What makes advocacy work? Stakeholders’ voices and insights from prioritisation of maternal and child health programme in Nigeria

Background: The Nigerian government introduced and implemented a health programme to improve maternal and child health (MCH) called Subsidy Reinvestment and Empowerment programme for MCH (SURE-P/MCH). It ran from 2012 and ended abruptly in 2015 and was followed by increased advocacy for sustaining the MCH (antenatal, delivery, postnatal and immunization) services as a policy priority. Advocacy is important in allowing social voice, facilitating prioritization, and bringing different forces/actors together. Therefore, the study set out to understand how advocacy works – through understanding what effective advocacy implementation processes comprise and what mechanisms are triggered by which contexts to produce the intended outcomes. Methods: The study used a Realist Evaluation design through a mixed quantitative and qualitative methods case study approach. The programme theory (PT) was developed from three substantive social theories (power politics, media influence communication theory, and the three-streams theory of agenda-setting), data and programme design documentation, and subsequently tested. We report information from 22 key informant interviews including national and State policy and law makers, policy implementers, CSOs, Development partners, NGOs, health professional groups, and media practitioners and review of relevant documents on advocacy events post-SURE-P. Results: Key advocacy organizations and individuals including health professional groups, the media, civil society organizations, powerful individuals, and policymakers were involved in advocacy activities. The nature of their engagement included organizing workshops, symposiums, town hall meetings, individual meetings, press conferences, demonstrations, and engagements with media. Effective advocacy mechanism involved alliance brokering to increase influence, the media supporting and engaging in advocacy, and the use of champions, influencers, and spouses (Leadership and Elite Gendered Power Dynamics). The key contextual influences which determined the effectiveness of advocacy measures for MCH included the political cycle, availability of evidence on the issue, networking with powerful and interested champions, and alliance building in advocacy. All these enhanced the entrenchment of MCH on the political and financial agenda at the State and Federal levels. Conclusions: Our result suggest that advocacy can be a useful tool to bring together different forces by allowing expression of voices and ensuring accountability of different actors including policymakers. In the context of poor health outcomes, interest from policymakers and politicians in MCH, combined with advocacy from key policy actors armed with evidence, can improve prioritization and sustained implementation of MCH services. This paper is a component of a study titled “Determinants of effectiveness and sustainability of a novel community health workers programme in improving MCH in Nigeria”. In this study. The sudden withdrawal of SURE-P is used as an explanatory case study [27] to explore cause-effect relationships of advocacy activities in MCH within the Nigerian context using Anambra State as a case. Anambra state was identified in consultation with the Federal and State Ministry of Health (MOH) and the SURE-P national team lead [28]. Thus Anambra state was used for the advocacy study as advocacy activities concentrated mostly at the national level and needed to show that events were also taking place at the subnational level but none at the local governments. The study used realist evaluation through mixed-methods approach, as described in another study [28]. Realist Evaluation is based on the supposition that interventions constitute ideas and assumptions (programme theories), about how and why they are expected to work [29]. It is a theory-driven approach that involves developing, testing, and refining specific programme theories (PTs). The authors first conducted a literature and document review of MNCH advocacy activities carried out after the SURE-P programme ended. This review included a systematic search and synthesis of published peer-reviewed articles, reports and articles from agencies and research studies, and news stories. The objective of the advocacy process was to sensitize stakeholders on the need to keep MCH services (antenatal, delivery, postnatal and immunization) on the political and financial agenda and our purpose was to map changes in policy and programme environments at federal and state levels as well as mapping advocacy and lobbying events that helped to keep MCH on the political agenda. The search and data extraction were done by two of the authors using a proforma (see Table 1). The headings of the proforma included advocacy event and why; person/group who led event; date and venue of event; contextual features of the event; mechanism (What made the event work); the outcome of the event (e.g. what was the effect of advocacy and lobbying). Advocacy issues formed one of the eight PTs which were initially developed from the literature, document review and consultations with key policy actors, and then were empirically tested, validated, and refined. This led to the identification of the advocacy issues used to develop the initial programme theory (gleaned from the mapping of advocacy/policy timelines and relevant literature). Mapped advocacy events at the national and Anambra State (2015–2017) The Minister set up a committee to revitalise the MSS programme that contained activities similar to SURE-P 24–27/11/ 2015. Ladi Kwali Conference Centre, Sheraton Abuja 4/2017 Lagos State. 