Strengthening routine data reporting in private hospitals in Lagos, Nigeria.

The availability of routine health information is critical for effective health planning, especially in resource-limited countries. Nigeria adopted the web-based District Health Information System (DHIS) to harmonize the collection, analysis and storage of data for informed decision-making. However, only 44% of all private hospitals in Lagos State reported to the DHIS despite constituting 90% of all health facilities in the state. To bridge this gap, this study implemented targeted interventions. This paper describes (1) the implemented interventions, (2) the effects of the interventions on data reporting on DHIS during the intervention period and (3) the evaluation of data reporting on DHIS after the intervention period in select private hospitals in Lagos State. A five-pronged intervention was implemented in 55 private hospitals (intervention hospitals), which entailed stakeholder engagement, on-the-job training, in-facility mentoring and the provision of data tools and job aids, to improve data reporting on DHIS from 2014 to 2017. A controlled before-and-after study design was employed to assess the effectiveness of the implemented interventions. A comparable cohort of 55 non-intervention private hospitals was selected, and data were extracted from both groups. Data analysis was conducted using paired and independent t-tests to assess the effect and measure the difference between both groups of hospitals, respectively. An average increase of 65.28% (P < 0.01) in reporting rate and 50.31% (P < 0.01) in the timeliness of reporting on DHIS was seen among intervention hospitals. Similarly, the difference between intervention and non-intervention hospitals post-intervention was significantly different for both data reporting (mean difference = -22.38, P < 0.01) and timeliness (mean difference = -18.81, P < 0.01), respectively. Furthermore, a sustained improvement in data reporting and timeliness of reporting on DHIS was observed among intervention hospitals 24 months after interventions. Thus, implementing targeted interventions can strengthen routine data reporting for better performance and informed decision-making.

Is Nigeria on course to achieve universal health coverage in the context of its epidemiological and financing transition? A knowledge, capacity and policy gap analysis (a qualitative study).

OBJECTIVES: This study aimed to assess Nigeria's preparedness to finance and drive the universal health coverage (UHC) agenda within the context of changing health conditions and resource needs associated with the disease, demographic and funding transitions.Nigeria is undergoing transitions in the healthcare system that include a double burden of infectious and non-communicable diseases, and transition from concessional donor assistance towards domestic financing for health. These transitions will affect Nigeria's attainment of UHC. DESIGN AND SETTING: We conducted a qualitative study, including semistructured interviews with relevant stakeholders at national and subnational levels in Nigeria. Data from the interviews were analysed using thematic analysis. PARTICIPANTS: Our study involved 18 respondents from government ministries, departments, and agencies, development partners, civil society organisations and academia. RESULTS: Capacity gaps identified by respondents included limited knowledge to implement health insurance schemes at subnational levels, poor information/data management to monitor progress towards UHC and limited communication and interagency collaboration between government agencies and ministries. Furthermore, participants in our study expressed those current policies driving major health reforms like the National Health Act (basic healthcare provision fund) appear adequate to support UHC advancement in theory, but policy implementation is a key challenge due to a lack of policy awareness, low government spending on health and poor evidence generation for information to support decisions. CONCLUSION: Our study found major gaps in knowledge and capacity for UHC advancement in the context of Nigeria's demographic, epidemiological and financing transitions. These included poor knowledge of demographic transitions, poor capacity for health insurance implementation at subnational levels, low government spending on health, poor policy implementation and poor communication and collaboration among stakeholders. To address these challenges, collaborative efforts are needed to bridge knowledge gaps and increase policy awareness through targeted knowledge products, improved communication and interagency collaboration.

Influence of context on quality improvement priorities: a qualitative study of three facility types in Lagos State, Nigeria.

BACKGROUND: Quality improvement (QI) collaboratives are increasingly popular. However, there is a need for an in-depth understanding of the influence of context on its implementation. We explored the influence of context on the change concepts considered by public primary (primary health centres), public secondary (public hospitals) and private (private facilities) collaboratives established to improve maternal and newborn health outcomes in Lagos State, Nigeria. METHODS: Between February 2019 and January 2020, we conducted a qualitative study using meeting reports, key informant interviews and participant observation. Data were analysed using the high-quality health system framework for assessing health system and user experience that distinguished three quality domains: quality impacts, processes of care and health system foundations. RESULTS: Nineteen change concepts and 158 change ideas were observed across 28 facility QI teams. Change concepts and ideas prioritised were influenced by government and non-governmental leaders but ultimately shaped by facility QI capacity, time allocated for QI activities and availability of local data. Of the three quality domains, process of care, including patient satisfaction, received the most attention across facility types. There was considerable variation in the change concepts considered across domains. For example, more public hospitals focused on complication management because of a relatively high prevalence of and capacity to manage maternal complications; primary health centres focused more on complication referrals, while private facilities prioritised revenue generation. Problems with availability of resources were particularly highlighted in primary health centres which had relatively less financial commitment from stakeholders. CONCLUSION: Our findings provide insights into QI collaboratives' mechanism of change in which external stakeholders, including government, drove QI priorities for action but the ultimate decisions depended on local realities of facilities. Our findings underscore the need for strong QI leadership and sufficient resources to enable facility QI teams to prioritise change concepts for greater health impact.

