Willingness to pay for haemodialysis among patients with chronic kidney disease in Abuja, Nigeria.

BACKGROUND: Evidence of willingness to pay for kidney replacement therapy is scarce in low-middle-income countries, including Nigeria's Formal Sector Social Health Insurance Programme. The study, therefore, assessed the willingness to pay for haemodialysis among chronic kidney disease patients in Abuja, Nigeria. METHODS: The study adopted a cross-sectional survey design. We used the contingent valuation method to estimate the maximum stated willingness to pay (WTP) for haemodialysis among end-stage kidney disease (ESKD) patients. We obtained informed written consent from respondents before data collection. The socio-demographic characteristics and willingness to pay data were summarized using descriptive statistics. We evaluated the mean differences in respondents' WTP using Mann-Whitney and Kruskal-Wallis tests. All variables that had p < 0.25 in the bivariate analysis were included in the Generalized Linear Model (gamma with link function) to determine the predictors of the WTP for one's and another's haemodialysis. The level of significance in the final model was ρ < 0.05. RESULTS: About 88.3% and 64.8% of ESKD patients were willing to pay for personal and altruistic haemodialysis, correspondingly. The mean annual WTP for haemodialysis for one's and altruistic haemodialysis was USD25,999.06 and USD 1539.89, respectively. Private hospital patients were likelier to pay for their haemodialysis (ß = 0.39, 95%CI: 0.21 to 0.57, p < 0.001). Patients attending public-private partnership hospitals were less likely to pay for altruistic haemodialysis than those attending public hospitals (ß = -1.65, 95%CI: -2.51 to -0.79, p < 0.001). CONCLUSIONS: The willingness to pay for haemodialysis for themselves and others was high. The type of facility ESKD patients attended influenced their willingness to pay for haemodialysis. The findings highlight the need for policies to enhance affordable and equitable access to haemodialysis in Nigeria through pre-payment mechanisms and altruistic financing strategies.

Cost analysis of the management of end-stage renal disease patients in Abuja, Nigeria.

BACKGROUND: Although the treatment for end-stage renal disease (ESRD) under Nigeria's National Health Insurance Authority is haemodialysis (HD), the cost of managing ESRD is understudied in Nigeria. Therefore, this study estimated the provider and patient direct costs of haemodialysis and managing ESRD in Abuja, Nigeria. METHOD: The study was a cross-sectional survey from both healthcare provider and consumer perspectives. We collected data from public and private tertiary hospitals (n = 6) and ESRD patients (n = 230) receiving haemodialysis in the selected hospitals. We estimated the direct providers' costs using fixed and variable costs. Patients' direct costs included drugs, laboratory services, transportation, feeding, and comorbidities. Additionally, data on the sociodemographic and clinical characteristics of patients were collected. The costs were summarized in descriptive statistics using means and percentages. A generalized linear model (gamma with log link) was used to predict the patient characteristics associated with patients' cost of haemodialysis. RESULTS: The mean direct cost of haemodialysis was $152.20 per session (providers: $123.69; and patients: $28.51) and $23,742.96 annually (providers: $19,295.64; and patients: $4,447.32). Additionally, patients spent an average of $2,968.23 managing comorbidities. The drivers of providers' haemodialysis costs were personnel and supplies. Residing in other towns (HD:ß = 0.55, ρ = 0.001; ESRD:ß = 0.59, ρ = 0.004), lacking health insurance (HD:ß = 0.24, ρ = 0.038), attending private health facility (HD:ß = 0.46, ρ < 0.001; ESRD: ß = 0.75, ρ < 0.001), and greater than six haemodialysis sessions per month (HD:ß = 0.79, ρ < 0.001; ESRD: ß = 0.99, ρ < 0.001) significantly increased the patient's out-of-pocket spending on haemodialysis and ESRD. CONCLUSION: The costs of haemodialysis and managing ESRD patients are high. Providing public subsidies for dialysis and expanding social health insurance coverage for ESRD patients might reduce the costs.

Determinants of cigarette smoking and smoking frequency among women of reproductive age in Nigeria: evidence from a nationwide cross-sectional survey.

