Improving Program Outcomes Through Responsive Feedback: A Case Study of a Leadership Development Academy in Nigeria.

BACKGROUND: In 2018, the National Primary Health Care Development Agency (NPHCDA), under the Nigeria Federal Ministry of Health, recognized that inadequate personnel competencies limited its ability to provide technical assistance to state primary health care development boards (SPHCBs). In response, NPHCDA instituted a cohort-based leadership development academy (LDA) to develop its staff's leadership and management skills. NPHCDA LEADERSHIP DEVELOPMENT ACADEMY PROGRAM: A baseline assessment identified critical gaps in leadership and management competencies. Agency leaders and midlevel staff aligned on the gaps and approaches to bridge them. Participants in the LDA were selected across headquarters and zones to ensure equitable spread. The NPHCDA adopted a mix of capacity-building approaches that prioritized 6 core leadership and management skills with the application of the 70-20-10 learning philosophy to ensure participants learn and apply skills. Responsive feedback (RF) mechanisms were key in program design and implementation. NPHCDA collaborated with development partners through an iterative cocreation process to design and revise for implementation. The program embraced information and communication technology to collate qualitative and quantitative data across activities in real-time and used insights to drive continuous improvement. RESULTS: Incorporating feedback from the first cohort led to an increase in the proportion of trainees acquiring intermediate to advanced competencies in target skill areas from 41% to 57% in the second cohort. The trainees have taken on more challenging roles at NPHCDA, delivering technical assistance to SPHCBs and bolstering the agency's ability to independently execute activities such as the COVID-19 vaccine introduction. The agency continues to adopt RF mechanisms in the coordination and delivery of advanced technical training for staff and institution of a capacity-building and acculturation program for new hires. CONCLUSION: RF has demonstrated that identifying and engaging key stakeholders to participate in continuous learning and adaptation is critical to achieving program effectiveness and sustainability.

Perceptions of patent and proprietary medicine vendors and communities of the tiered accreditation programme for family planning services in Lagos and Kaduna states, Nigeria.

This study evaluated the perception of patent and proprietary medicine vendors (PPMVs) of the accreditation programme to improve their capacity to provide family planning (FP) services in Lagos and Kaduna, Nigeria. A cross-sectional mixed-method approach among 224 PPMVs was used to investigate their perception, willingness to pay for and adhere to the programme, its benefits, and the community women's perception of the value of PPMVs. Chi-square analysis and structural equation modelling (SEM) were used to analyse survey data, while focus group discussions (FGDs) were analysed using the grounded theory. PPMVs were enthusiastic because of the benefits, including increased clientele, revenue, and improved service provision capacity. Approximately 97% of PPMVs found the programme acceptable and were willing to pay, with 56% and 71% willing to pay between N5000-N14900 ($12-36) and N25000-N35000 ($60-87), respectively. A significant relationship between educational attainment, location, and willingness to pay was revealed. Among community women, the fear of side effects, lack of partners' support, myths and misconceptions, and lack of access to modern contraceptives were factors affecting contraceptive uptake. The capacity of PPMVs to improve FP uptake is promising and can be leveraged to improve health outcomes in communities while strengthening their businesses.

Historical reconstruction of inaccessibility status in Local Government Areas (LGAs) of Borno and Yobe States, Nigeria, 2010-2020.

Introduction: ultimately detected in 2016, wild poliovirus (WPV) transmission continued undetected after 2011 in Northeast Nigeria Borno and Yobe States in security-compromised areas, inaccessible due to armed insurgency. Varying inaccessibility prevented children aged <5 years in these areas from polio vaccination interventions and surveillance, while massive population displacements occurred. We examined progress in access over time to provide data supporting a very low probability of undetected WPV circulation within remaining trapped populations after 2016. Methods: to assess the extent of inaccessibility in security-compromised areas, we obtained empirical historical data in 2020 on a quarterly and annual basis from relevant polio eradication staff for the period 2010-2020. The extent of access to areas for immunization by recall was compared to geospatial data from vaccinator tracking. Population estimates over time in security-compromised areas were extracted from satellite imagery. We compared the historical access data from staff with tracking and population esimates. Results: access varied during 2010-2020, with inaccessibility peaking during 2014-2016. We observed concurrent patterns between historical recalled data on inaccessibility and contemporaneous satellite imagery on population displacements, which increased confidence in the quality of recalled data. Conclusion: staff-recalled access was consistent with vaccinator tracking and satellite imagery of population displacments. Despite variability in inaccessibility over time, innovative immunization initiatives were implemented as access allowed and surveillance initiatives were initiated to search for poliovirus transmission. Along with escape and liberation of residents by the military in some geographic areas, these initiatives resulted in a massive reduction in the size of the unvaccinated population remaining resident.

Patient and health facility attributes associated with retention and virologic suppression in private for-profit health facilities in Nigeria.

