Josephine Exley

The effect of increasing the supply of skilled health providers on pregnancy and birth outcomes: evidence from the midwives service scheme in Nigeria

BackgroundLimited availability of skilled health providers in developing countries is thought to be an important barrier to achieving maternal and child health-related MDG goals. Little is known, however, about the extent to which scaling-up supply of health providers will lead to improved pregnancy and birth outcomes. We study the effects of the Midwives Service Scheme (MSS), a public sector program in Nigeria that increased the supply of skilled midwives in rural communities on pregnancy and birth outcomes.MethodsWe surveyed 7,104 women with a birth within the preceding five years across 12 states in Nigeria and compared changes in birth outcomes in MSS communities to changes in non-MSS communities over the same period.ResultsThe main measured effect of the scheme was a 7.3-percentage point increase in antenatal care use in program clinics and a 5-percentage point increase in overall use of antenatal care, both within the first year of the program. We found no statistically significant effect of the scheme on skilled birth attendance or on maternal delivery complications.ConclusionThis study highlights the complexity of improving maternal and child health outcomes in developing countries, and shows that scaling up supply of midwives may not be sufficient on its own.

Evaluation of telephone first approach to demand management in English general practice: observational study

Objective To evaluate a “telephone first” approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation. Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data. Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England. Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies. Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies’ protocols. Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices −38%, 95% confidence interval −45% to −29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval −1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs. Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.

Better Obstetrics in Rural Nigeria study: evaluating the Nigerian Midwives Service Scheme

This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RANDs publications do not necessarily reflect the opinions of its research clients and sponsors. R® is a registered trademark. iii Preface Limited availability of skilled providers, particularly in rural areas, is thought to be an important constraint to increasing rates of use of maternal and child health services in low-and middle-income countries. There are, however, few well-identified studies of the relationship between the supply of skilled workers and outcomes. In this project, we studied the effects of a government program in Nigeria that sought to alleviate supply-side constraints by deploying skilled midwives to primary health facilities in rural communities to provide round-the-clock access to skilled care. The contents of this report will be of interest to policymakers and public health professionals interested in improving maternal and child health. Summary We evaluate the impact of the Midwives Service Scheme (MSS), a government program introduced in 2009 to increase access to skilled care in rural underserved areas in Nigeria. At rollout, the MSS deployed nearly 2,500 midwives to 652 primary health care centers across 36 states. To evaluate the impact of the program, we surveyed 7,104 women with a birth within the preceding five years in 386 communities across 12 states. The intervention group consisted of communities that participated in the initial rollout; the comparison group consisted of communities that would later receive the program (approximately three years later). To understand implementation challenges and contextualize the quantitative results, we carried out a nested qualitative study in three states, consisting of in-depth interviews and focus group discussions with policymakers, providers, childbearing women, and community stakeholder groups. Overall, we find that the programs effects are smaller than anticipated. The main effect is a 7.3-percentage-point increase in antenatal …

Tele-First. Evaluation of a ‘telephone first’ approach to demand management in English general practice: observational study

The study was funded by the National Institute for Health Research (HS&DR Project 13/59/40).

Going to scale: design and implementation challenges of a program to increase access to skilled birth attendants in Nigeria

BackgroundThe lack of availability of skilled providers in low- and middle- income countries is considered to be an important barrier to achieving reductions in maternal and child mortality. However, there is limited research on programs increasing the availability of skilled birth attendants in developing countries. We study the implementation of the Nigeria Midwives Service Scheme, a government program that recruited and deployed nearly 2,500 midwives to rural primary health care facilities across Nigeria in 2010. An outcome evaluation carried out by this team found only a modest impact on the use of antenatal care and no measurable impact on skilled birth attendance. This paper draws on perspectives of policymakers, program midwives, and community residents to understand why the program failed to have the desired impact.MethodsWe conducted semi-structured interviews with federal, state and local government policy makers and with MSS midwives. We also conducted focus groups with community stakeholders including community leaders and male and female residents.ResultsOur data reveal a range of design, implementation and operational challenges ranging from insufficient buy-in by key stakeholders at state and local levels, to irregular and in some cases total non-provision of agreed midwife benefits that likely contributed to the program’s lack of impact. These challenges not only created a deep sense of dissatisfaction with the program but also had practical impacts on service delivery likely affecting households’ uptake of services.ConclusionThis paper highlights the challenge of effectively scaling up maternal and child health interventions. Our findings emphasize the critical importance of program design, particularly when programs are implemented at scale; the need to identify and involve key stakeholders during planning and implementation; the importance of clearly defining lines of authority and responsibility that align with existing structures; and the necessity for multi-faceted interventions that address multiple barriers at the same time.

