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.

The invisible hands in policy making: A qualitative study of the role of advocacy in priority setting for maternal and child health in Nigeria.

Background: Maternal and child health is a priority for most governments, especially those in low and middle-income countries (LMICs), due to high mortality rates. The combination of individual and social actions designed to gain political commitment, policy support and social acceptance for health goals are influenced by the interplay between the advocates and the strategies they deploy in planning and advocating for maternal and child health issue. This study aims to deepen our understanding of how advocacy has influenced maternal and child health priority setting in Nigeria. Methods: This is a mixed method study that involved 24 key informant interviews, document review, policy tracking and mapping of advocacy events that contributed to the repositioning of maternal and child health on the political agenda was done. Respondents were deliberately selected according to their roles and positions. Analysis was based on Shiffman and Smith's policy analysis framework of agenda setting. Results: Our findings suggest that use of various strategies for advocacy such as influencers, media, generated different outcomes and the use of a combination of strategies was found to be more effective. The role of advocacy in issue emergence was prominent and the presence of powerful actors, favorable policy window helped achieve desired outcomes. The power of the advocates and the strength of the individuals involved played a key role. Conclusion: This study finds it possible to understand the role of advocacy in policy agenda setting through the application of agenda setting framework. To achieve the health SDG goals, advocacy barriers need to be addressed at multiple levels.

Estimating vaccine coverage in conflict settings using geospatial methods: a case study in Borno state, Nigeria.

Reliable estimates of subnational vaccination coverage are critical to track progress towards global immunisation targets and ensure equitable health outcomes for all children. However, conflict can limit the reliability of coverage estimates from traditional household-based surveys due to an inability to sample in unsafe and insecure areas and increased uncertainty in underlying population estimates. In these situations, model-based geostatistical (MBG) approaches offer alternative coverage estimates for administrative units affected by conflict. We estimated first- and third-dose diphtheria-tetanus-pertussis vaccine coverage in Borno state, Nigeria, using a spatiotemporal MBG modelling approach, then compared these to estimates from recent conflict-affected, household-based surveys. We compared sampling cluster locations from recent household-based surveys to geolocated data on conflict locations and modelled spatial coverage estimates, while also investigating the importance of reliable population estimates when assessing coverage in conflict settings. These results demonstrate that geospatially-modelled coverage estimates can be a valuable additional tool to understand coverage in locations where conflict prevents representative sampling.

Disease perception, impacts and coping strategies for onchocerciasis in Southeast Nigeria: a qualitative study among patients and program managers.

BACKGROUND: Onchocerciasis is a disease of public health concern due to the devastating consequences of the disease which impacts negatively on the lives of the people. The negative impact of the disease may affect its perception and lead to the adoption of some coping strategies. Therefore, understanding the disease perception, impacts and coping strategies used by onchocerciasis patients will help plan health interventions aimed at improving their general well-being. METHODS: This was a community-based study that employed a qualitative method through Key informant interviews (KII) with program managers and focus group discussions (FGD) among people who had Onchocerciasis. Four sessions of FGDs with a total of thirty-two (32) participants and eleven KIIs were conducted to ascertain their in-depth experience in five thematic areas. RESULTS: In these communities, onchocerciasis is perceived to have been caused mainly by the bite of blackflies. Other presumed causes by the patients included drinking polluted water, poor environmental sanitation and witchcraft. The disease had a significant detrimental influence on both the physical and financial aspects of life with limited emotional and social impacts. The long-term clinical manifestations of onchocerciasis triggered pain and insufficient mobility. Thus, onchocerciasis patients experienced impairment in normal daily life activities (farming, etc.), dependency, depression and inability to participate in social events. These manifestations stimulated various coping strategies, mainly, nodulectomy by traditional healers. Others included self-medication, taking an overdose of ivermectin, and the use of alcohol. CONCLUSION: Misconceptions about the cause of onchocerciasis still exist among people with the disease. The consequences of the disease impact negatively on various aspects of their lives and stimulate various coping strategies. Therefore, health promotion messages to the public should aim at dispelling misconceptions about the disease and promote healthy coping strategies.

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.

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.

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.

Are rural pregnant women disadvantaged in accessing intermittent preventive treatment in pregnancy in Ebonyi State, Nigeria?

