Is the national health insurance scheme a pathway to sustained access to medicines in Nigeria?

OBJECTIVE: The debate surrounding access to medicines in Nigeria has become increasingly necessary due to the high cost of essential medicine drugs and the prevalence of counterfeit medicines in the country. The Nigerian government has proposed the implementation of the National Health Insurance Scheme (NHIS) to address these issues and guarantee universal access to essential medicines. Access was investigated using the 3 A's (accessibility, affordability, and availability). This paper investigates whether the NHIS is a viable pathway to sustained access to medicines in Nigeria. DESIGN: This was a cross-sectional study using a mixed-methods design. Both qualitative and quantitative methods were utilized for the study. SETTING: This study was conducted at NHIS-accredited public and private facilities in Enugu State. PARTICIPANTS: 296 randomly selected enrollees took part in the quantitative component, while, 6 participants were purposively selected for the qualitative component, where in-depth interviews (IDIs) were conducted face-to-face with NHIS desk officers in selected public and private health facilities. RESULTS: The quantitative findings showed that 94.9% of respondents sought medical help. Our data shows that 78.4% of the respondents indicated that the scheme improved their access to care (accessibility, affordability, and availability). The qualitative results from the NHIS desk officers showed that respondents across all the socio-economic groups reported that the NHIS had marginally improved access to medicine over the years. It was also observed that most of the staff in NHIS-accredited facilities were not adequately trained on the scheme's requirements and that most times, essential drugs were not readily available at the accredited facilities. CONCLUSION: The study findings revealed that although the NHIS has successfully expanded access to medicines, there remain several challenges to its effective implementation and sustainability. Additionally, the scheme's coverage of essential medicines is could be improved even more, leading to reduced access to needed drugs for many Nigerians. A focus on the 3As for the scheme means that all facility categories (private and public) and their interests (where necessary) must be considered in further planning of the scheme to ensure that things work out well.

Demand and supply analysis for maternal and child health services at the primary healthcare level in Nigeria.

BACKGROUND: The low demand for maternal and child health services is a significant factor in Nigeria's high maternal death rate. This paper explores demand and supply-side determinants at the primary healthcare level, highlighting factors affecting provision and utilization. METHODS: This qualitative study was undertaken in Anambra state, southeast Nigeria. Anambra state was purposively chosen because a maternal and child health programme had just been implemented in the state. The three-delay model was used to analyze supply and demand factors that affect MCH services and improve access to care for pregnant women/mothers and newborns/infants. RESULT: The findings show that there were problems with both the demand and supply aspects of the programme and both were interlinked. For service users, their delays were connected to the constraints on the supply side. On the demand side, the delays include poor conditions of the facilities, the roads to the facilities are inaccessible, and equipment were lacking in the facilities. These delayed the utilisation of facilities. On the supply side, the delays include the absence of security (fence, security guard), poor citing of the facilities, inadequate accommodation, no emergency transport for referrals, and lack of trained staff to man equipment. These delayed the provision of services. CONCLUSION: Our findings show that there were problems with both the demand and supply aspects of the programme, and both were interlinked. For service users, their delays were connected to the constraints on the supply side.

Village health worker motivation for better performance in a maternal and child health programme in Nigeria: A realist evaluation.

BACKGROUND: Community health workers play an important role in linking communities with formal health service providers, thereby improving access to and utilization of health care. A novel cadre of community health workers known as village health workers (VHWs) were recruited to create demand for maternal health services in the Nigerian Subsidy Reinvestment Programme (SURE-P/MCH). In this study, we investigated the role of contextual factors and underlying mechanisms motivating VHWs. METHODS: We used realist evaluation to understand the impact of a multi-intervention maternal and child health programme on VHW motivation using Anambra State as a case study. Initial working theories and logic maps were developed through literature review and stakeholder engagement; programme theories were developed and tested using focus group discussions and in-depth interviews with various stakeholder groups. Interview transcripts were analysed through an integrated approach of Context, Mechanism and Outcomes (CMO) categorisation and connecting, and matching of patterns of CMO configurations. Motivation theories were used to explain factors that influence VHW motivation. Explanatory configurations are reported in line with RAMESES reporting standards. RESULTS: The performance of VHWs in the SURE-P maternal and child health programme was linked to four main mechanisms of motivation: feelings of confidence, sense of identity or feeling of acceptance, feeling of happiness and hopefulness/expectation of valued outcome. These mechanisms were triggered by interactions of programme-specific contexts and resources such as training and supervision of VHWs by skilled health workers, provision of first aid kits and uniforms, and payments of a monthly stipend. The monthly payment was considered to be the most important motivational factor by VHWs. VHWs used a combination of innovative approaches to create demand for maternity services among pregnant women, and their performance was influenced by health system factors such as organisational capacity and culture, and societal factors such as relationship with the community and community support. CONCLUSION: This paper highlights important contextual factors and mechanisms for VHW motivation that can be applied to other interventions that seek to strengthen community engagement and demand creation in primary health care. Future research on how to sustain VHW motivation is also required.

Achieving universal health coverage in Nigeria: the dilemma of accessing dental care in Enugu state, Nigeria, a mixed methods study.

