, effective champions, funding by international donors, and a receptive government bureaucracy led to successful implementation. In Niger, despite a relatively conservative socio-cultural context, state bureaucratic bottlenecks overwhelmed proponents' efforts. In summary, the interaction of socio-cultural context, domestic champions, adaptive capacity of state bureaucracies, and international funders explains variable implementation of FLHE. The Nigerian experience highlights the need for sexuality education proponents to anticipate and prepare for local opposition and bureaucratic barriers.

Integrating the Demographic and Health Surveys, IPUMS-I, and TerraPopulus to Explore Mortality and Health Outcomes at the District Level in Ghana, Malawi, and Tanzania.

In this paper, we first show how the Demographic and Health Surveys (DHS) can be integrated with other data sources to expand the types of variables available for analysis of population and health outcomes. Second, we demonstrate one particular example of such integration by modelling the social, physical, and built environment determinants of health outcomes at the district level in Ghana, Malawi, and Tanzania. To do so, we created district-level measures of a number of variables from the DHS, and then merged them with district-level data from the IPUMS, an environmental data set called TerraPopulus, and other sources. We find that it is feasible to combine the DHS with other data sources, and that many health and environment indicators are heterogeneous within countries, justifying further analysis at low levels of geography and suggesting benefits to using such techniques to design fine-grained programmatic interventions.

Understanding the capacity of community-based groups to mobilise and engage in social action for health: Results from Avahan.

Community mobilisation improves outcomes from HIV to maternal and child health. Yet, little health research has explored why some community groups are better able to mobilise than others. We address this gap by considering the case of Avahan, the India AIDS Initiative, which sought to foster community mobilisation, including the creation of community-based groups serving men who have sex with men (MSM), female sex workers (FSWs), and injection drug users (IDUs). Using quantitative and qualitative data collected from 58 community-based groups from 2009-2012 across six Indian states, we analyse variation in groups' action on behalf of their members. Based on a mixed effects logistic regression, we find that older groups and those with bank accounts, crisis committees, or strategic relationships were most likely to take action on behalf of members by demanding rights or confronting gatekeepers and opinion leaders. Analysis of qualitative data reveals the types of action organisations took on behalf of members (mediation, removal of community members from harm, and advocacy), but also that sometimes organisations refused to take action, or community members declined their assistance. These findings indicate that organisations formalising, creating structures for social action, and building networks are important strategies to foster community mobilisation.

Prioritising sexuality education in Mississippi and Nigeria: The importance of local actors, policy windows and creative strategy.

Mississippi and Nigeria are two socially conservative places unlikely to prioritise sexuality education. Nonetheless, Mississippi passed a bill in 2011 mandating all school districts to offer sexuality education, and Nigeria approved a national sexuality education curriculum in 2001. To identify the factors that drove the process of prioritisation of sexuality education in each context, we conducted more than 70 semi-structured interviews with nongovernmental organisations/nonprofits, donor organisations and federal and state ministries involved in the prioritisation and implementation of sexuality education in Mississippi and Nigeria. Prioritisation of sexuality education occurred for similar reasons in both Mississippi and Nigeria: (1) local individuals and organisations committed to sexuality education and supported by external actors; (2) the opening of a policy window that made sexuality education a solution to a pressing social problem (teen pregnancy in Mississippi and HIV/AIDS in Nigeria) and (3) strategic action on the part of proponents. We conclude that promoting sexuality education in challenging contexts requires fostering committed local individuals and organisations, identifying external resources to support implementation costs and building on existing relationships of trust between actors, even if those relationships are unrelated to sexuality education.

From population to HIV: the organizational and structural determinants of HIV outcomes in sub-Saharan Africa.

BACKGROUND: There exists no consistent explanation for why some countries are successful in combating HIV/AIDS and others are not, and we need such an explanation in order to design effective policies and programmes. Research evaluating HIV interventions from a biomedical or public health perspective does not always take full account of the historical and organizational characteristics of countries likely to influence HIV outcomes. The analysis in this paper addresses this shortcoming by testing the impact of organizational and structural factors, particularly those resulting from population interventions, on HIV outcomes at the country level in sub-Saharan Africa. METHODS: The primary independent variables are factors that originated from efforts to slow population growth: whether a country has a long-time affiliate of the International Planned Parenthood Federation and whether a country has a population policy. Additional structural factors likely to impact HIV outcomes include the level of wealth, the level of cultural fractionalization, and the former colonial power. The present study uses multivariate regression techniques with countries in sub-Saharan Africa as the unit of analysis, and four measures of success in addressing HIV: the change in prevalence between 2001 and 2009; the change in incidence between 2001 and 2009; the level of overall antiretroviral coverage in 2009; and the level of antiretroviral coverage for prevention of vertical transmission in 2009. RESULTS: Countries with the greatest declines in HIV prevalence and incidence had older International Planned Parenthood Federation affiliates and had adopted population policies, even after controlling for age of epidemic, level of antiretroviral coverage, and funding for HIV. Population policies are also important predictors of levels of overall antiretroviral coverage and of coverage of HIV-positive pregnant women to prevent vertical transmission. Structural factors with significant impacts include wealth, cultural fractionalization and former colonial power. CONCLUSIONS: The organizational and structural context of African countries is strongly predictive of HIV outcomes. This finding implies that policy and programmatic efforts should be put towards strengthening existing organizations and perhaps even creating new ones. The fact that cultural fractionalization also influences HIV outcomes suggests that efforts must be put towards identifying ways to reach political consensus in diverse societies.

Counting women's labour: a reanalysis of children's net production using Cain's data from a Bangladeshi village.

The economic contribution of children to their parents' households has long interested demographers because of its potential to influence fertility levels. Valuing children's labour in pre-industrial economies, however, is inherently difficult. The same is true of women's labour, a crucial component of any analysis of net production. Here we use Mead Cain's seminal study (Population and Development Review 3(3): 201-227, 1977) of children's economic contributions in a Bangladeshi village to illustrate these points. We combine Cain's data on landless women's and men's hours of work with data on the efficiency per hour of work from other pre-industrial settings (Mueller, Population and Development: The Search for Selective Interventions. Baltimore, MD: Johns Hopkins University Press, pp. 98-153, 1976; Kramer, Dissertation, Department of Anthropology, University of New Mexico, 1998). When women's labour is incorporated, we find that the Bangladeshi children begin to produce as much as they consume by ages 10 (girls) or 11 (boys). Despite these productive contributions, neither women nor men 'pay' for their cumulative consumption until their early 20s. We believe our methods could be usefully applied in other contexts.