Willingness and ability to pay for health insurance in Afghanistan.

The study assessed willingness to join and willingness to pay for health-insurance in Afghanistan and identified associated determinants. A household survey was conducted. Two health-insurance and two medicine-insurance packages were explained to respondents, who were then asked if they would be willing to join the packages and pay for them. The double-bounded dichotomous choice contingent valuation method was used to elicit the maximum amount respondents would be willing to pay for the various benefit packages. Logistic and linear regression models were used to examine determinants of willingness to join and willingness to pay. Most respondents had never heard of health insurance. And yet, when they were told about it, the vast majority of respondents said they would be willing to join one of the four benefit packages and pay for them, ranging from 70.7% for a medicine-only package that included only essential medicines, to 92.4% for a health-insurance package that would cover only primary and secondary care. The average willingness to pay cost was 1,236 (US$21.3), 1,512 (US$26.0), 778 (US$13.4) and 430 (US$7.4) Afghani per person, per year for the primary and secondary; comprehensive primary, secondary and some tertiary; all medicine; and essential medicine packages; respectively. Key determinants of willingness to join, and to pay were similar, including the provinces where respondents were located, wealth status, health expenditures and some demographic characteristics.

Documenting HIV research-utilization activities, outputs and outcomes: examples and lessons learned from Project SOAR.

The importance of using research findings to inform policy and program decisions is well recognized, but the literature on measuring research utilization activities is scarce. As funding to support some areas of research wanes or remains stagnant, the need to document the value of investing in research by its' effect on improved programs and policies becomes increasingly necessary. We present the experience of Project SOAR, a six-year USAID-funded project focusing on HIV/AIDS-related implementation research, to demonstrate measurement of research utilization. We follow the project's research-utilization logic model, including inputs, activities, outputs, and outcomes. We present tools the project developed and examples from project studies and discuss what works, remaining challenges and how to overcome them, and lessons learned. We then make recommendations for incorporating research-utilization activities and measurement in implementation-research studies.

Factors associated with the knowledge of obstetric danger signs, and perceptions of the need for obstetric care amongst married young women in northern Nigeria.

BACKGROUND: Married adolescents contribute to poor maternal health indicators in many low-and middle-income countries, where restrictive social norms hinder access to, and utilisation of maternal health services. Addressing these barriers is key to improving health outcomes of young mothers and their children. AIM: This study assessed married young women's knowledge of obstetric danger signs and perceptions of the need to attend obstetric services. METHODS: A cross sectional descriptive design, interviewing 1624 randomly selected married young women aged 12-25 years. Data were collected in early 2017 using an interviewer-administered questionnaire on mobile phones, and exported into a statistical software for analysis. RESULTS: We found low levels of knowledge of danger signs, especially those pertaining to the post-partum period. Respondents' age, literacy and household wealth were significantly associated with knowledge of danger signs across the continuum of care. Awareness of danger signs during delivery, was strongly associated with perceptions of need for antenatal care (odds ratio[OR]= 2.269; p 0.05), and delivery in a health facility (OR = 1.883; P 0.05). Most respondents believed they must wait for their husband's approval to attend a health facility when in labour. CONCLUSION: Our findings show that the low levels of knowledge of obstetric danger signs, low perceptions of the importance of facility delivery, and the need to obtain husband's permission before seeking care, are highly contextualised and reflect the socio-cultural and economic circumstances of married young women in northern Nigeria. Interventions must consider these cultural context, and include a strong male-involvement component.

Unmet need for family planning and barriers to contraceptive use in Kaduna, Nigeria: culture, myths and perceptions.

