'Government don't know me and if I stop, they won't know': A qualitative study on the lived experiences of volunteer health workers in the Nigerian health system and their implications for the sustainable development goals.

BACKGROUND: Volunteer health workers play an important, but poorly understood role in the Nigerian health system. We report a study of their lived experiences, enabling us to understand their motivations, the nature of their work, and their relationships with formally employed health workers in Primary Healthcare Centres (PHCs) in Nigeria, the role of institutional incentives, and the implications for attaining the health-related sustainable development goals (SDGs) targets. METHODS: The study used ethnographic observation of PHCs in Enugu State, supplemented with in-depth interviews with volunteers, formally employed health workers and health managers. The analysis employed a combination of narrative and reflexive thematic approaches. FINDINGS: The lived experiences of most volunteers unfold in four stages as they move into and out of their volunteering status. The first stage signifies hope, arising from the ease with which they are accepted and integrated into the PHC space. The anger stage emerges when volunteers confront the marked disparity in their treatment compared to formal staff, despite their substantial contributions to healthcare. Then, the bargaining stage sets in, where they strive for recognition and respect by pursuing formal employment and advocating for fair treatment and improved stipends. A positive response, such as improved stipends, can reignite hope among volunteers. If not, most volunteers transition to the acceptance stage - the acknowledgement that their status may never be formalised, prompting many to lose hope and disengage. CONCLUSION: There should be a clear policy on recruitment, compensation, and protection of volunteers in the health systems, to enhance the contribution they can make to the achievement of the health-related SDG targets.

Implications of absenteeism of health workers on achieving universal health coverage in Nigeria: exploring lived experiences in primary healthcare.

Primary healthcare facilities are the bedrock for achieving universal health coverage (UHC) because of their closeness to the grassroots and provision of healthcare at low cost. Unfortunately, in Nigeria, the access and quality of health services in public primary healthcare centres (PHCs) are suboptimal, linked with persistent occurrence of absenteeism of health workers. We used a UHC framework developed by the World Health Organization-African Region to examine the link between absenteeism and the possible achievement of UHC in Nigeria. We undertook a qualitative study to elicit lived experiences of healthcare providers, service users, chairpersons of committees of the health facilities, and policymakers across six PHCs from six local government areas in Enugu, southeast Nigeria. One hundred and fifty participants sourced from the four groups were either interviewed or participated in group discussions. The World Health Organization-African Region UHC framework and phenomenological approach were used to frame data analysis. Absenteeism was very prevalent in the PHCs, where it constrained the possible contribution of PHCs to the achievement of UHC. The four indicators toward achievement of UHC, which are demand, access, quality, and resilience of health services, were all grossly affected by absenteeism. Absenteeism also weakened public trust in PHCs, resulting in an increase in patronage of both informal and private health providers, with negative effects on quality and cost of care. It is important that great attention is paid to both availability and productivity of human resources for health at the PHC level. These factors would help in reversing the dangers of absenteeism in primary healthcare and strengthening Nigeria's aspirations of achieving UHC.

Targeting systems not individuals: Institutional and structural drivers of absenteeism among primary healthcare workers in Nigeria.

Universal Health Coverage (UHC) can only be achieved if people receive good quality care from health workers, yet in Nigeria, as in many other low- and middle-income countries (LMICs), many health workers are absent from work. Absenteeism is a well-known phenomenon but is often considered as the self-serving behaviour of individuals, independent from the characteristics of health systems structures and processes and the broader contexts that enable it. We undertook a qualitative inquiry among 40 key informants, comprising health facility heads and workers, community leaders and state-level health policymakers in Nigeria. We employed a phenomenology approach to examine their lived experiences and grouped findings into thematic clusters. Absenteeism by health workers was found to be a response to structural problems at two levels -midstream (facility-level) and upstream (government level) - rather than being a result of moral failure of individuals. The problems at midstream level pointed to an inconsistent and unfair application of rules and regulations in facilities and ineffective management, while the upstream drivers relate mainly to political interference and suboptimal health system leadership. Reducing absenteeism requires two-pronged interventions that tackle defects in the upstream and midstream rather than just focusing on sanctioning deviant staff (downstream).