Rethinking malaria: Governance lessons from other disease programs.

The global disruptions brought about by the COVID-19 pandemic as well as the stagnation of progress of global malaria elimination efforts have provided an opportunity to rethink several aspects of the global malaria program, including its governance at all levels, from the community to the nation and to the world. Approaching this issue requires an examination of the critical governance factors that affect malaria elimination as well as lessons that could be learned from the governance of other global health programs. The paper, therefore, first reviews malaria program governance challenges at the global, national, and sub-national levels. We then conducted a literature review of governance factors that affected four major global disease elimination programs; (1) the global smallpox eradication program; (2) polio eradication efforts (focus on Latin America); (3) the onchocerciasis eradication program; and (4) global COVID-19 pandemic control efforts. Based on this review, we identified eight comment governance themes that impact disease elimination programs. These include 1) International support and coordination; 2) Financing; 3) Data use for engagement and decision making, 4) Country ownership; 5) National program structure and management, 6) Community support/engagement; 7) Multisectoral engagement; and 8) Technology and innovation The paper then illustrates how these eight governance themes were factored in the four disease control programs, draws lessons and insights about the role of governance from these programs and outlines the implications for governance of malaria elimination efforts. The paper concludes by making recommendations for improving governance of malaria elimination programs and how the analyses of other global disease control programs can provide new ideas and inspiration for a more robust push towards malaria eradication.

From Theory to Implementation: Adaptations to a Quality Improvement Initiative According to Implementation Context.

As countries continue to invest in quality improvement (QI) initiatives in health facilities, it is important to acknowledge the role of context in implementation. We conducted a qualitative study between February 2019 and January 2020 to explore how a QI initiative was adapted to enable implementation in three facility types: primary health centres, public hospitals and private facilities in Lagos State, Nigeria.Despite a common theory of change, implementation of the initiative needed to be adapted to accommodate the local needs, priorities and organisational culture of each facility type. Across facility types, inadequate human and capital resources constrained implementation and necessitated an extension of the initiative's duration. In public facilities, the local governance structure was adapted to facilitate coordination, but similar adaptations to governance were not possible for private facilities. Our findings highlight the importance of anticipating and planning for the local adaptation of QI initiatives according to implementation environment.

Evidence from the Kaduna State Health Accounts on the pattern of sub-national health spending in Nigeria, 2016.

Health accounts provide accurate estimates of health expenditure, which are important for effective resource allocation and planning in the health sector. In Nigeria, four rounds of health accounts have been conducted at the national level. However, the national estimates do not necessarily reflect realities at the subnational level and may only provide limited information for decision making at that level. This study highlights the pattern of health spending in Kaduna State from the 2016 Health Accounts, with a view to providing more reliable evidence for decision making in the state.Health accounts expenditure surveys were administered to government, donors, non-governmental organizations (NGOs), private health insurance organisations and employers in the health sector for the reference year 2016. Household health expenditure was derived from a household survey administered across a representative sample of 1024 households selected from six local government areas across the three senatorial districts in the state. We estimated disease expenditure by deploying a health provider survey across a sample of 100 health facilities. Analysis was conducted using Microsoft Excel, Stata and the Health Accounts Production Tool.Findings show that current health expenditure (CHE) accounted for only 7% of the total health expenditure in 2016. Out-of-pocket spending among households was about 81% of CHE, compared with a national average of 71.5% of CHE between 2010 and 2014. The health expenditure findings highlight several policy imperatives for the Kaduna State Health System. Primary among these is the heavy dependence on out-of-pocket financing for health, which has negative implications on vulnerable households. A shift to pooled prepaid mechanisms would reduce the financial burden on the most vulnerable households in Kaduna State. In addition, considering the government's current contribution to health expenditure, there is a strong need for increased government prioritisation of the Kaduna State health sector.

A checklist for designing health insurance programmes - a proposed guidelines for Nigerian states.