In 2017, just one-fifth of all married women of reproductive age reported using contraception in Kaduna state, Nigeria, while many more experienced unmet need for contraception. These realities drive risky fertility behaviours and compromise reproductive rights. This study explored the determinants of low modern contraceptive uptake and persistent unmet need among women in the state. Nine focus group discussions were conducted with married women who met study criteria for unmet need, and who had different levels of access to contraception. Discussions confirmed that many women in Kaduna do not feel empowered to make contraceptive decisions. Yet there is a growing preference for smaller families and decreased stigmatisation of contracepting women. Barriers at home, in the community and in health facilities impose a ceiling on the extent to which women's fertility desires may be achieved. These include cultural, normative, social and financial factors, such as the need for husband's permission to access services, service providers' insistence on spousal consent, subtle and overt pressures to use folkloric approaches by religious leaders, and high real, or perceived, out-of-pocket costs. These findings suggest that Kaduna is on the cusp of social change and study findings can be translated into programmatic interventions to improve voluntary uptake of contraception.

Improving Voluntary, Rights-Based Family Planning: Experience From Nigeria And Uganda.

BACKGROUND: Growing focus on the need for voluntary, rights-based family planning (VRBFP) has drawn attention to the lack of programs that adhere to the range of rights principles. This paper describes two first-of-their-kind interventions in Kaduna State, Nigeria and in Uganda in 2016-2017, accompanied by implementation research based on a conceptual framework that translates internationally agreed rights into family planning programming. METHODS: This paper describes the interventions, and profiles lessons learned about VRBFP implementation from both countries, as well as measured outcomes of VRBFP programming from Nigeria. RESULTS: The intervention components in both projects were similar. Both programs built provider and supervisor capacity in VRBFP using comparable curricula; developed facility-level action plans and supported action plan implementation; aimed to increase clients' rights literacy at the facility using posters and handouts; and established or strengthened health committee structures to support VRBFP. Through the interventions, rights literacy increased, and providers were able to see the benefits of taking a VRBFP approach to serving clients. The importance of ensuring a client focus and supporting clients to make their own family planning choices was reinforced. Providers recognized the importance of treating all clients, regardless of age or marital status, for example, with dignity. Privacy and confidentiality were enhanced. Recognition of what violations of rights are and the need to report and address them through strong accountability systems grew. Many lessons were shared across the two countries, including the need for rights literacy; attention to health systems issues; strong and supportive supervision; and the importance of working at multiple levels. Additionally, some unique lessons emanated from each country experience. CONCLUSION: The assessed feasibility and benefits of using VRBFP programming and outcome measures in both countries bode well for adoption of this approach in other geographies.

The experience of men who participated in interventions to improve demand for and utilization of maternal and child health services in northern Nigeria: a qualitative comparative study.

BACKGROUND: Men in northern Nigeria are considered the leaders and ultimate decision makers, including decisions about health-related behaviours of their wives and children. Yet many men in the region consider pregnancy and childbirth to be in the woman's domain (even if she cannot make related decisions), and may not see a need to educate themselves on the issues. These dynamics directly influence demand for, and utilization of, maternal, newborn, and child health services. This study examines an intervention that educated married men in northern Nigeria about health issues related to pregnancy, labour, delivery, and the postpartum period, as well as newborn and child health, through participation in male support groups. The curriculum also included interpersonal relationship and household decision making, with an emphasis on the need for men to give their wives standing approval to seek health services as needed, for themselves and their children. METHODS: We conducted 12 focus group discussions with married men in Kaduna and Katsina states in northern Nigeria - half with men who had participated in the male support groups and half with men from areas that the intervention had not reached. Analysis was thematic, focusing on participants' perceptions of the male support groups, the benefits of the intervention, and enablers and barriers to support group participation. RESULTS: Perceptions of the male support groups were overwhelmingly positive. Participants internalized important messages they learned, which influenced their decisions related to the health of their wives and children. Some take it upon themselves to educate others in their communities about what they learned, and many say they see changes at the community level, with more utilization of maternal, newborn, and child health services. CONCLUSIONS: In the northern Nigeria context, educating men about danger signs of pregnancy, labour, delivery, newborn, and child health, is crucial to improving maternal and newborn health outcomes. Our intervention was successful not only in educating men, but also in converting some into advocates such that the effect of the intervention went beyond participants to the community. Programmes that aim to improve health-service utilization in northern Nigeria should consider scaling up this, or similar, interventions.