BACKGROUND: Smoking is a leading cause of avoidable deaths and attributable disability-adjusted life years globally. Yet, the determinants of smoking practices among women are understudied. This study assessed the determinants of smoking and smoking frequency among women of reproductive age in Nigeria. METHODS AND MATERIALS: Data from the 2018 Nigeria Demographic and Health Survey (NDHS) were used in this study (n = 41,821). The data were adjusted for sampling weight, stratification, and cluster sampling design. The outcome variables were smoking status and smoking frequency (daily smoking and occasional smoking). The predictor variables included women's socio-demographic and household characteristics. Pearson's chi-squared test was used to evaluate the association between outcome and predictor variables. All variables significant in bivariate analyses were further analysed using complex sample logistics regression. Statistical significance was set at a p-value < 0.05. RESULTS: The prevalence of smoking among women of reproductive age is 0.3%. The prevalence of smoking frequency is 0.1% (daily) and 0.2% (occasionally). Overall, women aged 25-34 (AOR = 2.13, 95%CI: 1.06-4.29, ρ = 0.034), residing in the South-south region (AOR = 9.45, 95%CI: 2.04-43.72, ρ <0.001), being formerly married (AOR = 3.75, 95%CI: 1.52-9.21, ρ = 0.004), in female-headed households (AOR = 2.56, 95%CI: 1.29-5.08, ρ = 0.007) and owning mobile phones (AOR = 2.10, 95%CI: 1.13-3.90, ρ = 0.020) were more likely to smoke. Whereas female-headed households (AOR = 4.34, 95%CI: 1.37-13.77, ρ = 0.013) and being formerly married (AOR = 6.37, 95%CI: 1.67-24.24, ρ = 0.007) predisposed to daily smoking, age 15-24 (AOR = 0.11, 95%CI: 0.02-0.64, ρ = 0.014) was protective of daily smoking among women. Owning mobile phones (AOR = 2.43, 95%CI: 1.17-5.06, ρ = 0.018) increased the odds of occasional smoking among women. CONCLUSIONS: The prevalence rates of smoking and smoking frequency are low among women of reproductive age in Nigeria. Women-centred approaches to tobacco prevention and cessation must become evidence-informed by incorporating these determinants into interventions targeting women of reproductive age in Nigeria.

Determinants of anaemia prevalence in women of reproductive age in Nigeria: A cross-sectional study using secondary data from Nigeria Demographic and Health Survey 2018.

BACKGROUND: Anaemia disproportionately affects women of reproductive age in sub-Saharan Africa including Nigeria. Yet, community-based studies on the prevalence and determinants of anaemia among women of reproductive age are scarce in Nigeria. DESIGN: A cross-sectional community-based survey using a nationally representative sample. OBJECTIVES: This study described anaemia prevalence and its associated factors among women of reproductive age, pregnant women, and non-pregnant women in Nigeria. METHODS: We analysed data from the 2018 Nigeria Demographic and Health Survey. Pregnant women with a haemoglobin level less than 11 g/dL and non-pregnant women with a haemoglobin level less than 12 g/dL were considered anaemic. Anaemia was also categorized as mild, moderate, and severe. Pearson's chi-square test was used to evaluate the association between anaemia status and independent variables. All variables with ρ ⩽ 0.25 in bivariate analyses were further analysed using complex sample logistic regression. RESULTS: Anaemia prevalence was 57.8%, 57.4%, and 61.1% for women of reproductive age, non-pregnant women, and pregnant women, respectively. The prevalence of severe anaemia was 1.6%, 1.5%, and 2.3% for overall women of reproductive age, non-pregnant women, and pregnant women, correspondingly. The southern regions, rural residence, low education, unemployment, low wealth index, and non-use of modern contraceptives significantly increased the likelihood of anaemia and severe anaemia among women of reproductive age and non-pregnant women. The likelihood of being anaemic was significantly increased by large family size among women of reproductive age and by being underweight among non-pregnant women. The South-East region, rural residence, low education, and unemployment were significantly associated with anaemia among pregnant women. The South-South region and unemployment increased the likelihood of severe anaemia among pregnant women. Short stature significantly reduced the odds of being anaemic and severely anaemic among pregnant women. CONCLUSIONS: Anaemia prevalence among all categories of women of reproductive age is high in Nigeria. Predictors of anaemia prevalence and severity should be considered in policies intended to reduce anaemia among women of reproductive age in Nigeria.

Midwives' perspectives on person-centred maternity care in public hospitals in South-east Nigeria: A mixed-method study.