INTRODUCTION: Adequate intermittent preventive treatment (IPTp) uptake (≥3 doses) routinely delivered at antenatal clinics is effective in preventing malaria during pregnancy. Whereas, low IPTp uptake (24.0%) had been reported among pregnant women in Ebonyi State, there is paucity of studies comparing the uptake and its predictors in the urban and rural areas of Ebonyi State. We determined IPTp uptake and its predictors in the urban and rural areas of Ebonyi State. METHODS: We conducted a cross-sectional comparative study among 864 reproductive age women selected using multistage sampling. Using a structured interviewer-administered questionnaire, we collected data on respondent's socio-demographic characteristics and IPTp uptake. Uptake was adjudged adequate if ≥3 doses were taken, otherwise inadequate. We estimated the proportion of women with adequate IPTp uptake and determined the factors associated with adequate uptake in rural and urban areas using chi square and multiple logistic regression at 5% level of significance. RESULTS: The mean ages of respondents in the urban and rural areas were 28.5±4.6 and 27.4±5.0 years respectively. Adequate IPTp uptake was 82.5% and 60.8% in the urban and rural respectively (p<0.001). In the urban area, women whose husbands had attained ≥ secondary education (aOR:2.9; 95%CI:1.2-7.4; p = 0.02) and those who paid for sulfadoxine/pyrimethamime (aOR:0.2; 95%CI: 0.1-0.6; p = 0.01) were 2.9 times more likely and 5 times less likely to take adequate IPTp respectively compared to respondents whose husbands had attained ≤ primary education and those who had sulfadoxine/pyrimethamine free. In the rural area, women who had attended ANC <4 times (aOR:0.4; 95%CI: 0.3-0.7; p<0.001) were 2.5 times less likely to take adequate IPTp compared to women that had attended ANC ≥4 times. CONCLUSION: Uptake of IPTp was more in the urban than rural areas of Ebonyi State. Interventions that reinforce the importance of health professionals carrying out actions aimed at pregnant women and their partners (spousal) in order to guide them on preventive actions against malaria and other diseases are recommended in Ebonyi State.

Disability and its determinants among individuals with onchocerciasis in Southeast Nigeria: a cross-sectional study.

Introduction: although onchocerciasis is rarely a life-threatening disease, it causes chronic morbidity which ultimately leads to disability due to late detection and treatment of the infected people. Disability in Onchocerciasis results in activity limitation and social exclusion of the affected individuals through stigma. This study aimed at assessing the level of disability and its determinants among persons with onchocerciasis. Methods: multi-stage sampling technique was used to recruit 340 respondents from the randomly selected wards. Disability was assessed using WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) tool. Chi-square test and multivariate analysis using binary logistic regression were used to determine factors associated with disability. The level of statistical significance was determined by a p-value of < 0.05. Results: the highest proportion (35.6%) of the respondents was 55 years and above with a mean age of 46.8±17.5. About three-quarters (76.2%) of them had some form of disability and the disability domains mainly affected were participation in community activities (61.8%) and getting along with other people (54.1%) while the least affected were self-care (26.2%) and life activities including domestic responsibilities (45.0%). The Predictor of disability included being ≥48 years old, (AOR=0.2; 95%CI: 0.1-0.4). Conclusion: most people with onchocerciasis experience some form of disability and the major determinant for disability is being in the older age group. Thus, there is a need for stakeholders in the onchocerciasis control program to formulate and implement disability screening programs in the communities for early detection of onchocerciasis-associated disability, especially among the older age group.

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.

Antihypertensive medicine use differs between Ghana and Nigeria.

BACKGROUND: Non-communicable diseases are a growing burden in many African countries; cardiovascular disease is the main disease. Antihypertensive medicines (AHM) are a common treatment option but we know little about community use in most low- and medium-income countries (LMIC). We aimed to describe the use of antihypertensive medicines (AHM) in Ghana and Nigeria using a novel data source. METHODS: We used data from mPharma-a health and pharmaceutical company which distributes pharmaceuticals to hospital and retail pharmacies. We extracted data using the anatomical therapeutic chemical (ATC) classification codes and calculated use in defined daily doses and explored patterns by class, medicines, dose, and originator or generic product. RESULTS: AHM use differed between Ghana and Nigeria. The most used classes in Ghana were angiotensin receptor blockers (ARB) followed by calcium channel blockers (CCB) and angiotensin-converting-enzyme inhibitors (ACEi). The five most used products were 16 mg candesartan, 30 mg nifedipine, 10 mg lisinopril, 5 mg amlodipine and 50 mg losartan. In Nigeria ARB, CCB and diuretics were widely used; the top five products were 50 mg losartan, 10 mg lisinopril, 30 mg nifedipine, 40 mg furosemide, and 5 mg amlodipine. More originator products were used in Ghana than Nigeria. CONCLUSION: The differences between Ghana and Nigeria may result from a combination of medical, contextual and policy evidence and reflect factors related to clinical guidance (e.g. standard treatment guidelines), accessibility to prescribers and the role of community pharmacies, and structure of the health system and universal health coverage including funding for medicines. We show the feasibility of using novel data sources to gain insights on medicines use in the community.

Validation of a COVID-19 mental health and wellness survey questionnaire.