7–9/11/2016 Abuja 13/4/ 2017 Abuja Recognition of the need for CSOs to be carried along in the implementation processes of (SOML PforR) and the need for accountability. Attendance by FMoH, the World Bank, and CSOs enhanced the workshop 19/12/2017 Abuja Identification of opportunities for synergies/collaboration between public and private health sector players. Coming together of many organizations including the United Nations’ Every Woman Every Child initiative; Merck for Mothers; Nigeria Global Financing Facility (GFF) and presentation of diverse, but unique perspectives for improving RMNCAH service delivery 10/9/2017 Prof. Dora Akunyili Women Development Centre, Awka Anambra State. The need to be meaningfully engaged and earn an income to support the upkeep of the family including health bills and child nutrition. Support by the wife of the Governor, Governor of Anambra state and presence of mothers from the 179 communities of the state ensured the success of the event The advocacy issues that guided this PT were “In the context of poor health outcomes, interest from policymakers and politicians in maternal and child health care (MCH), combined with advocacy and lobbying from key policy actors to prioritise MCH, is likely to help generate and maintain political and economic commitment ultimately contributing to sustained implementation of and access to MCH services for vulnerable groups” A total of 14 advocacy events at the National and Anambra State levels related to changes in policy and programme environment were mapped during theory testing. Next, we sought to develop an in-depth understanding of the experiences and practices of advocacy groups at the national and state level and this provided a range and depth of experiences that were relevant to our phenomena of interest. Using purposive sampling methods, we developed the list of respondents for interviews based on their roles in advocacy events. These roles included organizational leads and key individuals spearheading the advocacy combined with policymakers who were on the ‘receiving end’ of advocacy. The document review and tracking of advocacy events in MCH in Nigeria informed our selection of the respondents at the Federal level and in Anambra State (the study state for the larger project to understand what happened at the sub-national level). They included 22 in-depth interviews (IDIs) with stakeholders (a stakeholder being a person, group or organization that has interest or concern in the issue at hand and in this advocacy case, they are the government, the policymakers, the public servants (eg. FMOH), the CSOs, the international organizations, the media, the professional groups and representatives of the community). On the whole, 3 CSOs, 3 Development Partners, 3 NGOs, 2 health professional groups, 3 media practitioners, and 8 policy-makers (5 from the National and 3 from the State level) all of who were active in advocacy events were selected. They were also selected to reflect differences in groups, occupations, and professional backgrounds. Using an IDI guide, they were interviewed by 4 interviewers. This gave the details of the activities they carried out, the output and outcome as they continued advocating for these until the desired effect was achieved. The IDIs were semi-structured around our programme theory to validate, test, and refine it using a topic guide (see Additional file) [30]. We developed the semi-structured interview guide around the programme theory because we needed to conform with the realist evaluation methodology where the initial ‘program theories are formed from the findings of the literature review, then a guide is developed to ask questions that will either confirm or disprove the findings of the first theory i.e. the gleaning stage. This included the context of MCH in Nigeria and how actors perceived maternal health as a problem, the strategies adopted by the actors, the outcome of the advocacy, and what enabled or constrained the advocacy events. The interview guides were different for the producers and users of advocacy and designed to focus on each group’s strength, though they were also asked to corroborate that they knew what the other group was doing. All interviews were undertaken in person in English generally after written informed consent was obtained from all respondents. All interviews were also conducted in the participants’ offices, were audio-recorded and transcribed verbatim by professional transcribers for analysis. To ensure quality, we used the realist and meta-narrative evidence synthesis (RAMESES) publication standards [31] for reporting realist synthesis as quality assurance checks within our study. This recommends in line with a realist approach, that existing theory is mixed with the developed PT to enhance the explanatory endeavour of the study. Also, the quality was ensured at different steps of the process (piloting and post-piloting revision of tools, collection, transcription, translation, anonymization, digitization/entry into software, coding, and analysis). Mechanisms for quality assurance used included appropriate training (e.g. of transcribers of key concepts/terms used), multiple researchers working on the same data (e.g. coding by at least two researchers), continuous peer-review and peer-support within and between the different partner teams. Retroductive approach to analysis [32] was used which involved continuous engagements and refining of the theory against the data and the existing literature on the subject. Qualitative data recordings were transcribed verbatim, anonymised, double coded in MS Word using colour-coded highlights and, analysed using manual thematic and framework analysis of the main topics outlined in the interview guide. Other codes not included in the guide emerged during the reading of the interviews. Findings were supplemented and validated with document review. The combination of three substantive theories of power politics, media influence communication theory and the three-streams theory of agenda-setting was used to infer causal relationships within certain circumstances.