Menu
Menu
Menu
Menu
Background: Increasing access to maternal and child health (MCH) services is crucial to achieving universal health coverage (UHC) among pregnant women and children under-five (CU5). The Nigerian government between 2012 and 2015 implemented an innovative MCH programme to reduce maternal and CU5 mortality by reducing financial barriers of access to essential health services. The study explores how the implementation of a financial incentive through conditional cash transfer (CCT) influenced the uptake of MCH services in the programme. Methods: The study used a descriptive exploratory approach in Anambra state, southeast Nigeria. Data was collected through qualitative [in-depth interviews (IDIs), focus group discussions (FGDs)] and quantitative (service utilization data pre- and post-programme) methods. Twenty-six IDIs were conducted with respondents who were purposively selected to include frontline health workers (n = 13), National and State policymakers and programme managers (n = 13). A total of sixteen FGDs were conducted with service users and their family members, village health workers, and ward development committee members from four rural communities. We drew majorly upon Skinner’s reinforcement theory which focuses on human behavior in our interpretation of the influence of CCT in the uptake of MCH services. Manual content analysis was used in data analysis to pull together core themes running through the entire data set. Results: The CCTs contributed to increasing facility attendance and utilization of MCH services by reducing the financial barrier to accessing healthcare among pregnant women. However, there were unintended consequences of CCT which included a reduction in birth spacing intervals, and a reduction of trust in the health system when the CCT was suddenly withdrawn by the government. Conclusion: CCT improved the utilization of MCH, but the sudden withdrawal of the CCT led to the opposite effect because people were discouraged due to lack of trust in government to keep using the MCH services. Understanding the intended and unintended outcomes of CCT will help to build sustainable structures in policy designs to mitigate sudden programme withdrawal and its subsequent effects on target beneficiaries and the health system at large.
This study was undertaken in Anambra State, southeast Nigeria. Anambra state was chosen as a case study for in-depth understanding of the inquiry into the CCT component of SURE-P/MCH programme. The state has a population of about 4.1 million and has a mix of urban and rural areas. MCH services are primarily provided from the Primary Health Centres (PHCs), each of which covers a given catchment population. In the context of the SURE-P/MCH programme, four PHCs are linked to a named general hospital for referral of Emergency Obstetric Complications (EOCs), and this is referred to as a cluster (4 PHCs +1 General hospital). Four PHC implemented the CCT programme in the State. However, there are some trained (maternity homes) and untrained (TBAs, Patent medicine Vendors) services who also offer unmonitored MCH provision. The CCT intervention was originally designed to be administered using the above design as outlined in Figure 1. In practice, during implementation, beneficiaries only received money after their attendance of each service has been logged and verified, sometimes the length of this verification process meant that they were paid lump sums at the end of the delivery (28). This was a 5-year multi-phased mixed-methods retrospective study in which various components of the intervention were evaluated to provide a conceptual information on the process (including barriers and enablers) that underlie the effect of CCTs on the uptake of health services. Qualitative data collection and secondary quantitative analysis of routinely collected administrative and CCT data were used to enable adequate triangulation and an in-depth and rich description of findings. CCT is a fairly new initiative in the country at the time and was initiated as a pilot intervention (28). The full methodology protocol is explained in detail elsewhere (29). This paper focuses one component (CCT intervention) of the wider study which was carried out in four (4) out of the 12 PHCs that implemented the programme. Qualitative data [document reviews, in-depth interviews (IDIs) and focus group discussions] and quantitative methods [service utilization data from the Health Information Management System (HMIS)] were collected to cover pre-, during and post-SURE P/MCH programme. All the data collection tools/guides (Additional file 1) were developed by the researchers for the purpose of the study. Document reviews of relevant contextual literature were carried out. A logic map (30), of the expected process of programme interventions and how these could lead to outcomes was also developed. In-depth interviews of relevant stakeholders on both demand and supply-side were conducted to explore various dimensions of the CCT component of this programme and stakeholders’ experiences in implementing CCT in the selected health facilities. The SURE-P/MCH intervention was carried out in three health facility clusters, all three had the MCH interventions and only one had an additional CCT intervention. For this study, we purposively selected the SURE-P/MCH + CCT cluster within the larger project which is the focus of our study. The respondents were purposively recruited from these facilities to include the facility managers (n = 4) and other health workers (Midwives and CHEWs) (n = 9). On the demand side, we also conducted four FGDs (6-8 participants per group) with service users (pregnant women who had received/were receiving maternal care services at the time of the study), and four FGDs with Village Health Workers (VHWs) (4-6 participants per group). The VHWs who were members of the communities were responsible for identifying pregnant