BACKGROUND AND AIM: COVID-19 affected mental health and wellbeing. Research is needed to assess its impact using validated tools. The study assessed the content validity, reliability and dimensionality of a multidimensional tool for assessing the mental health and wellbeing of adults. METHODS: An online questionnaire collected data in the second half of 2020 from adults in different countries. The questionnaire included nine sections assessing: COVID-19 experience and sociodemographic profile; health and memory; pandemic stress (pandemic stress index, PSI); financial and lifestyle impact; social support; post-traumatic stress disorder (PTSD); coping strategies; self-care and HIV profile over 57 questions. Content validity was assessed (content validity index, CVI) and participants evaluated the test-retest reliability (Kappa statistic and intra-class correlation coefficient, ICC). Internal consistency of scales was assessed (Cronbach α). The dimensionality of the PSI sections and self-care strategies was assessed by multiple correspondence analysis (MCA) using all responses and SPSS. For qualitative validation, we used a semi-structured interview and NVivo was used for coding and thematic analysis. RESULTS: The overall CVI = 0.83 with lower values for the memory items. Cronbach α for the memory items = 0.94 and ICC = 0.71. Cronbach α for PTSD items was 0.93 and ICC = 0.89. Test-retest scores varied by section. The 2-dimensions solution of MCA for the PSI behavior section explained 33.6% (precautionary measures dimension), 11.4% (response to impact dimension) and overall variance = 45%. The 2-dimensions of the PSI psychosocial impact explained 23.5% (psychosocial impact of the pandemic dimension), 8.3% (psychosocial impact of the precautionary measures of the pandemic dimension) and overall variance = 31.8%. The 2-dimensions of self-care explained 32.9% (dimension of self-care strategies by people who prefer to stay at home and avoid others), 9% (dimension of self-care strategies by outward-going people) and overall variance = 41.9%. Qualitative analysis showed that participants agreed that the multidimensional assessment assessed the effect of the pandemic and that it was better suited to the well-educated. CONCLUSION: The questionnaire has good content validity and can be used to assess the impact of the pandemic in cross-sectional studies especially as individual items. The PSI and self-care strategies need revision to ensure the inclusion of items with strong discrimination.

The Role of Contextual Factors in Private Sector Engagement: A Case Study of Private Sector Contribution to COVID-19 Mitigation in Nigeria.

The Private Sector Coalition against COVID-19 (CACOVID) was established on the 27th of March 2020 to mobilize private sector resources toward supporting the government's response to the COVID-19 pandemic. More specifically, CACOVID set out to provide leadership functions, raise public awareness, provide buy-in for COVID-19 prevention, and provide direct support to strengthen the health system's capacity to respond to the crisis. In this paper, we examine the contextual factors that shaped the private sector's engagement in the fight against the pandemic with a view to identifying progress and learning opportunities. A desk review of the existing literature and documents from relevant stakeholders (government, organized private sector, and civil society organizations) was carried out. Using both the Grindle and Thomas (1) and Husted and Salazar (2) frameworks, we identified individual characteristics (industry expertise and position, philanthropy, and personal/economic interest); the economic crises created by the pandemic; a weak health system; and the multi-sectoral nature of the response to the pandemic.as contextual factors that influenced public-private collaboration in tackling the COVID-19 pandemic in Nigeria. That is, the private sector collaborated with the government based on several interrelated contexts that confront them with issues they need to address; determine what options are feasible politically, economically, and administratively; set limits on what solutions are eventually considered; and respond to efforts to alter existing policies and institutional practices. The identified contextual factors provide learning opportunities for enhancing public-private partnership in advancing healthcare not just in Nigeria, but also in related countries in Africa and other developing countries.

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.

Sex differences in the experience of COVID-19 post-traumatic stress symptoms by adults in South Africa.

BACKGROUND: The COVID-19 pandemic has created multiple mental health challenges. Many residents in South Africa face pre-existing elevated levels of stress and the pandemic may have had varying impacts on sub-populations. The aims of this study were to determine: 1) the factors associated with post-traumatic stress symptoms (PTSS) and 2) sex differences in the factors associated with PTSS in adults residing in South Africa during the COVID-19 pandemic. METHODS: Study participants aged 18 years and above, were recruited for this cross-sectional study through an online survey implemented from June 29, 2020 to December 31, 2020. The outcome variable was PTSS; explanatory variables were sex at birth, COVID-19 status, social isolation and access to emotional support. Confounders considered were age, education level completed and current work status. Logistic regressions were used to determine the association between the outcome and explanatory variables after adjusting for confounders. OUTCOMES: There were 489 respondents. Among all respondents, those who were older (AOR: 0.97; 95% CI: 0.95 - 0.99) and had access to emotional support from family and relatives (AOR: 0.27; 95% CI: 0.14 - 0.53) had significantly lower odds of PTSS. Respondents who felt socially isolated had higher odds of PTSS (AOR: 1.17; 95% CI: 1.08 - 1.27). Females had higher PTSS scores and higher odds of PTSS compared to males (AOR: 2.18; 95% CI: 1.41-3.39). Females (AOR: 0.27; 95% CI: 0.08 - 0.95) and males (AOR: 0.26; 95% CI: 0.11, 0.59) who had access to emotional support had significantly lower odds of PTSS than those who had no support. Females (AOR: 1.15; 95% CI: 1.04 -1.27) and males (AOR: 1.19; 95% CI: 0.11, 0.59) who felt socially isolated had higher odds of PTSS compared to those who did not feel socially isolated. INTERPRETATION: Compared to males, females had higher scores and higher odds of reporting PTSS during the COVID-19 pandemic. Access to emotional support ameliorated the odds of having PTSS for both sexes, while feeling socially isolated worsened the odds for both sexes.

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.