Factors associated with knowledge of obstetric danger signs and perceptions of the need for obstetric care among married men in northern Nigeria: a cross-sectional survey.

BACKGROUND: Male involvement in maternal, newborn and child health contributes to better health outcomes for women and their children, especially in restrictive societies. There is evidence that when men have better understanding of women's health needs, attitudes toward utilization of maternal and child health services, of both women and men, are improved. Given the role of men as the ultimate decision makers in families in northern Nigerian society, this study assessed the determinants of men's knowledge of danger signs in pregnancy and the continuum of obstetric care, and their perceptions of the importance of antenatal care utilization and health facility delivery. METHODS: This was a cross-sectional descriptive study. Structured questionnaires with close ended questions were administered to 1627 married men who had at least one wife younger than 25 years in communities in Nigeria northern states of Kaduna and Katsina. We use crosstabulations and means to compare characteristics of study respondents in the two states, assessing statistical significance of the differences with χ2-square and Anova tests as appropriate, and logistic regressions to assess the determinants of knowledge and perceptions. RESULTS: Knowledge of obstetric danger signs, especially during the postpartum period, was poor overall, but respondents were relatively more knowledgeable about danger signs during pregnancy and delivery compared with the postpartum period. Most perceived that antenatal care can reduce the risk of complications. Literate men were twice more likely to have positive health-behaviour perceptions. Wealth was positively associated with the perception that women should deliver in a health facility or hospital but did not have a statistically significant effect on the perception that antenatal care can reduce the risk of complications. CONCLUSIONS: While knowledge of obstetric danger signs was poor, literacy and household wealth significantly influenced knowledge of obstetric danger signs and perceptions that women should deliver at a health facility. Male involvement programmes need to ensure that men are empowered to understand obstetric danger signs along the continuum of obstetric care to improve perception and utilization of maternal health services for better maternal and newborn health outcomes.

Emergency transport for obstetric emergencies: integrating community-level demand creation activities for improved access to maternal, newborn, and child health services in northern Nigeria.

PURPOSE: Ensuring adequate access to skilled birth attendants during and after childbirth is a key strategy to reducing maternal and newborn mortalities. Transportation difficulties in emergency situations continue to be a significant barrier to accessing emergency obstetric care, especially in rural and hard-to-reach areas. Emergency transport schemes (ETS) have been introduced in various settings to increase access to emergency care and reduce the second obstetric delay with varying degrees of success. This qualitative study assessed the perceptions of stakeholders and beneficiaries of ETS in two states in northern Nigeria, comparing two models of ETS: one in which the ETS were introduced as a stand-alone intervention, and another in which ETS were part of a package of interventions for increasing demand and improving utilization of maternal and newborn health services. METHODS: We carried out focus group discussions with ETS drivers, mothers who delivered in the past year and utilized ETS, husbands of women who benefited from the schemes in the past year, health care providers, traditional birth attendants, and religious leaders, supplemented by in-depth interviews with program focal persons. RESULTS: Demand creation activities - especially working with traditional birth attendants and religious leaders - provided a strong linkage between the ETS and families of women in need of emergency transport services. Community members perceived the ETS model that included demand-generating activities as being more reliable and responsive to women's needs. CONCLUSION: ETS remain a key solution to lack of transport as a barrier to utilizing maternal and newborn health services in emergency situations in many rural and hard-to-reach communities. Programs utilizing ETS to improve access to emergency obstetric care should explore the potential of increasing their utility and reach by integrating the schemes with additional demand-side interventions, especially engagement with traditional birth attendants and religious leaders.

Programmatic implications of unmet need for contraception among men and young married women in northern Nigeria.