OBJECTIVE: Equitable access to oral healthcare is a major focus of the Universal health coverage debate in Nigeria. However, a great majority of the population still do not have full coverage for essential oral healthcare services. This study will determine the extent of inequities in accessing oral healthcare services and the factors influencing access to equitable oral healthcare in Enugu state Nigeria. METHODS: A descriptive cross-sectional, urban and rural study conducted over two months in Enugu state Nigeria, using a mixed method approach. The quantitative study design used interviewer administered questionnaires to elicit information from 774 household members (394 urban and 380 rural) in study area who had sought dental care 6 months prior to study, and dental care providers (52) in selected dental health facilities. The qualitative study design involved in-depth interview of heads of selected dental health facilities to investigate factors influencing provision of dental care. Household data was collected house to house from randomly selected households in the LGA, while a face-to-face in-depth interview was conducted for purposively selected oral health professionals from study facilities. RESULTS: Majority of respondents sought care when they had toothache (72%). There was inequity in utilization of dental care across socioeconomic status groups (SES). The least poor SES (Q5) sought dental care in the private facilities, and chose to have dental fillings more than the poorest (Q1) and very poor SES (Q2) who visited public facilities and patent medicine dealer shops more and opted more for tooth extractions.(p < 0.05) Cost of services influenced access and treatment choice more among Q1 and Q2 than Q5 (p < 0.05) Qualitative results show that facility location, low awareness, human resource shortage and oral health financing methods influenced access. CONCLUSION: Increased awareness and inclusion of oral healthcare in all health insurance schemes with expansion of current oral healthcare benefit package will improve access to care and further improve chances of attaining universal health coverage.

Oral health-seeking behavior among different population groups in Enugu Nigeria.

INTRODUCTION: This study investigates the oral health-seeking behaviour of households and its influence on demand for dental caries treatment services in Enugu state Nigeria. METHODS: A quantitative descriptive cross-sectional study was used to explore the oral health seeking pattern of 378 urban and 348 rural household respondents in Enugu state Nigeria. The study explored dental caries treatment-seeking, oral health behavior of respondents using the three dynamics of the Andersen and Newman health utilization model; predisposing, enabling and need factors. FINDINGS: Recommendations from community members (48.9%), severity of disease (22.1%), and cost of treatment (19.4%) all influenced where oral healthcare was first sought. Gender and type of occupation, influenced positive oral health-seeking behavior (p<0.05). The least poor socioeconomic status (SES) group, sought dental treatment in the private dental clinics, while the very poor and most poor SES groups used traditional healers, home treatment and patent medicine dealers more. Dental fillings and extractions were generally the most accessed treatment options for dental caries. The tendency for all the SES groups (especially the least poor), to choose tooth extraction more as a treatment option for dental caries was influenced by the oral health awareness level of respondents and the cost of dental fillings. (p<0.05). CONCLUSION: The findings suggest that interventions to create increased oral health awareness targeted at education on preventive strategies, appropriate time and place to seek oral health care and dental caries treatment, as well devising and implementing health financing options such as dental insurance would enable individuals to seek appropriate treatment for dental caries on time. In addition, it will reduce the proportion of people visiting unorthodox healthcare providers for their oral health problems or choosing cheaper but inappropriate treatment options.

"If you are on duty, you may be afraid to come out to attend to a person": fear of crime and security challenges in maternal acute care in Nigeria from a realist perspective.

BACKGROUND: Maternal and Child Health is a global priority. Access and utilization of facility-based health services remain a challenge in low and middle-income countries. Evidence on barriers to providing and accessing services omits information on the role of security within facilities. This paper explores the role of security in the provision and use of maternal health services in primary healthcare facilities in Nigeria. METHODS: Study was carried out in Anambra state, Nigeria. Qualitative data were initially collected from 35 in-depth interviews and 24 focus groups with purposively identified key informants. Information gathered was used to build a programme theory that was tested with another round of interviews (17) and focus group (4) discussions. Data analysis and reporting were based on the Context-Mechanism-Outcome heuristic of Realist Evaluation methodology. RESULTS: The presence of a male security guard in the facility was the most important security factor that facilitated provision and uptake of services. Others include perimeter fencing, lighting and staff accommodation. Lack of these components constrained provision and use of services, by impacting on behaviour of staff and patients. Security concerns of facility staff who did not feel safe to let in people into unguarded facilities, mirrored those of pregnant women who did not utilize health facilities because of fear of not being let in and attended to by facility staff. CONCLUSION: Health facility security should be key consideration in programme planning, to avert staff and women's fear of crime which currently constrains provision and use of maternal healthcare at health facilities.

Access to Oral health care: a focus on dental caries treatment provision in Enugu Nigeria.

BACKGROUND: Dental caries, despite improvement in oral health across the globe, is still a large contributor to the global burden of oral diseases and a major public health concern. In Enugu state, Nigeria, there is minimal access to adequate and proper oral health care. This study examined the determinants of dental caries treatment provision and the challenges of providing equitable access to oral health care. METHOD: This was a mixed-method cross-sectional descriptive urban-rural study conducted in selected oral health facilities offering primary oral health care in Enugu state. The study was conducted in two phases over a 2 month period. Quantitative data was initially collected from all selected oral health care providers using a survey questionnaire format after which qualitative data were collected through in-depth interviews of heads of the selected oral health facilities. The determinants of dental caries treatment services were explored with a focus on provider behavior, cost of dental services, human resource availability and availability of dental equipment. RESULTS: Quantitative findings show that to a larger extent, the cost of raw materials (100%), human resources (98.1%), infection control resources (98.1%), geographical location (98.1), Government policies (88%) and the price of other goods (80.8%) influence provision of dental caries treatment services. Qualitative results show that location and number of oral health facilities, government funding and policies for oral health, cost of dental equipment and materials, the ability of consumers to pay, human resource availability and consumer awareness of oral health are also factors that influence the provision of dental caries treatment services. CONCLUSION: Adequate access to oral health care services is a major concern that affects all aspects of healthcare and a determining factor in the country's drive to achieve universal health coverage. In order to address this, oral health facilities need to be strategically located and have adequate materials, equipment and skilled staff. There is a need to incorporate oral health into the general health care system and improve government policies and funding for oral health.