The Promise of Grassroots Approaches to Solving Absenteeism in Primary Health-Care Facilities in Nigeria: Evidence from a Qualitative Study.

Absenteeism among primary health-care (PHC) workers in Nigeria is widespread and is a major obstacle to achieving Universal Health Coverage (UHC). There is increasing research on the forms it takes and what drives them, but limited evidence on how to address it. The dominant approach has involved government-led topdown solutions (vertical approach). However, these have rarely been successful in countries such as Nigeria. This paper explores alternative approaches based on grassroots (horizontal) approaches. Data collected from interviews with 40 PHC stakeholders in Enugu, Nigeria, were organized in thematic clusters that explored the contribution of horizontal interventions to solving absenteeism in primary health-care facilities. We applied phenomenology to analyze the lived (practical) experiences of respondents. Absenteeism by PHC workers was prevalent and is encouraged by the complex configuration of the PHC system and its operating environment, which constrains topdown interventions. We identified several horizontal approaches that may create effective incentives and compulsions to reduce absenteeism, which include leveraging community resources to improve security of facilities, tapping the resources of philanthropic individuals and organizations to provide accommodation for health workers, and engaging trained health workers as volunteers or placeholders to address shortages of health-care staff. Nevertheless, a holistic response to absenteeism must complement horizontal approaches with vertical measures, with the government supporting and encouraging the health system to develop self-enforcing mechanisms to tackle absenteeism.

Effects of corruption and unaccountability on responses of frontline health workers to COVID-19 in Nigeria: Lessons and considerations for the social work profession.

COVID-19 stretched health systems, exacerbated by concerns about those that are corrupt and lack equity. Twelve (12) health workers and 12 hospital social workers across Nigeria were purposively sampled and virtually interviewed to explore unaccountability and corruption effects on COVID-19 responses. Findings show that corruption and unaccountability negatively affected responses of frontline health workers to the pandemic. Lack of social care and justice services for patients and health workers across health facilities in Nigeria worsened the negative effects. Effectively mainstreaming social care and justice services into Nigeria's healthcare led by well-trained social workers will improve the health sector via anticorruption.

The gendered drivers of absenteeism in the Nigerian health system.

The ability to deliver primary care in Nigeria is undermined by chronic absenteeism, but an understanding of its drivers is needed if effective responses are to be developed. While there is a small but growing body of relevant research, the gendered dynamics of absenteeism remains largely unexplored. We apply a gendered perspective to understanding absenteeism and propose targeted strategies that appear likely to reduce it. We did so by means of a qualitative study that was part of a larger project examining corruption within the health system in six primary healthcare facilities across rural and urban regions in Enugu State, south-east Nigeria. We conducted 30 in-depth interviews with frontline health workers, healthcare managers and community members of the health facility committee. Six focus group discussions were held with male and female service users. Data were analysed using thematic analysis. Participants described markedly gendered differences in the factors contributing to health worker absenteeism that were related to gender norms. Absence by female health workers was attributed to domestic and caregiving responsibilities, including housekeeping, childcare, cooking, washing and non-commercial farming used to support their families. Male health workers were most often absent to fulfil expectations related to their role as breadwinners, with dual practice and work in other sectors to generate additional income generation as their formal salaries were considered irregular and poor. Demands arising from socio-cultural and religious events affected the attendance of both male and female health workers. Both men and women were subject to sanctions, but managers and facility chairs were more lenient with women when absence was due to caregiving and other domestic responsibilities. In summary, gender roles influence absenteeism amongst primary healthcare workers in Nigeria and thus should be taken into account in developing nuanced responses that take account of the social, economic and cultural factors that underpin these roles.

Absenteeism in primary health centres in Nigeria: leveraging power, politics and kinship.