PURPOSE: The study was designed to provide programmatic recommendations for interventions to increase contraceptive prevalence in northern Nigeria. Family-planning use in North-East and North-West regions of Nigeria has remained very low, despite years of domestic and donor investments. We examine respondents' perceptions of their own need for contraception and specifically focus on young women because of their higher risk for maternal mortality. METHODS: In this cross-sectional study, we interviewed 1,624 married women younger than 25 years and 1,627 men married to women younger than 25 years, in Kaduna and Katsina states in northern Nigeria. We classified respondents into five categories: 1) having no real need for contraception, 2) perceiving no need for contraception, despite physical or behavioral need, 3) having met need by using a modern contraceptive method, 4) perceiving met need by employing traditional practices, and 5) having unmet need for contraception. RESULTS: Half of female respondents had no need for contraception because they were either pregnant or desiring a pregnancy at the time of the survey. A quarter of female and male respondents were not using contraception because of their religious beliefs. Less than 2% of respondents had unmet need because of lack of availability or access, or due to poor quality of care. Men had more positive views of family planning than women. CONCLUSION: Our findings suggest that young women in northern Nigeria would benefit from a programmatic approach that targets men, utilizes religious leaders, and addresses the prevalent religious and sociocultural norms that present barriers to contraceptive use. Such interventions have the potential to increase contraceptive prevalence more substantially, but the literature on these types of interventions in northern Nigeria is scarce. Therefore, more research is needed to identify and document what approaches work or do not work to increase contraceptive use in northern Nigeria.

Improving management of tuberculosis in people living with HIV in South Africa through integration of HIV and tuberculosis services: a proof of concept study.

BACKGROUND: South Africa's tuberculosis burden is the third highest globally and is closely associated with the country's devastating HIV epidemic. The separation of HIV and TB services in primary healthcare services in South Africa hampers TB case finding in patients who are co-infected with HIV and TB. This operational proof of concept study assessed an approach to improving tuberculosis detection and treatment by integrating tuberculosis management into HIV care. METHODS: The intervention involved workforce re-engineering accompanied by changes to the physical environment in three primary healthcare facilities in Gert Sibande district, Mpumalanga Province, that allowed HIV providers to test their HIV patients for TB and initiate and monitor TB treatment when indicated. To assess the proof of concept we compared the management of TB patients by HIV and TB providers, by reviewing the records of all facility patients who tested positive for tuberculosis between July 2015 and February 2016. We also considered the perceptions of healthcare providers and facility managers about the intervention through structured interviews. RESULTS: Approximately 30% of the 1855 patients with presumed TB in the three clinics had been identified by HIV providers. The percentage of patients consecutively tested for TB was 81.0% and 85.0% (p = 0.0551) for HIV and TB providers, respectively. Of the patients identified with TB by HIV and TB providers, 75.4% and 79.2% (p = 0.2876), respectively, were initiated on treatment. The defaulter rate was higher among HIV, compared to TB, providers (12.8% versus 4.2%). Overall, healthcare providers and facility managers had positive views of the intervention but raised concerns regarding potential increase in workload and administrative issues, as well as infection control. CONCLUSIONS: The results of this proof-of-concept study indicate that the full spectrum of TB services can be easily and effectively integrated into existing HIV care programs. However, a possible shift in the service providers' workload, including administrative tasks, must be tackled and effective infection control must be ensured. Further research is needed to assess the impact of TB service integration into the scope of HIV care (or other chronic care programs) on patient outcomes, including analysis of routine data.

Overcoming barriers to access and utilization of maternal, newborn and child health services in northern Nigeria: an evaluation of facility health committees.

