Background: In 2005, Nigeria adopted the Reach Every Ward strategy to improve vaccination coverage for children, 0-23 months. By 2015, Ogun state had full coverage in 12 of its 20 local government areas but eight had pockets of unimmunized children, with the highest burden (37%) in Remo-North. This study aimed to identify factors in Remo-North influencing the use of immunization services, in order to inform intervention approaches to tackle barriers to immunization utilization. Methods: We carried out a cross-sectional study using mixed methods including a survey of caregivers of 215 children, 25 semi-structured interviews with stakeholders involved in immunization service delivery and 16 focus group discussions with community men and women (n = 98). Two wards (Ilara and Ipara) were purposively chosen for the study. Data was analyzed using the SAGE Working Group Vaccine Hesitancy model. Results: Only 56 children (32.6%) of the 172 children over 9 months of age had immunization cards available for inspection. Of these, 23 (59.6%) were fully immunized, noticeably higher in Ipara than Ilara. However, when immunization status was assessed by card and recall, 84.9% of the children were assessed as fully immunized. Caregivers in the more rural Ilara had less knowledge of vaccine schedules. The importance of all doses was recognized more by Ipara respondents (95.5%) than in Ilara (75.3%) (p < 0.05). Community links to immunization and household decision-making patterns influenced immunization use in both wards. Migrants and those living in hard-to-reach areas were disadvantaged in both wards. Health service factors like absence of delivery services, shortage of health workers, unavailability of vaccines at scheduled times, and indirect costs of immunization contributed to low utilization. Conclusion: Immunization utilization was influenced by interlinked community and health services issues. Intervention approaches should ensure that communities' priorities are addressed, actors at both levels involved and strategies are adjusted to suit contexts.

BackgroundPerformance based financing (PBF) has been increasingly implemented across low and middle-income 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.MethodsOur 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.ResultsOur 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.ConclusionsOur 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.Electronic supplementary materialThe online version of this article (10.1186/s13031-018-0166-9) contains supplementary material, which is available to authorized users.

BackgroundThe setting of realistic performance-based financing rewards necessitates not just knowledge of health workers’ salaries, but of the revenue that accrues from their additional income-generating activities. This study examined the coping mechanisms of health workers in the public health sector of Nasarawa and Ondo states in Nigeria to supplement their salaries and benefits; it also estimated the proportionate value of the revenues from those coping mechanisms in relation to the health workers’ official incomes.MethodsThis study adopted a mixed-methods approach, consisting of semi-structured interviews, a review of policy documents, a survey using self-administered questionnaires, and the randomized response technique (RRT). In all, 170 health workers (86 in Ondo, 84 in Nasarawa) participated in the survey. In-depth interviews were conducted with 24 health workers (12 per state) and nine policy makers from both states.ResultsThe health workers perceived their salaries as inadequate, though most policy makers differed in this assessment. There appeared to be a considerable expenditure–income disparity among the respondents. Approximately 56% (n = 93) of the study population reported having additional earning arrangements: most reported non-medical activities such as farming and trading, but private practice was also frequently reported.Half of the respondents with additional earning arrangements stated that their income from those activities was the equivalent of half or more of their monthly salaries. Specifically, 35% (n = 32) said that they earned about half of their official monthly salaries and 15% (n = 14) reported earning the same or more than their monthly salaries from these activities. Other coping mechanisms used by the health workers included prioritizing activities that enabled the earning of per diems, collecting informal payments and gifts from patients, and pilfering drugs from facilities.ConclusionsPredatory and non-predatory mechanisms accounted for the health workers’ additional income. It may be difficult for the health workers to meet their expenses with their salaries and financial incentives; this highlights the need for the regulation of additional earnings and to implement targeted accountability mechanisms. This study indicates the value of using mixed methods when investigating sensitive issues. Future studies of this type should employ mixed methods for triangulation purposes to provide better insight into health workers’ responses.

BackgroundThe ‘human resources for health’ crisis has highlighted the need for more health (care) professionals and led to an increased interest in health professional education, including master’s degree programmes. The number of these programmes in low- and middle-income countries (LMIC) is increasing, but questions have been raised regarding their relevance, outcome and impact. We conducted a systematic review to evaluate the outcomes and impact of health-related master’s degree programmes.MethodsWe searched the databases Scopus, Pubmed, Embase, CINAHL, ERIC, Psychinfo and Cochrane (1999 - November 2011) and selected websites. All papers describing outcomes and impact of health-related Master programmes were included. Three reviewers, two for each article, extracted data independently. The articles were categorised by type of programme, country, defined outcomes and impact, study methods used and level of evidence, and classified according to outcomes: competencies used in practice, graduates’ career progression and impact on graduates’ workplaces and sector/society.ResultsOf the 33 articles included in the review, most originated from the US and the UK, and only one from a low-income country. The programmes studied were in public health (8), nursing (8), physiotherapy (5), family practice (4) and other topics (8). Outcomes were defined in less than one third of the articles, and impact was not defined at all. Outcomes and impact were measured by self-reported alumni surveys and qualitative methods. Most articles reported that competencies learned during the programme were applied in the workplace and alumni reported career progression or specific job changes. Some articles reported difficulties in using newly gained competencies in the workplace. There was limited evidence of impact on the workplace. Only two articles reported impact on the sector. Most studies described learning approaches, but very few described a mechanism to ensure outcome and impact of the programme.ConclusionsEvidence suggests that graduates apply newly learned competencies in the field and that they progress in their career. There is a paucity of well-designed studies assessing the outcomes and impact of health-related master’s degree programmes in low- and middle-income countries. Studies of such programmes should consider the context and define outcomes and impact.