BACKGROUND: Primary health centres (PHCs) in Nigeria suffer critical shortages of health workers, aggravated by chronic absenteeism that has been attributed to insufficient resources to govern the system and adequately meet their welfare needs. However, the political drivers of this phenomenon are rarely considered. We have asked how political power and networks influence absenteeism in the Nigerian health sector, information that can inform the development of holistic solutions. METHODS: Data were obtained from in-depth interviews with three health administrators, 30 health workers and 6 health facility committee chairmen in 15 PHCs in Enugu State, Nigeria. Our analysis explored how political configurations and the resulting distribution of power influence absenteeism in Nigeria's health systems. RESULTS: We found that health workers leverage social networks with powerful and politically connected individuals to be absent from duty and escape sanctions. This reflects the dominant political settlement. Thus, the formal governance structures that are meant to regulate the operations of the health system are weak, thereby allowing powerful individuals to exert influence using informal means. As a result, health managers do not confront absentees who have a relationship with political actors for fear of repercussions, including retaliation through informal pressure. In addition, we found that while health system structures cannot effectively handle widespread absenteeism, networks of local actors, when interested and involved, could address absenteeism by enabling health managers to call politically connected staff to order. CONCLUSION: The formal governance mechanisms to reduce absenteeism are insufficient, and building alliances (often informal) with local elites interested in improving service delivery locally may help to reduce interference by other powerful actors.

Health Worker Absenteeism in Selected Health Facilities in Enugu State: Do Internal and External Supervision Matter?

Background: Absenteeism is widespread in Nigerian health facilities and is a major barrier to achievement of effective Universal Health Coverage. We have examined the role of internal (by managerial staff within facilities) and external (by managers at a higher level) supervision arrangements on health worker absenteeism. Specifically, we sought to determine whether these forms of supervision have any role to play in reducing health worker absenteeism in health facilities in Enugu State Nigeria. Methods: We conducted interviews with 412 health workers in urban and rural areas of Enugu State, in South-Eastern Nigeria. We used binary logistic regression to estimate the role of different types of supervision on health worker absenteeism in selected health facilities in Enugu State. Results: Internal supervision arrangements significantly reduce health worker absenteeism (odds ratio = 0.516, p = 0.03). In contrast, existing external supervision arrangements were associated with a small but significant increase in absenteeism (OR = 1.02, 0.043). Those reporting a better financial situation were more likely to report being absent (OR = 1.36, p < 0.01) but there was no association with age and marital status of respondents. Our findings also pointed to the potential for alternative forms of supervision, provided in a supportive rather than punitive way, for example by community groups monitoring the activities of health workers but trying to understand what support these workers may need, within or beyond the work environment. Conclusion: The existing system of external supervision of absenteeism in health facilities in Nigeria is not working but alternatives that take a more holistic approach to the lived experiences of health workers might offer an alternative.

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.

Private money-making indulgence and inefficiency of primary healthcare in Nigeria: a qualitative study of health workers' absenteeism.

OBJECTIVES: Generating additional personal income is common with primary healthcare (PHC) workforce in Nigeria, which could be because of the inconsistencies marring their monthly salaries. Therefore, this study investigates the drivers of private economic activities of PHC providers in the public sector, and the links to absenteeism, as well as inefficiency of PHC facilities in Nigeria. METHODS: A qualitative study design was used to collect data from 30 key-informants using in-depth interviews. They were selected from 5 PHC facilities across three local government areas in Enugu state, south-eastern Nigeria. Data were analysed thematically, and guided by phenomenology. RESULTS: Findings showed that majority of the health workers were involved in different private money-making activities. A main driver was inconsistencies in salaries, which makes it difficult for them to routinely meet their personal and household needs. As a result, PHC facilities were found less functional. CONCLUSIONS: Absenteeism of PHC providers can be addressed if efforts are made to close justifiable gaps that cause health workers to struggle informally. Such lesson can be instructive to low- and middle-income countries in strengthening their health systems.

Where Do We Start? Building Consensus on Drivers of Health Sector Corruption in Nigeria and Ways to Address It.