BACKGROUND: In Nigeria, private for-profit health facilities present an opportunity to achieve the UNAIDS 95-95-95 HIV targets because of their reach and patronage. However, little is known about determinants of outcomes in these facilities. This study describes patient outcomes and the patient and health facility characteristics associated with these outcomes in adults receiving HIV treatment in private facilities in the Federal Capital Territory (FCT), Benue and Nasarawa states in north-central Nigeria. METHODS: A retrospective longitudinal analysis of program data collected between 2013 and 2019 was done. Patient attributes and outcomes were compared across the two states and FCT. Incidence rates were determined for all cause exit, mortality and loss to follow up (LTFU). Cox proportional hazard models were used to identify associations between patient and facility attributes and these outcomes. Bivariate and multivariate logistic regression models were used to determine the factors associated with viral suppression among the study participants. RESULTS: Of the 22,010 study subjects, 42.7%, 22.2% and 35.1%, respectively, were in Benue, FCT and Nasarawa. Almost a third (31.8%) had received antiretroviral treatment (ART) for less than a year at censoring. Incidence rates for all-cause exit, mortality and loss to follow up (LTFU) were 17.2 (95% CI 16.8, 17.5), 2.1 (95% CI 2.0, 2.2), and 11.2 (95% CI 10.8, 11.8) per 100 person years respectively. Males had higher risks of death (HR = 1.47, 95% CI 1.25-1.73), and LTFU (HR = 1.08, 95% CI 1.00-1.16). Age at ART start showed a dose-response association with both mortality and LTFU. Care at model facilities (OR = 2.16, p < 0.001), Zidovudine (AZT)-based regimens (OR = 2.00, p < 0.001), and lowest quartile baseline CD4 + count (OR = 2.40, p < 0.001) were associated with regimen switch. 75.6% of subjects were viral suppressed. Male gender (OR = 0.84, p = 0.025); AZT-based regimen (OR = 0.72, p < 0.001), age in the bottom quartile (OR = 0.71, p = 0.002) were associated with virally suppression. CONCLUSION: Private for-profit facilities are a major provider of HIV and other health services in Nigeria. With appropriate technical support and engagement, they can help accelerate efforts to achieve epidemic control of HIV in Nigeria, and contribute to achievement of UNAIDS 95-95-95 target by 2030.

Preliminary results from direct-to-facility vaccine deliveries in Kano, Nigeria.

OBJECTIVE: As part of its vaccine supply chain redesign efforts, Kano state now pushes vaccines directly from 6 state stores to primary health centers equipped with solar refrigerators. Our objective is to describe preliminary results from the first 20months of Kano's direct vaccine delivery operations. METHODS: This is a retrospective review of Kano's direct vaccine delivery program. We analyzed trends in health facility vaccine stock levels, and examined the relationship between stock-out rates and each of cascade vaccine deliveries and timeliness of deliveries. Analysis of vaccination trends was based on administrative data from 27 sentinel health facilities. Costs for both the in-sourced and out-sourced approaches were estimated using a bottoms-up model-based approach. RESULTS: Overall stock adequacy increased from 54% in the first delivery cycle to 68% by cycle 33. Conversely, stock-out rates decreased from 41% to 10% over the same period. Similar trends were observed in the out-sourced and in-sourced programs. Stock-out rates rose incrementally with increasing number of cascade facilities, and delays in vaccine deliveries correlated strongly with stock-out rates. Recognizing that stock availability is one of many factors contributing to vaccinations, we nonetheless compared pre- and post- direct deliveries vaccinations in sentinel facilities, and found statistically significant upward trends for 4 out of 6 antigens. 1 antigen (measles) showed an upward trend that was not statistically significant. Hepatitis b vaccinations declined during the period. Overall, there appeared to be a one-year lag between commencement of direct deliveries and the increase in number of vaccinations. Weighted average cost per delivery is US$29.8 and cost per child immunized is US$0.7 per year. CONCLUSION: Direct vaccine delivery to health facilities in Kano, through a streamlined architecture, has resulted in decreased stock-outs and improved stock adequacy. Concurrent operation of insourced and outsourced programs has enabled Kano build in-house logistics capabilities.

How decentralisation influences the retention of primary health care workers in rural Nigeria.

BACKGROUND: In Nigeria, the shortage of health workers is worst at the primary health care (PHC) level, especially in rural communities. And the responsibility for PHC - usually the only form of formal health service available in rural communities - is shared among the three tiers of government (federal, state, and local governments). In addition, the responsibility for community engagement in PHC is delegated to community health committees. OBJECTIVE: This study examines how the decentralisation of health system governance influences retention of health workers in rural communities in Nigeria from the perspective of health managers, health workers, and people living in rural communities. DESIGN: The study adopted a qualitative approach, and data were collected using semi-structured in-depth interviews and focus group discussions. The multi-stakeholder data were analysed for themes related to health system decentralisation. RESULTS: The results showed that decentralisation influences the retention of rural health workers in two ways: 1) The salary of PHC workers is often delayed and irregular as a result of delays in transfer of funds from the national to sub-national governments and because one tier of government can blame failure on another tier of government. Further, the primary responsibility for PHC is often left to the weakest tier of government (local governments). And the result is that rural PHC workers are attracted to working at levels of care where salaries are higher and more regular - in secondary care (run by state governments) and tertiary care (run by the federal government), which are also usually in urban areas. 2) Through community health committees, rural communities influence the retention of health workers by working to increase the uptake of PHC services. Community efforts to retain health workers also include providing social, financial, and accommodation support to health workers. To encourage health workers to stay, communities also take the initiative to co-finance and co-manage PHC services in order to ensure that PHC facilities are functional. CONCLUSIONS: In Nigeria and other low- and middle-income countries with decentralised health systems, intervention to increase the retention of health workers in rural communities should seek to reform and strengthen governance mechanisms, using both top-down and bottom-up strategies to improve the remuneration and support for health workers in rural communities.