"I don't like to be seen by a male provider": health workers' strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria.

BACKGROUND: Ending maternal mortality has been a significant global health priority for decades. Many sub-Saharan African countries introduced user fee removal policies to attain this goal and ensure universal access to health facility delivery. However, many women in Nigeria continue to deliver at home. We examined the reasons for home birth in settings with free maternal healthcare in Southwestern and North Central Nigeria. METHODS: We adopted a fully mixed, sequential, equal-status design. For the quantitative study, we drew data from 211 women who reported giving birth at home from a survey of 1227 women of reproductive age who gave birth in the 5 y before the survey. The qualitative study involved six focus group discussions and 68 in-depth interviews. Data generated through the interviews were coded and subjected to inductive thematic analysis, while descriptive statistics were used to analyse the quantitative data. RESULTS: Women faced several barriers that limited their use of skilled birth attendants. These barriers operate at multiple levels and could be grouped as economic, sociocultural and health facility-related factors. Despite the user fee removal policy, lack of transportation, birth unpreparedness and lack of money pushed women to give birth at home. Also, sociocultural reasons such as hospital delivery not being deemed necessary in the community, women not wanting to be seen by male health workers, husbands not motivated and husbands' disapproval hindered the use of health facilities for childbirth. CONCLUSIONS: This study has demonstrated that free healthcare does not guarantee universal access to healthcare. Interventions, especially in the Nasarawa state of Nigeria, should focus on the education of mothers on the importance of health facility-based delivery and birth preparedness.

Do benefits in kind or refunds affect health service utilization and health outcomes? A natural experiment from Japan.

Although the payment systems of public health insurance vary greatly across countries, we still have limited knowledge of their effects. To quantify the changes from a benefits in kind system to a refund system, we exploit the largest physician strike in Japan since the Second World War. During the strike in 1971 led by the Japan Medical Association (JMA), JMA physicians resigned as health insurance doctors, but continued to provide medical care and even health insurance treatment in some areas. This study uses the regional differences in resignation rates as a natural experiment to examine the effect of the payment method of health insurance on medical service utilization and health outcomes. In the main analysis, aggregated monthly prefectural data are used (N=46). Our estimation results indicate that if the participation rate of the strike had increased by 1% point and proxy claims were refused completely, the number of cases of insurance benefits and the total amount of insurance benefits would have decreased by 0.78% and 0.58%, respectively compared with the same month in the previous year. Moreover, the average amount of insurance benefits per claim increased since patients with relatively less serious diseases might have sought health care less often. Finally, our results suggest that the mass of resignations did not affect death rates.

Medical Dominance and Resistance in Nigeria's Health Care System.

The health care system in Nigeria remains topical because of concerns over unremitting health outcomes, such as maternal and infant mortalities and frequent epidemic outbreaks, and more recently because of regular strikes by health workers. The strikes arise mostly from disputes between medical doctors and other health workers over a range of issues, including salary levels and emoluments, leadership of teaching hospitals, and appointment of the Minister of Health. Other health workers, who allege that doctors are favored in the system, have formed Joint Health Sector Unions to confront the doctors. Both groups have frequently engaged in strikes such that, within the past decade, there has always been a strike or the threat of a strike, a situation that causes disruption of health care services. Two presidential commissions have been instituted, to no avail. With the allegations of favoritism, only government even-handedness in more carefully delineating the areas of inclusion and exclusion in accordance with available legislations may stem the rising tide. Until solutions agreeable to both parties are found, the health system and the Nigerian people will continue to suffer frustrations of avoidable disruption of services.

Piecemeal approach could lead to confusion over industrial action.

Nurses and midwives will stage a four-hour strike as part of the ongoing pay dispute (News November 5). This will take place from 7am to 11am on Monday November 24.