Maia Sieverding

A Systematic Review of the Role of Proprietary and Patent Medicine Vendors in Healthcare Provision in Nigeria

Background Interventions to reduce the burden of disease and mortality in sub-Saharan Africa increasingly recognize the important role that drug retailers play in delivering basic healthcare services. In Nigeria, owner-operated drug retail outlets, known as patent and proprietary medicine vendors (PPMVs), are a main source of medicines for acute conditions, but their practices are not well understood. Greater understanding of the role of PPMVs and the quality of care they provide is needed in order to inform ongoing national health initiatives that aim to incorporate PPMVs as a delivery mechanism. Objective and Methods This paper reviews and synthesizes the existing published and grey literature on the characteristics, knowledge and practices of PPMVs in Nigeria. We searched published and grey literature using a number of electronic databases, supplemented with website searches of relevant international agencies. We included all studies providing outcome data on PPMVs in Nigeria, including non-experimental studies, and assessed the rigor of each study using the WHO-Johns Hopkins Rigor scale. We used narrative synthesis to evaluate the findings. Results We identified 50 articles for inclusion. These studies provided data on a wide range of PPMV outcomes: training; health knowledge; health practices, including drug stocking and dispensing, client interaction, and referral; compliance with regulatory guidelines; and the effects of interventions targeting PPMVs. In general, PPMVs have low health knowledge and poor health treatment practices. However, the literature focuses largely on services for adult malaria, and little is known about other health areas or services for children. Conclusions This review highlights several concerns with the quality of the private drug retail sector in Nigeria, as well as gaps in the existing evidence base. Future research should adopt a more holistic view of the services provided by PPMV shops, and evaluate intervention strategies that may improve the services provided in this sector.

Differences in malaria care seeking and dispensing outcomes for adults and children attending drug vendors in Nasarawa, Nigeria.

To characterise the differences in care seeking behaviour and dispensing outcomes between adults and children purchasing drugs for malaria at retail shops in Nigeria.

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya

Background Incorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers’ perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa—the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya. Methods In-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers’ reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically. Results Most providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers’ participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana. Conclusions In expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

Integrating informal providers into a people-centered health systems approach: qualitative evidence from local health systems in rural Nigeria

BackgroundThe presence of a large informal healthcare sector in many low- and middle-income countries poses both challenges and opportunities for achieving a people-centered health system. However, few studies have considered how informal providers may fit into a people-centered health systems approach. We examine the self-described roles and motivations of informal medicine vendors and public healthcare workers in rural Nigeria, as well as interactions between them, with the aim of identifying how local health systems may be reoriented for improved service delivery through a people-centered approach.MethodsWe analyzed data from in-depth interviews with 70 medicine vendors and 21 staff of public health facilities in 30 villages across Kogi, Kwara and Enugu states in Nigeria. Interview guides covered the respondent’s or her facility’s role in providing health services to the local community, motivation to work in her respective profession, and relationships and interactions with other frontline healthcare providers. Data were analyzed in Atlas.ti using an open coding approach.ResultsBoth medicine vendors and staff of public health facilities viewed themselves as fulfilling an essential primary healthcare function in their villages, and described their main motivation as the desire to help their communities. Medicine vendors were acknowledged by both groups to play an important role in providing care close to underserved rural communities, but within a limited scope of practice. Vendors described referring cases beyond their self-defined capacity to the local public facility. Health facility staff also sent clients to vendors to purchase drugs that were out of stock. However, referrals were informal and unspecific in nature, and the degree to which relationships between vendors and health facility staff were collaborative was highly context-dependent despite their recognized interdependencies in health services provision.ConclusionsPolicies aimed at fostering people-centered health systems should consider the role of informal providers in the delivery of integrated care. In the context of our rural study sites in Nigeria, supporting stronger and more consistent linkages between medicine vendors and public health facilities is a key step towards improving health service delivery.

The mental health of youth and young adults during the transition to adulthood in Egypt

BACKGROUND There has been growing interest in the stalled transition to adulthood in the Middle East and North Africa (MENA) and its consequences for young people’s socioeconomic outcomes. However, little is known about how important life transitions relate to youth psychosocial well-being in the region. OBJECTIVE Drawing on a life course framework, we estimate the associations between making transitions in education, employment, and marriage with changes in mental health among young people in Egypt. METHODS We descriptively analyze mental health scores, measured via the Self-Reporting Questionnaire-20 and disaggregated by gender, for a panel of young people first surveyed in 2009 at ages 13–29 and followed up in late 2013 and early 2014. We regress change in mental health scores against indicators of making different transitions. RESULTS Young women experience worse mental health than young men overall. Lower school achievement was associated with poorer mental health; being out of the labor force was an additional risk factor for young men. While average mental health scores improved over time, over a quarter of the sample experienced worsening mental health, related to failure to marry and find a job among older men, and failure to finish schooling among younger women. CONCLUSIONS Mental health is an important but often overlooked component of youth well-being during the transition to adulthood in MENA, and potentially other low- and middle-income countries. CONTRIBUTION This is the first paper to empirically examine the relationship between psychosocial well-being and achieving important socioeconomic milestones among a nationally representative cohort of young people in MENA.

Improved water and child health in Egypt: impact of interrupted water supply and storage of household water on the prevalence of diarrhoea.

Egypt is approaching universal access to improved water supply, but the variable quality of improved water may have a measureable health impact. We investigated the impact of different measures of improved water access on the prevalence of diarrhoea among children aged under 5 years. Using data from the 2008 Egypt Demographic and Health Survey and propensity score matching techniques we compared children in households with improved water supplies, with/without interruptions to supplies and with/without in-home storage of water. Access to improved water that was not subject to cuts resulted in a significant 2.6 percentage point reduction in the prevalence of diarrhoea (4.7% reduction in rural areas), and access to improved water that was not stored prior to use resulted in a 3.5% reduction. Further research is needed to better understand the nature and causes of piped water interruptions in Egypt, in order to address potential infrastructure challenges that are leading to poorer health outcomes.

Youth Perspectives on Social Insurance in Egypt: Qualitative Insights on the Gap between Legal and Effective Coverage

A gap between legal and effective coverage rates is a common challenge facing social insurance systems in Low‐ and Middle‐Income Countries. This article draws on an exploratory qualitative study with youth in Egypt to examine how labour market dynamics and worker preferences contribute to this gap. Labour market factors, particularly instability of employment and job mobility, were found to reduce the perceived value of social insurance. Poor understanding of how social insurance works was another contributing factor. However, youth displayed a high level of trust in the public social insurance system and saw pensions as valuable in the abstract. In combination with awareness promotion, eliminating penalties to discontinuous labour force participation could make social insurance more attractive to youth.