BACKGROUND: Person-centred maternity care (PCMC) is acknowledged as essential for achieving improved quality of care during labour and childbirth. Yet, evidence of healthcare providers' perspectives of person-centred maternity care is scarce in Nigeria. This study, therefore, examined the perceptions of midwives on person-centred maternity care (PCMC) in Enugu State, South-east Nigeria. MATERIALS AND METHODS: This study was conducted in seven public hospitals in Enugu metropolis, Enugu State, South-east Nigeria. A mixed-methods design, involving a cross-sectional survey and focus group discussions (FGDs) was used. All midwives (n = 201) working in the maternity sections of the selected hospitals were sampled. Data were collected from February to May 2019 using a self-administered, validated PCMC questionnaire. A sub-set of midwives (n = 56), purposively selected using maximum variation sampling, participated in the FGDs (n = 7). Quantitative data were entered, cleaned, and analysed with SPSS version 20 using descriptive and bivariate statistics and multivariate regression. Statistical significance was set at alpha 0.05 level. Qualitative data were analysed thematically. RESULTS: The mean age of midwives was 41.8 years ±9.6 years. About 53% of midwives have worked for ≥10 years, while 60% are junior midwives. Overall, the prevalence of low, medium, and high PCMC among midwives were 26%, 49% and 25%. The mean PCMC score was 54.06 (10.99). High perception of PCMC subscales ranged from 6.5% (dignity and respect) to 19% (supportive care). Midwives' perceived PCMC was not significantly related to any socio-demographic characteristics. Respectful care, empathetic caregiving, prompt initiation of care, paying attention to women, psychosocial support, trust, and altruism enhanced PCMC. In contrast, verbal and physical abuses were common but normalised. Midwives' weakest components of autonomy and communication were low involvement of women in decision about their care and choice of birthing position. Supportive care was constrained by restrictive policy on birth companion, poor working conditions, and cost of childbirth care. CONCLUSION: PCMC is inadequate in public hospitals as seen from midwives' perspectives. Demographic characteristics of midwives do not seem to play a significant role in midwives' delivery of PCMC. The study identified areas where midwives must build competencies to deliver PCMC.

Perceptions and predictors of organizational justice among healthcare professionals in academic hospitals in South-Eastern Nigeria.

BACKGROUND: Research on organizational justice in hospitals in African countries are limited despite being important for workforce performance and hospital operational efficiency. This paper investigated perceptions and predictors of organizational justice among health professionals in academic hospitals in South-east Nigeria. METHODS: The study was conducted in two teaching hospitals in Enugu State, South-east Nigeria using mixed-methods design. Randomly sampled 360 health professionals (doctors = 105, nurses = 200 and allied health professionals, AHPs = 55) completed an organizational justice scale. Additionally, semi-structured, in-depth interview with purposively selected 18 health professionals were conducted. Univariate and bivariate statistics and multivariable linear regression were used to analyze quantitative data. Statistical significance was set at alpha 0.05 level. Qualitative data were analyzed thematically using NVivo 11 software. RESULTS: The findings revealed moderate to high perception of different dimensions of organizational justice. Doctors showed the highest perception, whereas AHPs had the least perception. Among doctors, age and education predicted distributive justice (adjusted R2 = 22%); hospital ownership and education predicted procedural justice (adjusted R2 = 17%); and hospital ownership predicted interactional justice (adjusted R2 = 42%). Among nurses, age, gender and marital status predicted distributive justice (adjusted R2 = 41%); hospital ownership, age and gender predicted procedural justice (adjusted R2 = 28%); and hospital ownership, age, marital status and tenure predicted interactional justice (R2 = 35%). Among AHPs, marital status predicted distributive justice (adjusted R2 = 5%), while hospital ownership and tenure predicted interactional justice (adjusted R2 = 15%). Qualitative findings indicate that nurses and AHPs perceive as unfair, differences in pay, access to hospital resources, training, work schedule, participation in decision-making and enforcement of policies between doctors and other health professionals due to medical dominance. Overall, supervisors have a culture of limited information sharing with, and disrespectful treatment of, their junior colleagues. CONCLUSION: Perceptions of organizational justice range from moderate to high and predictors vary among different healthcare professionals. Addressing specific socio-demographic factors that significantly influenced perceptions of organizational justice among different categories of health professionals and departure from physician-centered culture would improve perceptions of organizational justice among health professionals in Nigeria and similar settings.

Through service providers' eyes: health systems factors affecting implementation of tuberculosis control in Enugu State, South-Eastern Nigeria.