BACKGROUND: There is widespread and growing interest in designing and implementing social health insurance schemes (SHIS) across many low- and middle-income countries as a means to improve financial protection and achieve universal health coverage. SHIS recently gained traction in Nigeria, but evidence regarding optimal design features of SHIS is sparse and there is lack of a simple and standardised checklist that scheme designers, implementers and researchers could use to assess, guide and inform the design of SHIS. This paper seeks to develop a checklist based on concepts as well as theoretical and empirical evidence that can inform and guide scheme designers and implementers on design options to maximise the effectiveness of the scheme. METHODS: We conducted a review of literature exploring the relevant concepts for the development of a framework and checklist to identify the key factors or variables required to inform the design of SHIS. The checklist details critical considerations/questions to address and options for design. The developed checklist was then used to examine conditions for readiness and appropriateness of SHIS design in two states in Nigeria (Kaduna and Niger). RESULTS: This paper describes the development of a SHIS checklist. The findings also demonstrate that the newly developed checklist, consisting of six design domains, can be used by scheme designers and policy-makers as a simple and effective tool to assess and inform SHIS design features across Nigeria to maximise the chances of the effectiveness of the schemes. CONCLUSION: In conclusion, given that the development of SHIS in the Nigerian states is still in its early stages, applying the SHIS design checklist can serve as a first step to ensuring a feasible and sustainable insurance scheme. The introduction of SHIS, if properly designed and implemented, can be a significant first step towards improving the accessibility, equity and efficiency of healthcare in Nigeria.

Factors influencing willingness and ability to pay for social health insurance in Nigeria.

BACKGROUND: Many low and middle-income countries are increasingly cognisant of the need to offer financial protection to its citizens through pre-payment schemes in order to curb high out of pocket expenditure and catastrophic spending on healthcare. However, there is limited rigorous contextual evidence to make decisions regarding optimal design of such schemes. This study assesses the willingness-to-pay (WTP) for the recently introduced state contributory health insurance scheme (SHIS) in Nigeria. METHODS: The study took place in 6 local government areas in Kaduna state, North-west Nigeria. Data were collected from a household survey using a three-stage cluster sampling approach, with each household having the same probability of being selected. Interviews were conducted with 4000 individuals in 1020 households. Contingent valuation was used to elicit the willing to pay (WTP) for the household using the bidding game technique. The relationship between socioeconomic status and WTP was also examined using logistic regression models. FINDINGS: About 82% of the household heads were willing to pay insurance premiums for their households, which came to an average of 513 Naira (1.68 USD) per month per person. The average amount individuals were willing to pay was lower in rural areas (611 Naira) compared to urban areas (463 Naira). These results were influenced by household size, level of education, occupation and household income. In addition, only 65% of the households had the ability to pay the average premium. CONCLUSION: Socioeconomic factors influence individuals' WTP for contributory health insurance schemes. It is important to create awareness about the benefits of the insurance scheme, especially in rural areas, and in both the formal and informal sectors in Nigeria. WTP information can inform the amount of insurance premiums. However, it is important to consider differences between the WTP and the cost of benefits package to be offered, as the premium amount may need to be subsidized with public financing.

Evaluating the quality of antihypertensive drugs in Lagos State, Nigeria.

BACKGROUND: As the burden of noncommunicable diseases grows, access to safe medical therapy is increasing in importance. The aim of this study was to develop a method for evaluating the quality of antihypertensive drugs and to examine whether this prevalence varies by socioeconomic variables. METHODS: We conducted a cross-sectional survey of registered pharmacies in 6 local government areas (LGAs) in Lagos State, Nigeria. In each LGA, we sampled 17 pharmacies from a list of all registered pharmacies derived from the Pharmacists Council of Nigeria. We assessed drug quality based on (1) the level of active pharmaceutical ingredients (APIs), which identified falsely labeled drug samples; and (2) the amount of impurities, which revealed substandard drug samples in accordance with the international pharmacopoeia guidelines. Good-quality drugs met specifications for both API and impurity. RESULTS: Of the 102 drug samples collected, 30 (29.3%) were falsely labeled, 76 (74.5%) were substandard,78 (76.5%) were of poor quality and 24 (23.5%) were of good quality.Among the falsely labeled drugs, 2 samples met standards set for purity while 28 did not. Among the 76 substandard drug samples, 28 were also falsely labeled. Of the falsely labeled drugs, 17 (56.7%) came from LGAs with low socioeconomic status, and 40 (52.6%) of the substandard drug samples came from LGAs with high socioeconomic status. Most of the good-quality drug samples, 14 (58.3%), were from LGAs with low socioeconomic status. Eighteen (60%) of the falsely labeled samples, 37 (48.7%) of the substandard samples, and 15 (62.5%) of the good-quality drug samples were from manufacturers based in Asia. The average price was 375.67 Nigerian naira (NGN) for falsely labeled drugs, 383.33 NGN for substandard drugs, and 375.67 NGN for good-quality drugs. The prevalence of falsely labeled and substandard drug samples did not differ by LGA-level socioeconomic status (P = .39) or region of manufacturer (P = .24); however, there was a trend for a difference by price (P = .06). CONCLUSION: The prevalence of falsely labeled and substandard drug samples was high in Lagos. Treatment of noncommunicable diseases in this setting will require efforts to monitor and assure drug quality.