BACKGROUND: Poor quality of health services and socio-cultural dynamics may severely limit utilization of health services. Facility health committees were established in several states in northern Nigeria to reduce these barriers. The committees were charged with mobilizing communities, improving quality of health services, and promoting utilization of maternal and child health services. This study assessed this intervention. METHODS: To obtain a comprehensive picture of facility health committees' influence on maternal and child health services, we selected 33 facilities in three states in northern Nigeria (Jigawa, Kaduna, Kano) where the intervention was active. For each of these facilities we interviewed committee members (n = 399), conducted focus group discussions with a subset of committee members (18 focus groups), interviewed facility health providers (two providers from each facility), and conducted client exit interviews (n = 501). RESULTS: Facility health committees appear to have a positive influence on quality of maternal and child health services in the selected facilities. Committee members, health providers, and facility clients all agree that the committees have a tangible positive effect. The most important roles of the committees are to mobilize the community and increase demand for maternal and child health services, in a region where demand is very low. Committee activities further improve health services in many ways, including advocacy, community-facility coordination, fund raising, money donation, and problem mitigation. CONCLUSION: Facility health committees can be invaluable in contributing to improved demand for and access to quality maternal and child health services in health facilities in northern Nigeria. They provide strong linkages between community members and the health facilities, directly work to increase demand for services, and address supply-side challenges that often limit utilization of services in health facilities. The intervention can be improved by more broadly communicating committee activities in the community, and by incentivizing facility health committee members.

Demand for Women's Health Services in Northern Nigeria: A Review of the Literature.

Demand for and utilization of women's health services in northern Nigeria are consistently low and health indicators in the region are among the poorest in the world. This literature review focuses on social and cultural barriers to contraceptive use, antenatal care, and facility births in northern Nigeria, and influencers of young women's health-seeking behavior. A thorough search of peer reviewed and grey literature yielded 41 publications that were synthesized and analyzed. The region's population is predominantly Muslim, practicing Islam as a complete way of life. While northern Nigerian society is slowly changing, most women still lack formal education, with a significant proportion married in their teens, and the majority neither socially nor economically empowered. The husband largely makes most household decisions, including utilization of healthcare services by members of his household. These practices directly impact women's health-seeking behaviors for themselves and for their children. Programs seeking to improve women's health outcomes in northern Nigeria should involve women's influencers to affect behavior change, including husbands, religious leaders, and others. More research is needed to identify pathways of information that can be utilized by programs designed to increase demand for health services.

A practical alternative to calculating unmet need for family planning.

The standard approach for measuring unmet need for family planning calculates actual, physiological unmet need and is useful for tracking changes at the population level. We propose to supplement it with an alternate approach that relies on individual perceptions and can improve program design and implementation. The proposed approach categorizes individuals by their perceived need for family planning: real met need (current users of a modern method), perceived met need (current users of a traditional method), real no need, perceived no need (those with a physiological need for family planning who perceive no need), and perceived unmet need (those who realize they have a need but do not use a method). We tested this approach using data from Mali (n=425) and Benin (n=1080). We found that traditional method use was significantly higher in Benin than in Mali, resulting in different perceptions of unmet need in the two countries. In Mali, perceived unmet need was much higher. In Benin, perceived unmet need was low because women believed (incorrectly) that they were protected from pregnancy. Perceived no need - women who believed that they could not become pregnant despite the fact that they were fecund and sexually active - was quite high in both countries. We posit that interventions that address perceptions of unmet need, in addition to physiological risk of pregnancy, will more likely be effective in changing behavior. The suggested approach for calculating unmet need supplements the standard calculations and is helpful for designing programs to better address women's and men's individual needs in diverse contexts.

Experiences in implementation and publication of operations research interventions: gaps and a way forward.

