The community is just a small circle: citizen participation in the free maternal and child healthcare programme of Enugu State, Nigeria

Abstract

Background: There is a gap in knowledge about how citizen participation impacts governance of free healthcare policies for universal health coverage in low- and middle-income countries. Objective: This study provides evidence about how social accountability initiatives influenced revenue generation, pooling and fund management, purchasing and capacity of health facilities implementing the free maternal and child healthcare programme (FMCHP) in Enugu State, Nigeria. Methods: The study adopted a descriptive, qualitative case-study design to explore how social accountability influenced implementation of the FMCHP at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected from policymakers (n = 16), providers (n = 16) and health facility committee leaders (n = 12) through in-depth interviews. We also conducted focus-group discussions (n = 4) with 42 service users and document review. Data were analysed using thematic analysis. Results: It was found that health facility committees (HFCs) have not been involved in the generation of funds, fund management and tracking of spending in FMCHP. The HFCs did not also seem to have increased transparency of benefits and payment of providers. The HFCs emerged as the dominant social accountability initiative in FMCHP but lacked power in the governance of free health services. The HFCs were constrained by weak legal framework, ineffectual FMCHP committees at the state and district levels, restricted financial information disclosure, distrustful relationships with policymakers and providers, weak patient complaint system and low use of service charter. Conclusion: The HFCs have not played a significant role in health financing and service provision in FMCHP. The gaps in HFCs’ participation in health financing functions and service delivery need to be considered in the design and implementation of free maternal and child healthcare policies that aim to achieve universal health coverage.

Implementation of free maternal and child healthcare policies: assessment of influence of context and institutional capacity of health facilities in South-east Nigeria

“…HFCs could have also established complaint boxes, displayed service charters and created awareness about usefulness of service charters in holding providers accountable. These gaps in the roles of HFCs provide insights into the potential of citizen participation for the improvement of free health services as has been argued in a previous study [49]. It would be imperative to train and mentor HFCs and health care providers on the mandate of HFCs within the FMCHP policy to ensure that health facilities implement changes to the free care programme based on concerns raised by citizens [53].…”

“…We categorised the seven health districts into two groups of three well-performing and four less-well-performing districts using provider payment data over five years (2009–2014), which ranged from 2% to 26% with a median of 14% serving as the cut-off point [46,49]. We used provider payment data for the categorisation, because the health information management system does not disaggregate maternal and child health utilisation by user fee and fee-exempt.…”

Scaling-up strategic purchasing: analysis of health system governance imperatives for strategic purchasing in a free maternal and child healthcare programme in Enugu State, Nigeria

“…The state-level policymakers ( n  = 12) were purposively selected from the Ministry of Health based on availability and willingness to participate in the study. The seven health districts were divided into two clusters of well-performing and poor-performing districts based on reimbursement of providers [28]. One district was selected from each cluster by simple random sampling.…”

“…We interviewed 44 participants between February and September 2015 using pre-tested, in-depth, semi-structured interview guide (for details see Additional file 1) as a part of large assessment of governance of the FMCHP [28]. The interview questions were informed by the Siddiqi and colleagues’ governance framework [19], adapted to purchasing concerns in the FMCHP (Table 2).…”

“…Enugu State, Nigeria, introduced tax-funded free maternal and child healthcare programme (FMCHP) in December 2007 to improve use of primary health care, ensure that households are protected against the financial risk of obtaining essential maternal and child healthcare and reduce maternal and child mortality [1]. A striking feature of the FMCHP is a mutually co-existing two-tier public health system - free maternal and child healthcare services are obtained exclusively from publicly owned health facilities in a system that usually charges user fees.…”