Inclusion strategies in multi-stakeholder dialogues: The case of a community-based participatory research on immunization in Nigeria.

BACKGROUND: Community-Based Participatory Research (CBPR) has been used to address health disparities within several contexts by actively engaging communities. Though dialogues are recognized as a medium by which community members and other actors can make their voices heard through processes that support shared-decision making, power asymmetries often impede the achievement of this objective. Traditionally such relationship asymmetries exist between communities, health workers, and other professionals resulting in the exclusion of communities from decision making in participatory practices and dialogues. This study aimed to explore the experiences in the dialogues between different groups within communities, health workers and local government officials in a CBPR project on immunization in Nigeria. We adapted the framework by Elberse et al. (2011) to structure the possible exclusion mechanisms that could exist in dialogues between the three groups and we set up inclusion strategies to diminish the inequalities as much as possible. METHODS AND FINDINGS: This is an exploratory and descriptive case study, using qualitative methods. Data was collected through observation and semi-structured interviews (SSI) with dialogue participants. All 24 participants in the multi-stakeholder dialogues were interviewed. Inclusion strategies involved creating enabling circumstances; influencing behaviour; and influencing use of language. Verbal and circumstantial strategies were of limited value in reducing exclusion. Behavioural inclusion strategies created more awareness of the importance of inclusion; and enabled different community stakeholders to direct their influences towards achieving the collective goals of the collaboration. An important learning is that if evidence is used in the dialogues, even when exclusion of certain individuals occurs, the outcomes could still favour them. A key issue is the difference between participation and representation and the need for more efficient ways of carrying out such interactive processes to ensure that the participation of the vulnerable groups is not merely symbolic. The study makes a case for the use of 'boundary spanners' in this dynamic-these are 'elite' individuals (or community champions) who can be a voice for the minorities and who could have the opportunity to influence decision making. CONCLUSION: CBPR can enable local governments to develop effective partnerships with health workers and communities to achieve health-related goals even in the presence of asymmetries in relationships. Inclusion strategies in dialogues can improve participation and enable shared decision making, however exclusion of vulnerable groups may still occur. Intra-community dynamics and socio-cultural contexts can drive exclusion and less privileged community members require proper representation to enable their issues to be captured effectively.

Using participatory action research to improve immunization utilization in areas with pockets of unimmunized children in Nigeria.

BACKGROUND: In 2005, Nigeria adopted the Reaching Every Ward strategy to improve vaccination coverage for children 0-23 months of age. By 2015, Ogun state had full coverage (100%) in 12 of its 20 local government areas, but eight had pockets of unimmunized children, with the highest burden (37%) in Remo North. A participatory action research (PAR) approach was used to facilitate implementation of local solutions to contextual barriers to immunization in Remo North. This article assesses and seeks to explain the outcomes of the PAR implemented in Remo North to understand whether and possibly how it improved immunization utilization. METHODS: The PAR intervention took place from 2016 to 2017. It involved two (4-month) cycles of dialogue and action between community members, frontline health workers and local government officials in two wards of Remo North, facilitated by the research team. The PAR was assessed using a pre/post-intervention-only design with mixed methods. These included household surveys of caregivers of 215 and 213 children, respectively, 25 semi-structured interviews with stakeholders involved in immunization service delivery and 16 focus group discussions with community members. Data were analysed using the Strategic Advisory Group of Experts (SAGE) vaccine hesitancy framework. RESULTS: Collaboration among the three stakeholder groups enabled the development and implementation of solutions to identified problems related to access to and use of immunization services. At endline, assessment by card for children older than 9 months revealed a significant increase in those fully immunized, from 60.7% at baseline to 90.9% (p < .05). A significantly greater number of caregivers visited fixed government health facilities for routine immunization at endline (83.2%) than at baseline (54.2%) (p < .05). The reasons reported by caregivers for improved utilization of routine immunization services were increased community mobilization activities and improved responsiveness of the health workers. Spillover effects into maternal health services enhanced the use of immunization services by caregivers. Spontaneous scale-up of actions occurred across Remo North due to the involvement of local government officials. CONCLUSION: The PAR approach achieved contextual solutions to problems identified by communities. Collection and integration of evidence into discussions/dialogues with stakeholders can lead to change. Leveraging existing structures and resources enhanced effectiveness.

Performance-Based Financing, Basic Packages of Health Services and User-Fee Exemption Mechanisms: An Analysis of Health-Financing Policy Integration in Three Fragile and Conflict-Affected Settings.