BACKGROUND: Well-functioning health systems are essential to achieving global and national tuberculosis (TB) control targets. This study examined health system factors affecting implementation of TB control programme from the perspectives of service providers. METHODS: The study was conducted in Enugu State, South-eastern Nigeria using qualitative, cross-sectional design involving 23 TB service providers (13 district TB supervisors and 10 facility TB focal persons). Data were collected through in-depth, semi-structured interviews using a health system dynamic framework and analysed thematically. RESULTS: Stewardship from National TB Control Programme (NTP) improved governance of TB control, but stewardship from local government was weak. Government spending on TB control was inadequate, whereas donors fund TB control. Poor human resources management practices hindered TB service delivery. TB service providers have poor capacity for data management because changes in recording and reporting tools were not matched with training of service providers. Drugs and other supplies to TB treatment centres were interrupted despite the use of a logistics agency. Poor integration of TB into general health services, weak laboratory capacity, withdrawal of subsidies to community volunteers and patent medicine vendors, poorly funded patient tracking systems, and ineffectual TB/HIV collaboration resulted in weak organisation of TB service delivery. CONCLUSION: Health systems strengthening for TB control service must focus on effective oversight from NTP and local health system; predictable domestic resource mobilisation through budgets and social health insurance; training and incentives to attract and retain TB service providers; effective supply and TB drug management; and improvements in organization of service delivery.

The influence of quality of work life on motivation and retention of local government tuberculosis control programme supervisors in South-eastern Nigeria.

INTRODUCTION: Significant gap exists in knowledge about employee-centred human resources practices that address motivation and retention of local government tuberculosis control programme supervisors (LGTBS) in Nigeria. The study examined the role of quality of worklife (QWL) in motivating and retaining LGTBS. MATERIALS AND METHODS: The study was conducted in south-eastern region of Nigeria comprising five states and 95 local government areas. The design was mixed-methods. We used cross-sectional survey to collect quantitative data on socio-demographic factors, QWL, motivation and retention from a total sample of LGTBS. The qualitative component involved focus group discussions (n = 3) with 26 LGTBS. Quantitative data were analysed using exploratory factor analysis, descriptive statistics, Spearman correlation, Mann-Whitney test, Kruskal-Wallis test and multiple linear regression. Qualitative data were analysed using a thematic framework approach. RESULTS: The final 40-item QWL scale was found to be valid and reliable. The LGTBS had high QWL (M = 5.15, SD = 0.88) and motivation (M = 5.92, SD = 1.08), but low intention to leave their jobs (M = 2.68, SD = 1.59). Education significantly predicted satisfaction with overall QWL, work-family balance and work design; but tenure predicted satisfaction with work context. Work design and work-family balance significantly predicted motivation of LGTBS. Motivation mediated the relationship between QWL and intention to leave and accounted for 29% variance in intention to leave. Whereas LGTBS were motivated by responsibility, learning opportunities, achievement and recognition; they were dissatisfied with lack of flexible work schedules, involvement in non-TB tasks, long hours at work, limited opportunities for vacation, resource inadequacy, work-related stigma, lack of promotional opportunities, and pay disparity and delay. CONCLUSION: Addressing work design, work-family balance and working conditions may increase the motivation and retention of LGTBS and improve human resources for TB at the district level and performance of the TB control programme.

Governance of tuberculosis control programme in Nigeria.

BACKGROUND: The role of governance in strengthening tuberculosis (TB) control has received little research attention. This review provides evidence of how institutional designs and organisational practices influence implementation of the national TB control programme (NTP) in Nigeria. MAIN TEXT: We conducted a scoping review using a five-stage framework to review published and grey literature in English, on implementation of Nigeria's NTP and identified themes related to governance using a health system governance framework. We included articles, of all study designs and methods, which described or analysed the processes of implementing TB control based on relevance to the research question. The review shows a dearth of studies which examined the role of governance in TB control in Nigeria. Although costed plans and policy coordination framework exist, public spending on TB control is low. While stakeholders' involvement in TB control is increasing, institutional capacity is limited, especially in the private sector. TB-specific legislation is absent. Deployment and transfer of staff to the NTP are not transparent. Health workers are not transparent in communicating service entitlements to users. Despite existence of supportive policies, integration of TB control into the community and general health services have been weak. Willingness to pay for TB services is high, however, transaction cost and stigma among patients limit equity. Effectiveness and efficiency of the NTP was hindered by inadequate human resources, dilapidated service delivery infrastructure and weak drug supply system. Despite adhering to standardized recording and reporting format, regular monitoring and evaluation, revision of reporting formats, and electronic data management system, TB surveillance system was found to be weak. Delay in TB diagnosis and initiation of care, poor staff attitude to patients, lack of privacy, poor management of drug reactions and absence of infection control measures breach ethical standards for TB care. CONCLUSIONS: This scoping review of governance of TB control in Nigeria highlights two main issues. Governance for strengthening TB control programmes in low-resource, high TB burden settings like Nigeria, is imperative. Secondly, there is a need for empirical studies involving detailed analysis of different dimensions of governance of TB control.