An Assessment of Data Availability, Quality, and Use in Malaria Program Decision Making in Nigeria.

Abstract-In 2014, Nigeria shifted its malaria policy and strategy from control to elimination. Studies show that data-driven decision making is essential to achieving elimination. It is therefore important that policy makers have access to and use good quality and relevant data to inform program decisions. This article presents findings from an assessment of availability, quality, and use of malaria data in three states in Nigeria, namely, Akwa-Ibom, Cross River, and Niger, as part of a larger study on how organizational structure affects outcomes of malaria programs. A literature search to determine the availability and range of malaria data in Nigeria was conducted, followed by 65 key informant interviews to understand how malaria data are used in the study states. It was observed that the District Health Information System (DHIS) was the major source of data used in managing programs; however, the range of malaria indicators in the DHIS is limited, lacking indicators such as active case detection and entomological data, which are important for surveillance and decision making toward malaria elimination. On data quality, routine data from the DHIS were reviewed using the national protocol for data quality assessment. Data quality was found to be suboptimal, with quality scores ranging from 54% to 64% compared to the national target of 80%. DHIS data were reportedly used most often for performance and/or supply chain management. Overall, the study demonstrates gaps in data availability and quality and highlights the need for more data sources and improved quality data to inform decision making toward malaria elimination in Nigeria.

Influence of Organizational Structure and Administrative Processes on the Performance of State-Level Malaria Programs in Nigeria.

Abstract-Studies have found links between organizational structure and performance of public organizations. Considering the wide variation in uptake of malaria interventions and outcomes across Nigeria, this exploratory study examined how differences in administrative location (a dimension of organizational structure), the effectiveness of administrative processes (earmarking and financial control, and communication), leadership (use of data in decision making, state ownership, political will, and resourcefulness), and external influences (donor influence) might explain variations in performance of state malaria programs in Nigeria. We hypothesized that states with malaria program administrative structures closer to state governors will have greater access to resources, greater political support, and greater administrative flexibility and will therefore perform better. To assess these relationships, we conducted semistructured interviews across three states with different program administrative locations: Akwa-Ibom, Cross River, and Niger. Sixty-five participants were identified through a snowballing approach. Data were analyzed using a thematic framework. State program performance was assessed across three malaria service delivery domains (prevention, diagnosis, and treatment) using indicators from Nigeria Demographic and Health Surveys conducted in 2008 and 2013. Cross River State was best performing based on 2013 prevention data (usage of insecticide-treated bednets), and Niger State ranked highest in diagnosis and treatment and showed the greatest improvement between 2008 and 2013. We found that organizational structure (administrative location) did not appear to be determinative of performance but rather that the effectiveness of administrative processes (earmarking and financial control), strong leadership (assertion of state ownership and resourcefulness of leaders in overcoming bottlenecks), and donor influences differed across the three assessed states and may explain the observed varying outcomes.

Roundtable discussion: what is the future role of the private sector in health?

BACKGROUND: The role for the private sector in health remains subject to much debate, especially within the context of achieving universal health coverage.This roundtable discussion offers diverse perspectives from a range of stakeholders--a health funder, a representative from an implementing organization, a national-level policy-maker, and an expert working in a large multi-national company--on what the future may hold for the private sector in health. DISCUSSION: The first perspective comes from a health funder, who argues that the discussion about the future role of the private sector has been bogged down in language. He argues for a 'both/and' approach rather than an 'either/or' when it comes to talking about health service provision in low- and middle-income countries.The second perspective is offered by an implementer of health insurance in sub-Saharan Africa. The piece examines the comparative roles of public sector actors, private sector actors and funding agencies, suggesting that they must work together to mobilize domestic resources to fund and deliver health services in the longer term.Thirdly, a special advisor working in the federal government of Nigeria considers the situation in that country. He notes that the private sector plays a significant role in funding and delivering health services there, and that the government must engage the private sector or forever be left behind.Finally, a representative from a multi-national pharmaceutical corporation gives an overview of global shifts that are creating opportunities for the private sector in health markets. SUMMARY: Overall, the roundtable discussants agree that the private sector will play an important role in future health systems. But we must agree a common language, work together, and identify key issues and gaps that might be more effectively filled by the private sector.

