03. Journals
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These are journal articles published in World Bank journals as well as externally by World Bank authors.
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Publication
Looking into the performance-based financing black box: Evidence from an impact evaluation in the health sector in Cameroon
(Oxford University Press, 2021-07)Performance-based financing (PBF) is a complex health systems intervention aimed at improving the coverage and quality of care. Several studies have shown a positive impact of PBF on health service coverage, often coupled with improvements in quality, but relatively little is known about the mechanisms driving those results. This article presents results of a randomized impact evaluation in Cameroon designed to isolate the role of specific components of the PBF approach with four study groups: (i) PBF with explicit financial incentives linked to results, (ii) direct financing with additional resources available for health providers not linked to performance, (iii) enhanced supervision and monitoring without additional resources and (iv) a control group. Overall, results indicate that, when compared with the pure control group, PBF in Cameroon led to significant increases in utilization for several services (child and maternal vaccinations, use of modern family planning), but not for others like antenatal care visits and facility-based deliveries. In terms of quality, PBF increased the availability of inputs and equipment, qualified health workers, led to a reduction in formal and informal user fees but did not affect the content of care. However, for many positively impacted outcomes, the differences between the PBF group and the group receiving additional financing not linked to performance are not significant, suggesting that additional funding rather than the explicit incentives might be driving improvements. In contrast, the intervention group offering enhanced supervision, coaching and monitoring without additional funding did not experience significant impacts compared to the control group. -
Publication
Disruptions in Maternal and Child Health Service Utilization during COVID-19: Analysis from Eight Sub-Saharan African Countries
(Oxford University Press, 2021-06-19)The coronavirus-19 pandemic and its secondary effects threaten the continuity of essential health services delivery, which may lead to worsened population health and a protracted public health crisis. We quantify such disruptions, focusing on maternal and child health, in eight sub-Saharan countries. Service volumes are extracted from administrative systems for 63 954 facilities in eight countries: Cameroon, Democratic Republic of Congo, Liberia, Malawi, Mali, Nigeria, Sierra Leone and Somalia. Using an interrupted time series design and an ordinary least squares regression model with facility-level fixed effects, we analyze data from January 2018 to February 2020 to predict what service utilization levels would have been in March–July 2020 in the absence of the pandemic, accounting for both secular trends and seasonality. Estimates of disruption are derived by comparing the predicted and observed service utilization levels during the pandemic period. All countries experienced service disruptions for at least 1 month, but the magnitude and duration of the disruptions vary. Outpatient consultations and child vaccinations were the most commonly affected services and fell by the largest margins. We estimate a cumulative shortfall of 5 149 491 outpatient consultations and 328 961 third-dose pentavalent vaccinations during the 5 months in these eight countries. Decreases in maternal health service utilization are less generalized, although significant declines in institutional deliveries, antenatal care and postnatal care were detected in some countries. There is a need to better understand the factors determining the magnitude and duration of such disruptions in order to design interventions that would respond to the shortfall in care. Service delivery modifications need to be both highly contextualized and integrated as a core component of future epidemic response and planning. -
Publication
Exploring Behavioral Competencies for Effective Medical Practice in Nigeria
(Sage Publications, 2020-12-01)Clinical performance varies due to academic, clinical, and behavioral factors. However, in many countries, selection of medical professionals tends to focus on exclusively academic ability and clinical acumen. Appropriate selection processes for medical professionals should consider behavioral factors, which may vary across contexts. This study was conducted to identify behavioral competencies considered relevant for effective medical practice in Nigeria, by medical students and doctors, and compared with other contexts. This study is one of the few to examine the perspectives of medical students and physicians on behavioral competencies for effective medical practice in an African country. We found differences in the perspectives of medical physicians and students, and in the prioritized competencies across countries. Our study illustrates the need for careful consideration in identifying subject matter experts and in generalizing competencies across contexts. Future research in this field in Nigeria should examine effective ways of testing for key behavioral competencies among medical students and for residency programs. Also, investigating the perspectives of medical faculty and administrators on important competencies, and exploring the generalizability of these competencies across cultures in Nigeria should be considered. -
Publication
Death Registration in Nigeria: A Systematic Literature Review of its Performance and Challenges