INTRODUCTION: According to UNAIDS, the world currently has an adequate collection of proven HIV prevention, treatment and diagnostic tools, which, if scaled up, can lay the foundation for ending the AIDS epidemic. HIV operations research (OR) tests and promotes the use of interventions that can increase the demand for and supply of these tools. However, current publications of OR mainly focus on outcomes, leaving gaps in reporting of intervention characteristics, which are essential to address for the utilization of OR findings. This has prompted WHO and other international public health agencies to issue reporting requirements for OR studies. The objective of this commentary is to review experiences in HIV OR intervention design, implementation, process data collection and publication in order to identify gaps, contribute to the body of knowledge and propose a way forward to improve the focus on "implementation" in implementation research. DISCUSSION: Interventions in OR, like ordinary service delivery programmes, are subject to the programme cycle, which continually uses insights from implementation and the local context to modify service delivery modalities. Given that some of these modifications in the intervention may influence study outcomes, the documentation of process data becomes vital in OR. However, a key challenge is that study resources tend to be skewed towards documentation and the reporting of study outcomes to the detriment of process data, even though process data is vital for understanding factors influencing the outcomes. CONCLUSIONS: Interventions in OR should be viewed using the lens of programme evaluation, which includes formative assessment (to determine concept and design), followed by process evaluation (to monitor inputs and outputs) and effectiveness evaluation (to assess outcomes and effectiveness). Study resources should be equitably used between process evaluation and outcome measurement to facilitate inclusion of data about fidelity and dose in publications in order to enable explanation of the relationship between dosing and study outcomes for purposes of scaling up and further refinement through research.

Increasing literate and illiterate women's met need for contraception via empowerment: a quasi-experiment in rural India.

BACKGROUND: Virtually all the evidence on the relationship between women's empowerment and use of contraception comes from cross-sectional studies that have emphasized macrosocial factors.This analysis tested whether literate and illiterate women are empowered by an intervention designed to provide information addressing technical and gender concerns and expand contraceptive choice, and evaluated the effects of women's decision-making power on contraceptive behavior. METHODS: The data came from a three-year quasi-experiment conducted in two comparable, yet not equivalent, rural blocks in Jharkhand, India. At the intervention block, a new contraceptive method was introduced at Ministry of Health health centers, providers were trained to offer family planning information and services which took into consideration gender power dynamics, and promotional messages and information about contraception were disseminated community-wide. Married women ages 15-49 who lived in the intervention and control blocks were sampled and interviewed before and after the intervention by a professional research firm. Data analyses included generalized linear models with interactions and covariate control. RESULTS: Women's normative beliefs concerning wives' power in decisions regarding money earned and visits to relatives and friends vis-à-vis their husbands' power were increased by the intervention; similar was the case among illiterate, but not literate, women regarding decisions related to childbearing. Concerning met need for contraception, the change for women with relatively more power who were illiterate was greater in the intervention than in the control area. CONCLUSION: The findings suggest that women were empowered by outreach visits that addressed gender dynamics and that their empowerment contributed to their met need for contraception. Generalizations to other settings, however, may be limited by cultural differences.

Systems approach to monitoring and evaluation guides scale up of the Standard Days Method of family planning in Rwanda.

There is no guarantee that a successful pilot program introducing a reproductive health innovation can also be expanded successfully to the national or regional level, because the scaling-up process is complex and multilayered. This article describes how a successful pilot program to integrate the Standard Days Method (SDM) of family planning into existing Ministry of Health services was scaled up nationally in Rwanda. Much of the success of the scale-up effort was due to systematic use of monitoring and evaluation (M&E) data from several sources to make midcourse corrections. Four lessons learned illustrate this crucially important approach. First, ongoing M&E data showed that provider training protocols and client materials that worked in the pilot phase did not work at scale; therefore, we simplified these materials to support integration into the national program. Second, triangulation of ongoing monitoring data with national health facility and population-based surveys revealed serious problems in supply chain mechanisms that affected SDM (and the accompanying CycleBeads client tool) availability and use; new procedures for ordering supplies and monitoring stockouts were instituted at the facility level. Third, supervision reports and special studies revealed that providers were imposing unnecessary medical barriers to SDM use; refresher training and revised supervision protocols improved provider practices. Finally, informal environmental scans, stakeholder interviews, and key events timelines identified shifting political and health policy environments that influenced scale-up outcomes; ongoing advocacy efforts are addressing these issues. The SDM scale-up experience in Rwanda confirms the importance of monitoring and evaluating programmatic efforts continuously, using a variety of data sources, to improve program outcomes.