BACKGROUND: As performance-based financing (PBF) is increasingly implemented across sub-Saharan Africa, some authors have suggested that it could be a 'stepping stone' for health-system strengthening and broad health-financing reforms. However, so far, few studies have looked at whether and how PBF is aligned to and integrated with national health-financing strategies, particularly in fragile and conflict-affected settings. OBJECTIVE: This study attempts to address the existing research gap by exploring the role of PBF with reference to: (1) user fees/exemption policies and (2) basic packages of health services and benefit packages in the Central African Republic, Democratic Republic of Congo and Nigeria. METHODS: The comparative case study is based on document review, key informant interviews and focus-group discussions with stakeholders at national and subnational levels. RESULTS: The findings highlight different experiences in terms of PBF's integration. Although (formal or informal) fee exemption or reduction practices exist in all settings, their implementation is not uniform and they are often introduced by external programmes, including PBF, in an uncoordinated and vertical fashion. Additionally, the degree to which PBF indicators lists are aligned to the national basic packages of health services varies across cases, and is influenced by factors such as funders' priorities and budgetary concerns. CONCLUSIONS: Overall, we find that where national leadership is stronger, PBF is better integrated and more in line with the health-financing regulations and, during phases of acute crisis, can provide structure and organisation to the system. Where governmental stewardship is weaker, PBF may result in another parallel programme, potentially increasing fragmentation in health financing and inequalities between areas supported by different donors.

Exploring Factors Influencing Immunization Utilization in Nigeria-A Mixed Methods Study.

Background: In 2005, Nigeria adopted the Reach Every Ward strategy to improve vaccination coverage for children, 0-23 months. By 2015, Ogun state had full coverage in 12 of its 20 local government areas but eight had pockets of unimmunized children, with the highest burden (37%) in Remo-North. This study aimed to identify factors in Remo-North influencing the use of immunization services, in order to inform intervention approaches to tackle barriers to immunization utilization. Methods: We carried out a cross-sectional study using mixed methods including a survey of caregivers of 215 children, 25 semi-structured interviews with stakeholders involved in immunization service delivery and 16 focus group discussions with community men and women (n = 98). Two wards (Ilara and Ipara) were purposively chosen for the study. Data was analyzed using the SAGE Working Group Vaccine Hesitancy model. Results: Only 56 children (32.6%) of the 172 children over 9 months of age had immunization cards available for inspection. Of these, 23 (59.6%) were fully immunized, noticeably higher in Ipara than Ilara. However, when immunization status was assessed by card and recall, 84.9% of the children were assessed as fully immunized. Caregivers in the more rural Ilara had less knowledge of vaccine schedules. The importance of all doses was recognized more by Ipara respondents (95.5%) than in Ilara (75.3%) (p < 0.05). Community links to immunization and household decision-making patterns influenced immunization use in both wards. Migrants and those living in hard-to-reach areas were disadvantaged in both wards. Health service factors like absence of delivery services, shortage of health workers, unavailability of vaccines at scheduled times, and indirect costs of immunization contributed to low utilization. Conclusion: Immunization utilization was influenced by interlinked community and health services issues. Intervention approaches should ensure that communities' priorities are addressed, actors at both levels involved and strategies are adjusted to suit contexts.

Performance-based financing in three humanitarian settings: principles and pragmatism.

BACKGROUND: Performance based financing (PBF) has been increasingly implemented across low and middle-income countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn. METHODS: Our comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities. RESULTS: Our analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called 'PBF principles' that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes. CONCLUSIONS: Our study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.

Who benefits from the Obio Community Health Insurance Scheme in Rivers State, Nigeria? A benefit incidence analysis.

BACKGROUND: A key aspect of monitoring and evaluating health programs is ensuring that benefits are reaching their target population. We conducted a benefit incidence analysis (BIA) of a Shell-sponsored community health insurance scheme in Nigeria to determine the extent to which the target group (the poor) was benefitting. METHODS: We examined a sample of 616 patients' hospital attendance, financial and administrative records from 2012-2013. We estimated annual utilization rates and average unit costs for inpatient and outpatient services. We multiplied the two to produce a total cost per patient, then deducted annual out-of-pocket expenditures to estimate the total community-based health insurance scheme benefit per person. Benefits were multiplied by the total number of persons in each socioeconomic group to aggregate benefits. We used concentration curves and dominance tests to determine statistical significance at 5% and 10% levels of significance. RESULTS: Collectively, the poorest 20% of the population received 12% of benefits while the richest quintile received the largest share (23%). Inpatient and outpatient benefits are weakly regressive (pro-rich), statistically significant at a 10% level of significance. CONCLUSIONS: Although the poor were found to benefit, this BIA revealed a tendency towards pro-rich distributions. Removing co-payments for the poorest, reducing long wait and visit times and using community volunteers to help increase access to health services may improve benefits for the poor.