(Taylor and Francis, 2020-09-07)Death registration provides an opportunity for the legal documentation of death of persons. Documentation of deaths has several implications including its use in the recovery of inheritance and insurance benefits. It is also an important input for construction of life tables which are crucial for national planning. However, the registration of deaths is poor in several countries including Nigeria. This paper describes the performance of death registration in Nigeria and factors that may affect its performance. We conducted a systematic literature review of death registration completeness in Nigeria to identify, characterize issues as well as challenges associated with realizing completeness in death registration. Only 13.5% of deaths in Nigeria were registered in 2007 which regressed to 10% in 2017. There was no data reported for Nigeria in the World Health Organization database between 2008 and 2017. The country scored less than 0.1 (out of a maximum of 1) on the Vital Statistics Performance Index. There are multiple institutions with parallel constitutional and legal responsibilities for death registration in Nigeria including the National Population Commission, National Identity Management Commission and Local Government Authorities, which may be contributing to its overall poor performance. -
Publication
Quality of Clinical Assessment and Child Mortality: A Three-Country Cross-Sectional Study
(Oxford University Press, 2020-06)This analysis describes specific gaps in the quality of health care in Central Africa and assesses the association between quality of clinical care and mortality at age 2–59 months. Regionally representative facility and household surveys for the Democratic Republic of the Congo, Cameroon and Central African Republic were collected between 2012 and 2016. These data are novel in linking facilities with households in their catchment area. Compliance with diagnostic and danger sign protocols during sick-child visits was observed by trained assessors. We computed facility- and district-level compliance indicators for patients aged 2–59 months and used multivariate multi-level logistic regression models to estimate the association between clinical assessment quality and mortality at age 2–59 months in the catchment areas of the observed facilities. A total of 13 618 live births were analysed and 1818 sick-child visits were directly observed and used to rate 643 facilities. Eight percent of observed visits complied with 80% of basic diagnostic protocols, and 13% of visits fully adhered to select general danger sign protocols. A 10% greater compliance with diagnostic protocols was associated with a 14.1% (adjusted odds ratio (aOR) 95% CI: 0.025–0.244) reduction in the odds of mortality at age 2–59 months; a 10% greater compliance with select general danger sign protocols was associated with a 15.3% (aOR 95% CI: 0.058–0.237) reduction in the same odds. The results of this article suggest that compliance with recommended clinical protocols remains poor in many settings and improvements in mortality at age 2–59 months could be possible if compliance were improved. -
Publication
Predicting Dynamic Patterns of Short-Term Movement
(Published by Oxford University Press on behalf of the World Bank, 2020-02)Short-term human mobility has important health consequences, but measuring short-term movement using survey data is difficult and costly, and use of mobile phone data to study short-term movement is only possible in locations that can access the data. Combining several accessible data sources, Senegal is used as a case study to predict short-term movement within the country. The focus is on two main drivers of movement—economic and social—which explain almost 70 percent of the variation in short-term movement. Comparing real and predicted short-term movement to measure the impact of population movement on the spread of malaria in Senegal, the predictions generated by the model provide estimates for the effect that are not significantly different from the estimates using the real data. Given that the data used in this paper are often accessible in other country settings, this paper demonstrates how predictive modeling can be used by policy makers to estimate short-term mobility. -
Publication
The Impact of Monetary Incentives on Referrals by Traditional Birth Attendants for Postnatal Care in Nigeria
(World Bank, Washington, DC, 2019-05-20)Gaps in postnatal care use represent missed opportunities to prevent maternal and neonatal death in sub-Saharan Africa. As one in every three non-facility deliveries in Nigeria is assisted by a traditional birth attendant (TBA), and the TBA’s advice is often adhered to by their clients, engaging TBAs in advocacy among their clients may increase maternal and neonatal postnatal care use. This study estimates the impact of monetary incentives for maternal referrals by TBAs on early maternal and neonatal postnatal care use (within 48 h of delivery) in Nigeria. Overall, 207 TBAs participated in this study: 103 in the treatment group and 104 in the control group. The intervention increased the proportion of maternal clients of TBAs that reported attending postnatal care within 48 h of delivery by 15.4 percentage points [95% confidence interval (CI): 7.9–22.9]. The proportion of neonatal clients of TBAs that reportedly attended postnatal care within 48 h of delivery also increased by 12.6 percentage points [95% CI: 5.9–19.3]. However, providers often did not address the issues that may have led to maternal and newborn postnatal complications during these visits. We show that motivating TBAs using monetary incentives for maternal postnatal care use can increase skilled care use after delivery among their maternal and neonatal clients, who have a higher risk of mortality because of their exposure to unskilled birth attendance. However, improving the quality of care is key to ensuring maternal and neonatal health gains from postnatal care attendance. -