Aligning public financial management system and free healthcare policies: lessons from a free maternal and child healthcare programme in Nigeria.

BACKGROUND: Relatively little is known about how public financial management (PFM) systems and health financing policies align in low- and middle-income countries. This study assessed the alignment of PFM systems with health financing functions in the free maternal and child healthcare programme (FMCHP) of Enugu State, Nigeria. METHODS: Data were collected through quantitative and qualitative document review, and semi-structured, in-depth interview with 16 purposively selected policymakers involved in FMCHP. Data collection and analysis were by guided a framework for assessing alignment of PFM systems and health financing policies. Revenue and expenditure trend analyses were done using descriptive statistics and analysis of variance (ANOVA). Level of significance was set at ρ < 0.05. Qualitative data were analysed using a framework approach. RESULTS: The results showed that no more than 50% of FMCHP fund were collected despite that the promised fund remained unchanged since inception. Revenue generation significantly varied between 2010 and 2016 (ρ < 0.05). Level of pooling was limited by non-compliance with contribution rules, recurrent unauthorised expenditure and absence of expenditure caps. The unauthorised expenditure significantly varied between 2010 and 2016 (ρ < 0.05). Misalignment of budget monitoring and purchasing revealed absence of auditing and delays in provider payment. Refunds to providers significantly varied between 2010 and 2016 (ρ < 0.05) due to weak Steering Committee, weak vetting team, paper-based claims management and institutional conflicts between Ministry of Health and district-level officials. CONCLUSIONS: This study identified important lessons to align PFM systems and FMCHP. A realistic and evidence-informed budget and enforcement of contribution rules are critical to adequate and sustainable revenue generation. Clarity of roles for various FMCHP committees and use of clear resource allocation strategy would strengthen pooling and fund management. Enforcement of provider payment standards, regular auditing, and a stronger role for the parliament in budgetary processes are warranted.

Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria.

BACKGROUND: Significant knowledge gaps exist in the functioning of institutional designs and organisational practices in purchasing within free healthcare schemes in low resource countries. The study provides evidence of the governance requirements to scale up strategic purchasing in free healthcare policies in Nigeria and other low-resource settings facing similar approaches. METHODS: The study was conducted at the Ministry of Health and in two health districts in Enugu State, Nigeria, using a qualitative case study design. Semi-structured interviews were conducted with 44 key health system actors (16 policymakers, 16 providers and 12 health facility committee leaders) purposively selected from the Ministry of Health and the two health districts. Data collection and analysis were guided by Siddiqi and colleagues' health system governance framework. Data were analysed using a framework approach. RESULTS: The key findings show that supportive governance practices in purchasing included systems to verify questionable provider claims, pay providers directly for services, compel providers to procure drugs centrally and track transfer of funds to providers. However, strategic vision was undermined by institutional conflicts, absence of purchaser-provider split and lack of selective contracting of providers. Benefit design was not based on stakeholder involvement. Rule of law was limited by delays in provider payment. Benefits and obligations to users were not transparent. The criteria and procedure for resource allocation were unclear. Some target beneficiaries seemed excluded from the scheme. Effectiveness and efficiency was constrained by poor adherence to purchasing rules. Accountability of purchasers and providers to users was weak. Intelligence and information is constrained by paper-based system. Rationing of free services by providers and users' non-adherence to primary gate-keeping role hindered ethics. CONCLUSION: Weak governance of purchasing function limits potential of FMCHP to contribute towards universal health coverage. Appropriate governance model for strengthening strategic purchasing in the FMCHP and possibly free healthcare interventions in other low-resource countries must pay attention to the creation of an autonomous purchasing agency, clear framework for selective contracting, stakeholder involvement, transparent benefit design, need-based resource allocation, efficient provider payment methods, stronger roles for citizens, enforcement of gatekeeping rules and use of data for decision-making.