2014 Nigeria: Impact Evaluation of Water, Sanitation, and Hygiene (WASH) within the UNICEF Country Programme of Cooperation, Government of Nigeria and UNICEF, 2009-2013

The Nigerian situation mirrors the Sub Saharan African situation where out of an estimated population of 160 million, approximately 63 million still lack access to safe water supply and 113 million people lack access to basic sanitation facilities. Wide disparities between the six geopolitical zones and within states also worsen the situation, with the poor and more vulnerable populations at greater risk of WASH related health and non-health (such as time saving, productivity, school enrolment and attendance, gender inequality) human development problems.

Assessing health workers' revenues and coping strategies in Nigeria--a mixed-methods study.

BACKGROUND: The setting of realistic performance-based financing rewards necessitates not just knowledge of health workers' salaries, but of the revenue that accrues from their additional income-generating activities. This study examined the coping mechanisms of health workers in the public health sector of Nasarawa and Ondo states in Nigeria to supplement their salaries and benefits; it also estimated the proportionate value of the revenues from those coping mechanisms in relation to the health workers' official incomes. METHODS: This study adopted a mixed-methods approach, consisting of semi-structured interviews, a review of policy documents, a survey using self-administered questionnaires, and the randomized response technique (RRT). In all, 170 health workers (86 in Ondo, 84 in Nasarawa) participated in the survey. In-depth interviews were conducted with 24 health workers (12 per state) and nine policy makers from both states. RESULTS: The health workers perceived their salaries as inadequate, though most policy makers differed in this assessment. There appeared to be a considerable expenditure-income disparity among the respondents. Approximately 56% (n = 93) of the study population reported having additional earning arrangements: most reported non-medical activities such as farming and trading, but private practice was also frequently reported.Half of the respondents with additional earning arrangements stated that their income from those activities was the equivalent of half or more of their monthly salaries. Specifically, 35% (n = 32) said that they earned about half of their official monthly salaries and 15% (n = 14) reported earning the same or more than their monthly salaries from these activities. Other coping mechanisms used by the health workers included prioritizing activities that enabled the earning of per diems, collecting informal payments and gifts from patients, and pilfering drugs from facilities. CONCLUSIONS: Predatory and non-predatory mechanisms accounted for the health workers' additional income. It may be difficult for the health workers to meet their expenses with their salaries and financial incentives; this highlights the need for the regulation of additional earnings and to implement targeted accountability mechanisms. This study indicates the value of using mixed methods when investigating sensitive issues. Future studies of this type should employ mixed methods for triangulation purposes to provide better insight into health workers' responses.

A systematic review of outcome and impact of master's in health and health care.

BACKGROUND: The 'human resources for health' crisis has highlighted the need for more health (care) professionals and led to an increased interest in health professional education, including master's degree programmes. The number of these programmes in low- and middle-income countries (LMIC) is increasing, but questions have been raised regarding their relevance, outcome and impact. We conducted a systematic review to evaluate the outcomes and impact of health-related master's degree programmes. METHODS: We searched the databases Scopus, Pubmed, Embase, CINAHL, ERIC, Psychinfo and Cochrane (1999 - November 2011) and selected websites. All papers describing outcomes and impact of health-related Master programmes were included. Three reviewers, two for each article, extracted data independently. The articles were categorised by type of programme, country, defined outcomes and impact, study methods used and level of evidence, and classified according to outcomes: competencies used in practice, graduates' career progression and impact on graduates' workplaces and sector/society. RESULTS: Of the 33 articles included in the review, most originated from the US and the UK, and only one from a low-income country. The programmes studied were in public health (8), nursing (8), physiotherapy (5), family practice (4) and other topics (8). Outcomes were defined in less than one third of the articles, and impact was not defined at all. Outcomes and impact were measured by self-reported alumni surveys and qualitative methods. Most articles reported that competencies learned during the programme were applied in the workplace and alumni reported career progression or specific job changes. Some articles reported difficulties in using newly gained competencies in the workplace. There was limited evidence of impact on the workplace. Only two articles reported impact on the sector. Most studies described learning approaches, but very few described a mechanism to ensure outcome and impact of the programme. CONCLUSIONS: Evidence suggests that graduates apply newly learned competencies in the field and that they progress in their career. There is a paucity of well-designed studies assessing the outcomes and impact of health-related master's degree programmes in low- and middle-income countries. Studies of such programmes should consider the context and define outcomes and impact.