Publication
Health Service Delivery and Political Trust in Nigeria
(Elsevier, 2019-04)Do improvements in health service delivery affect trust in political leaders in Africa? Citizens expect their government to provide social services. Intuitively, improvements in service delivery should lead to higher levels of trust in and support for political leaders. However, in contexts where inadequate services are the norm, and where political support is linked to ethnic or religious affiliation, there may be weak linkages between improvements in service delivery and changes in trust in political leaders. To examine this question empirically, we take advantage of a national intervention that improved health service delivery in 500 primary health care facilities in Nigeria, to estimate the impact of residence within 10 km of one or more of the intervention facilities on trust in the president, local councils, the ruling party, and opposition parties. Using difference-in-difference models, we show that proximity to the intervention led to increases in trust in the president and the ruling party. By contrast, we find no evidence of increased trust in the local council or opposition parties. Our study also examines the role of ethnicity and religious affiliation in mediating the observed increases in trust in the president. While there is a large literature suggesting that both the targeting of interventions, and the response of citizens to interventions is often mediated by ethnic, geographic or religious identity, by contrast, we find no evidence that the intervention was targeted at the president's ethnic group, zone, or state of origin. Moreover, there is suggestive evidence that the intervention increased trust in the president more among those who did not share these markers of identity with the president. This highlights the possibility that broad-based efforts to improve health services can increase trust in political leaders even in settings where political attitudes are often thought to be mediated by group identity. -
Publication
Armed Conflict and Maternal Health Care Utilization: Evidence from the Boko Haram Insurgency in Nigeria
(Elsevier, 2019-04)Retention in maternal health care is essential to decreasing preventable mortality. By reducing access to care, armed conflicts such as the Boko Haram Insurgency (BHI), contribute to the high maternal mortality rates in Nigeria. While there is a rich literature describing the mechanisms through which conflict affects health care access, studies that estimate the impact of conflict on maternal health care use are sparse and report mixed findings. In this study, we examine the impact of the BHI on maternal care access in Nigeria. We spatially match 52,675 birth records from the Nigeria Demographic and Health Survey (NDHS) with attack locations in the Armed Conflict Location and Event Dataset (ACLED). We define BH conflict area as NDHS clusters with at least five attacks within 3000, 5000 and 10,000 m of BH activity during the study period and employ difference-in-differences methods to examine the effect of the BHI on antenatal care visits, delivery at the health center and delivery by a skilled professional. We find that the BHI reduced the probability of any antenatal care visits, delivery at a health center, and delivery by a skilled health professional. The negative effects of the BHI on maternal health care access extended beyond the Northeastern region, that is the current focus of humanitarian programs. Systematic efforts to identify and address the mechanisms underlying reductions in maternal health care use due to the BHI, and to target the affected populations, are essential to improving maternal health in Nigeria. -
Publication
'Once the delivery is done, they have finished': A Qualitative Study of Perspectives on Postnatal Care Referrals by Traditional Birth Attendants in Ebonyi State, Nigeria
(Springer Nature, 2017-12-19)While 79% of Nigerian mothers who deliver in facilities receive postnatal care within 48 h of delivery, this is only true for 16% of mothers who deliver outside facilities. Most maternal deaths can be prevented with access to timely and competent health care. Thus, the World Health Organization, International Confederation of Midwives, and International Federation of Gynecology and Obstetrics recommend that unskilled birth attendants be involved in advocacy for skilled care use among mothers. This study explores postnatal care referral behavior by TBAs in Nigeria, including the perceived factors that may deter or promote referrals to skilled health workers. Differences in TBA referral before, during, and after delivery appear to reflect the TBAs understanding of the added value of skilled care for the client and the TBA, as well as the TBA’s perception of the implications of referral for her credibility as a maternal care provider among her clients. We also found that there are opportunities to engage TBAs in routine postnatal care referrals to facilities in Nigeria by using incentives and promoting a cordial relationship between TBAs and skilled health workers. Thus, despite the potential negative consequences TBAs may face with postnatal care referrals, there are opportunities to promote these referrals using incentives and promoting a cordial relationship between TBAs and skilled health workers. Further research is needed on the interactions between postnatal maternal complications, TBA referral behavior, and maternal perception of TBA competence.