women in their community and encouraging them to attend and use health care facilities. VHWs also assisted the women in registering for antenatal care (ANC) and enrolment into the CCT registers. We also had four FGDs with the family members of service users (6-8 participants per group), and four FGDs with the ward development committee (WDC) members (5-10 participants per group), who are community representatives that oversee the functioning of the facilities. National and State-level policymakers and programme managers (n = 13), who were either involved in the design or administration of the CCT intervention were also interviewed. These groups of respondents were interviewed by experienced researchers about their experiences of the CCT intervention from their various perspectives. Each interview was audio recorded, and handwritten notes were taken. Interviews and discussion were conducted at places convenient for the respondents/participants including health facilities, offices, village halls, and houses. Each interview lasted for an average of 60 min. Prior to commencement of the data collection a relationship was established with some of the respondents during the research project planning meetings and mobilization phase of data collection. The quality of data collection 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. Secondary data on facility attendance and utilization from 2012 to 2017 were also collected from the facility Health Management Information System (HMIS) using a standardized pro forma developed for the study. Data was collected from registers stored in the facilities, and from monthly utilization data summaries sent to the local government authorities. The indicators collected include attendance for ANC, facility delivery, child immunization, post-natal care, and family Planning. To understand how CCT influences utilization of MCH services we drew majorly upon Skinner’s (1957) reinforcement theory which focuses on human behavior in our interpretation of the influence of CCT in the uptake of MCH. According to the theory, behavior is a “function of its consequences,” which implies that desirable behavior can be increased through the positive reinforcement technique or rewards. The reinforcers could be financial or non-financial (31, 32). The theory proposes that someone’s behavior could be influenced by using reinforcement, punishment, and extinction. The key concept of the theory is “reinforcement,” “punishment,” and “extinction.” Skinner, stated that rewards used to reinforce the desired behavior, punishments are used to avert undesirable behavior while extinction means to terminate a learned behavior. Skinner classified reinforcement into positive and negative reinforcement. The positive reinforcement occurs when the consequence resulting in the behavior one is trying to produce increases the probability that the desired behavior will continue. On the other hand, negative reinforcement is when a negative consequence is withheld if undesired behavior is demonstrated, which will increase the likelihood that the behavior you are seeking out for will continue. Punishment occurs when you enforce a negative consequence to decrease undesirable behavior. While negative reinforcement involves withholding a negative consequence to encourage desirable behavior, punishment is imposing a negative consequence to discourage unwanted behavior. The third concept; extinction trick up Operant Conditioning’s sleeve which tries to attempt to terminate a learned behavior by withdrawing the positive reinforcement that stimulated the desired behavior. In this paper, the theory has utility in explaining the use of CCT as a financial reinforcement that stimulates pregnant women’s decision to register for and utilize MCH services as well as deliver in health facilities. The extinction concept explains the sudden withdrawal of CCT leading to a reduction in attendance and utilization of MCH services among pregnant women. The desired learned behavior for MCH uptake among pregnant women in the implementing facilities was extinguished although not completely. Similarly, Motivation Crowding Theory reflects on the impact/effect of withdrawal of the monetary incentives in community perceptions of society and motivation. It suggests that discounting monetary incentives of a programme lead to a reduction in intrinsic motivation and, consequently decrease zeal/effort to engage in a task or role (33). The study used manual content analysis approach. Audio files were first transcribed in the language of the interview, and then translated to English language, where necessary. Initially two FGD and IDI transcripts with rich information were selected for thorough study and coding. Key themes relating to CCT and its influence on utilization of MCH services were generated and this formed the initial coding scheme. The scheme was then tested on four new transcripts (two FGD and IDI each) and refined into a final coding scheme which was then applied to all the transcripts. After which, related codes were grouped into four broad themes, which were used in interpreting and reporting the findings. The themes identified were: process of payment of CCT; facility attendance and utilization of MCH services; unintended consequences of the provision of CCT and; sustainability of CCT as a strategy for uptake of MCH services. The secondary analysis of MCH facility data monthly HMIS data on key MCH indicators were analyzed using SPSS. All were measured as counts per facility across the SURE-P/CCT cluster: (1) total antenatal clinic (ANC) visits (the total number of women that month who visited the PHC for any ANC meeting); (2) total postnatal clinic (PNC) visits, (the total number of women that month who visited the PHC for any PNC meeting) and; (3) number of deliveries taken by a skill birth attendant. Frequencies and simple bar-chart were used for representing the results.
N/A