BACKGROUND: Corruption is widespread in Nigeria's health sector but the reasons why it exists and persists are poorly understood and it is often seen as intractable. We describe a consensus building exercise in which we asked health workers and policy-makers to identify and prioritise feasible responses to corruption in the Nigerian health sector. METHODS: We employed three sequential activities. First, a narrative literature review identified which types of corruption are reported in the Nigerian health system. Second, we asked 21 frontline health workers to add to what was found in the review (based on their own experiences) and prioritise them, based on their significance and the feasibility of assessing them, by means of a consensus building exercise using a Nominal Group Technique (NGT). Third, we presented their assessments in a meeting of 25 policy-makers to offer their views on the practicality of implementing appropriate measures. RESULTS: Participants identified 49 corrupt practices from the literature review and their own experience as most important in the Nigerian health system. The NGT prioritised: absenteeism, procurement-related corruption, under-the-counter payments, health financing-related corruption, and employment-related corruption. This largely reflected findings from the literature review, except for the greater emphasis on employment-related corruption from the NGT. Absenteeism, Informal payments and employment-related corruption were seen as most feasible to tackle. Frontline workers and policy-makers agreed that tackling corrupt practices requires a range of approaches. CONCLUSION: Corruption is recognized in Nigeria as widespread but often seems insurmountable. We show how a structured approach can achieve consensus among multiple stakeholders, a crucial first step in mobilizing action to address corruption.

Risky sexual behaviours among adolescent undergraduate students in Nigeria: does social context of early adolescence matter?

INTRODUCTION: adolescent undergraduate students engage in sexual acts that put them at risk of contracting Sexually Transmitted Infections (STIs) and unwanted pregnancies. Even though the social context of early adolescence accounts for developmental changes in later phase of life, its impact on adolescents' risky sexual behaviour has not been extensively explored. In this study, we examined how the social context of early adolescence influenced adolescent's risky sexual behaviour in the university. METHODS: qualitative data were collected from 24 adolescent undergraduate students of four universities in South-eastern Nigeria. Both males and females, within the age of 16-19 years were interviewed. The data were coded, managed with the use of Atlas.ti software and thematically analysed. RESULTS: the findings indicated that risky sexual behaviours among adolescent undergraduate students are embedded in the quality of sex education by parents at early adolescence. As such, unprotected sex and multiple sexual partners were rampant among adolescents who were not exposed to quality sex education at early adolescence. Adolescents whose parents are religious and/or authoritative but did not teach sex education during early adolescence engaged in risky sexual behaviours in the university. Also, adolescent undergraduate students that were raised in rural areas indulged in unprotected sex because of limited access to sex education during early adolescence. CONCLUSION: social context of early adolescence means a lot for adolescents' sexual experience in later phase of life. When parents provide their children the right information about sex, it can protect them from risky sexual behaviours as they grow older.

Corruption in Anglophone West Africa health systems: a systematic review of its different variants and the factors that sustain them.

West African countries are ranked especially low in global corruption perception indexes. The health sector is often singled out for particular concern given the role of corruption in hampering access to, and utilization of health services, representing a major barrier to progress to universal health coverage and to achieving the health-related Sustainable Development Goals. The first step in tackling corruption systematically is to understand its scale and nature. We present a systematic review of literature that explores corruption involving front-line healthcare providers, their managers and other stakeholders in health sectors in the five Anglophone West African (AWA) countries: Gambia, Ghana, Liberia, Nigeria and Sierra Leone, identifying motivators and drivers of corrupt practices and interventions that have been adopted or proposed. Boolean operators were adopted to optimize search outputs and identify relevant studies. Both grey and published literature were identified from Research Gate, Yahoo, Google Scholar, Google and PubMed, and reviewed and synthesized around key domains, with 61 publications meeting our inclusion criteria. The top five most prevalent/frequently reported corrupt practices were (1) absenteeism; (2) diversion of patients to private facilities; (3) inappropriate procurement; (4) informal payments; and (5) theft of drugs and supplies. Incentives for corrupt practices and other manifestations of corruption in the AWA health sector were also highlighted, while poor working conditions and low wages fuel malpractice. Primary research on anti-corruption strategies in health sectors in AWA remains scarce, with recommendations to curb corrupt practices often drawn from personal views and experience rather that of rigorous studies. We argue that a nuanced understanding of all types of corruption and their impacts is an important precondition to designing viable contextually appropriate anti-corruption strategies. It is a particular challenge to identify and tackle corruption in settings where formal rules are fluid or insufficiently enforced.