Evaluation of the UCLH-Macmillan Partnership to deliver improvements in the care, treatment, support, and information to patients with cancer throughout their individual journeys

The authors would like to thank those individuals across the two partnership organisations for their support throughout this study, in particular, Nikki Cannon, Tatyana Guveli, Nick Kirby, Hilary Plant, Amanda Quincey, David Salisbury and Jo Swiecicka. As part of the study we engaged with a wide range of stakeholders involved in the partnership and delivery of cancer care at UCLH. We would like to thank them all for generously donating their time to participate in our study. Dr Ellen Nolte provided insight and inspiration at the start of this evaluation before taking up her current position at the European Observatory on Health Systems and Policies. Finally, we gratefully acknowledge the helpful, and insightful, comments provided by Professor Martin Roland and Dr Stephen Barclay, who acted as the quality assurance reviewers for this report.

Persistent barriers to care; a qualitative study to understand women’s experiences in areas served by the midwives service scheme in Nigeria

BackgroundThe Nigerian Midwives Service Scheme (MSS) is an ambitious human resources project created in 2009 to address supply side barriers to accessing care. Key features include the recruitment and deployment of newly qualified, unemployed and retired midwives to rural primary healthcare centres (PHCs) to ensure improved access to skilled care. This study aimed to understand, from multiple perspectives, the views and experiences of childbearing women living in areas where it has been implemented.MethodsA qualitative study was undertaken as part of an impact evaluation of the MSS in three states from three geo-political regions of Nigeria. Semi-structured interviews were conducted around nine MSS PHCs with women who had given birth in the past six months, midwives working in the PHCs and policy makers. Focus group discussions were held with wider community members. Coding and analysis of the data was performed in NVivo10 based on the constant comparative approach.ResultsThe majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a PHC, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principle reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care.ConclusionsOur research highlights a number of barriers to accessing care exist, which are likely to have limited the potential for the MSS to have an impact. It suggests that in addition to scaling up the workforce through the MSS, efforts are also needed to address the determinants of care seeking. For the MSS this means that the while the supply side, through the provision of skilled attendance, still needs to be strengthened, this should not be in isolation of addressing demand-side factors.

Not that different or just not measurable? The contribution of health care to changes in population health outcomes in the UK before and after devolution

Abstract Background The extent to which health care makes a difference to population health outcomes continues to be debated among researchers and practitioners alike. The National Health Service (NHS) in the UK provides an important natural experiment to study this association. In this study we aimed to quantify it using mortality from causes considered amenable to health care (amenable mortality), assessing trends before and after political devolution in 2000 in the four countries of the UK. Methods We assessed pre-devolution (1990–2000) and post-devolution (2000–12) trends in age-standardised death rates from amenable mortality among those aged 0–64 years, 65–74, and 0–74. We estimated absolute change over 1990–2012 by fitting a linear regression and relative change as the average annual percentage change. We fitted a Poisson regression model to estimate relative risk (RR) of amenable death rates between given timepoints. Findings Between 1990 and 2012, amenable mortality per 100 000 was highest in Scotland and lowest in England for both men and women; death rates fell in all countries, and the change accelerated after devolution. During 1990–2000, the greatest decline was seen in Northern Ireland (men RR 0·66, 95% CI 0·53–0·81; women 0·66, 0·53–0·81), and the lowest was seen in Wales (0·70, 0·56–0·87 and 0·74, 0·57–0·95, respectively). Similar patterns were seen during 2000–12, although the declines were larger than those for 1990–2000 in all four countries among both men and women, ranging from 0·50 (0·38–0·67) in Northern Ireland to 0·56 (0·43–0·74) in Wales (women in Northern Ireland 0·50, 0·36–0·69 and Scotland 0·65, 0·48–0·87). As a result of these mortality trends, differences in levels of amenable mortality between England and the other three countries narrowed between 1990 and 2012. Interpretation This study suggests that different NHS policies associated with political devolution has had little measurable effect on population health outcomes as measured by amenable mortality. An acceleration of the decline in amenable mortality since 2000 in all four countries might be indicative of an increase in the availability of resources for health care in each system. Funding Part funded by the Nuffield Trust and the Health Foundation.