Integration of priority population, health and nutrition interventions into health systems: systematic review.

BACKGROUND: Objective of the study was to assess the effects of strategies to integrate targeted priority population, health and nutrition interventions into health systems on patient health outcomes and health system effectiveness and thus to compare integrated and non-integrated health programmes. METHODS: Systematic review using Cochrane methodology of analysing randomised trials, controlled before-and-after and interrupted time series studies. We defined specific strategies to search PubMed, CENTRAL and the Cochrane Effective Practice and Organisation of Care Group register, considered studies published from January 1998 until September 2008, and tracked references and citations. Two reviewers independently agreed on eligibility, with an additional arbiter as needed, and extracted information on outcomes: primary (improved health, financial protection, and user satisfaction) and secondary (improved population coverage, access to health services, efficiency, and quality) using standardised, pre-piloted forms. Two reviewers in the final stage of selection jointly assessed quality of all selected studies using the GRADE criteria. RESULTS: Of 8,274 citations identified 12 studies met inclusion criteria. Four studies compared the benefits of Integrated Management of Childhood Illnesses in Tanzania and Bangladesh, showing improved care management and higher utilisation of health facilities at no additional cost. Eight studies focused on integrated delivery of mental health and substance abuse services in the United Kingdom and United States of America. Integrated service delivery resulted in better clinical outcomes and greater reduction of substance abuse in specific sub-groups of patients, with no significant difference found overall. Quality of care, patient satisfaction, and treatment engagement were higher in integrated delivery models. CONCLUSIONS: Targeted priority population health interventions we identified led to improved health outcomes, quality of care, patient satisfaction and access to care. Limited evidence with inconsistent findings across varied interventions in different settings means no general conclusions can be drawn on the benefits or disadvantages of integrated service delivery.

A systematic review of the evidence on integration of targeted health interventions into health systems.

A longstanding debate on health systems organization relates to benefits of integrating health programmes that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration arguing the relative merits of each approach. However, all too frequently these arguments have not been based on hard evidence. The presence of both integrated and non-integrated programmes in many countries suggests there may be benefits to either approach, but the relative merits of integration in various contexts and for different interventions have not been systematically analysed and documented. In this paper we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of the integration of targeted health programmes that emphasize specific interventions into critical health systems functions, (ii) how the integration or non-integration of health programmes into critical health systems functions in different contexts has influenced programme success, (iii) how contextual factors have affected the extent to which these programmes were integrated into critical health systems functions. Our analysis shows few instances where there is full integration of a health intervention or where an intervention is completely non-integrated. Instead, there exists a highly heterogeneous picture both for the nature and also for the extent of integration. Health systems combine both non-integrated and integrated interventions, but the balance of these interventions varies considerably.

Integration of targeted health interventions into health systems: a conceptual framework for analysis.

The benefits of integrating programmes that emphasize specific interventions into health systems to improve health outcomes have been widely debated. This debate has been driven by narrow binary considerations of integrated (horizontal) versus non-integrated (vertical) programmes, and characterized by polarization of views with protagonists for and against integration arguing the relative merits of each approach. The presence of both integrated and non-integrated programmes in many countries suggests benefits to each approach. While the terms 'vertical' and 'integrated' are widely used, they each describe a range of phenomena. In practice the dichotomy between vertical and horizontal is not rigid and the extent of verticality or integration varies between programmes. However, systematic analysis of the relative merits of integration in various contexts and for different interventions is complicated as there is no commonly accepted definition of 'integration'-a term loosely used to describe a variety of organizational arrangements for a range of programmes in different settings. We present an analytical framework which enables deconstruction of the term integration into multiple facets, each corresponding to a critical health system function. Our conceptual framework builds on theoretical propositions and empirical research in innovation studies, and in particular adoption and diffusion of innovations within health systems, and builds on our own earlier empirical research. It brings together the critical elements that affect adoption, diffusion and assimilation of a health intervention, and in doing so enables systematic and holistic exploration of the extent to which different interventions are integrated in varied settings and the reasons for the variation. The conceptual framework and the analytical approach we propose are intended to facilitate analysis in evaluative and formative studies of-and policies on-integration, for use in systematically comparing and contrasting health interventions in a country or in different settings to generate meaningful evidence to inform policy.