The Institute for Global Health and Development
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Item Enablers and barriers to implementing cholera interventions in Nigeria: a community–based system dynamics approach(Oxford University Press (OUP), 2024-07-26) Elimian, Kelly; Diaconu, Karin; Ansah, John; King, Carina; Dewa, Ozius; Yennan, Sebastian; Gandi, Benjamin; Forsberg, Birger Carl; Ihekweazu, Chikwe; Alfvén, TobiasNigeria accounts for a substantial cholera burden globally, particularly in its northeast region, where insurgency is persistent and widespread. We used participatory group model building (GMB) workshops to explore enablers and barriers to implementing known cholera interventions, including water, sanitation, and hygiene (WASH), surveillance and laboratory, case management, community engagement, oral cholera vaccine, and leadership and coordination, as well as explore leverage points for interventions and collaboration. The study engaged key cholera stakeholders in the northeastern states of Adamawa and Bauchi, as well as national stakeholders in Abuja. Adamawa and Bauchi States’ GMB participants comprised 49 community members and 43 healthcare providers, while the 23 national participants comprised government ministry, department and agency staff, and development partners. Data were analysed thematically and validated via consultation with selected participants. The study identified four overarching themes regarding the enablers and barriers to implementing cholera interventions: (1) political will, (2) health system resources and structures, (3) community trust and culture, and (4) spill-over effect of COVID-19. Specifically, inadequate political will exerts its effect directly (e.g., limited funding for prepositioning essential cholera supplies) or indirectly (e.g., overlapping policies) on implementing cholera interventions. The healthcare system structure (e.g., centralisation of cholera management in a state capital) and limited surveillance tools weaken the capacity to implement cholera interventions. Community trust emerges as integral to strengthening the healthcare system’s resilience in mitigating the impacts of cholera outbreaks. Lastly, the spill-over effects of COVID-19 helped promote interventions similar to cholera (e.g., WASH) and directly enhanced political will. In conclusion, the study offers insights into the complex barriers and enablers to implementing cholera interventions in Nigeria’s cholera-endemic settings. Strong political commitment, strengthening the healthcare system, building community trust, and an effective public health system can enhance the implementation of cholera interventions in Nigeria.Item Barriers and enabling structural forces affecting access to antiretroviral therapy in Nigeria(BioMed Central, 2024-01-06) Oturu, Kingsley; O’Brien, Oonagh; Ozo-Eson, Philomena I.Background: Access to antiretroviral therapy (ART) helps to improve quality of life and reduces the spread of HIV. However, while a lot of studies focus on supply factors, such as resources for the purchase of antiretroviral drugs, demand and structural forces are not given much emphasis. In this paper it is argued that structural forces shape the way people access antiretroviral therapy in Nigeria. Methods: A Grounded Theory methodology was undertaken in the research. Semi structured qualitative interviews were administered to select people living with HIV/AIDS in Nigeria. This was facilitated by the Network of People Living with HIV/AIDS in Nigeria (NEPWHAN) to understand their perspectives with regard to barriers and enablers to ART access in Nigeria. Thirty persons living with HIV/AIDS were interviewed and recorded. The interview recordings were transcribed and coded using a constructionist epistemological approach. This was triangulated with results of preliminary and secondary literature review analysis. Results: In this research, the participants discussed structural forces (barriers and enablers) that influenced how they accessed ART. These included economic factors such as poverty that enabled transactional sex. Unequal gender relations and perceptions influenced how they accessed ART. The participants’ belief in ‘God’ and religious activities such as ‘prayer’ and the use of ‘traditional medicine’ had an impact on how and when they accessed ART. Political activity at the international, national, and local levels influenced access to ART as well as resources. The individual’s familial, social, and organisational connections also influenced their ease of accessing ART. Conclusions: This study identifies structural forces that affect access to antiretroviral therapy and provides recommendations on how they can be harnessed to enable improved access to ART and consequently improved health.Item Performance-based financing in three humanitarian settings: Principles and pragmatism(BioMed Central, 2018-06-27) Bertone, Maria Paola; Jacobs, Eelco; Toonen, Jurrien; Akwataghibe, Ngozi; Witter, SophieBackground: Performance based financing (PBF) has been increasingly implemented across low and middleincome countries, including in fragile and humanitarian settings, which present specific features likely to require adaptation and to influence implementation of any health financing programme. However, the literature has been surprisingly thin in the discussion of how PBF has been adapted to different contexts, and in turn how different contexts may influence PBF. With case studies from three humanitarian settings (northern Nigeria, Central African Republic and South Kivu in the Democratic Republic of Congo), we examine why and how PBF has emerged and has been adapted to those unsettled and dynamic contexts, what the opportunities and challenges have been, and what lessons can be drawn. Methods: Our comparative case study is based on data collected from a document review, 35 key informant interviews and 16 focus group discussions with stakeholders at national and subnational level in the three settings. Data were analysed in order to describe and compare each setting in terms of underlying fragility features and their implications for the health system, and to look at how PBF has been adopted, implemented and iteratively adapted to respond to acute crisis, deal with other humanitarian actors and involve local communities. Results: Our analysis reveals that the challenging environments required a high degree of PBF adaptation and innovation, at times contravening the so-called ‘PBF principles’ that have become codified. We develop an analytical framework to highlight the key nodes where adaptations happen, the contextual drivers of adaptation, and the organisational elements that facilitate adaptation and may sustain PBF programmes. Conclusions: Our study points to the importance of pragmatic adaptation in PBF design and implementation to reflect the contextual specificities, and identifies elements (such as, organisational flexibility, local staff and knowledge, and embedded long-term partners) that could facilitate adaptations and innovations. These findings and framework are useful to spark a reflection among PBF donors and implementers on the relevance of incorporating, reinforcing and building on those elements when designing and implementing PBF programmes.