Journal of Obstetrics and Gynaecology
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Community health insurance as a catalyst for uptake of family planning and reproductive health services: The Obio Cottage Hospital experience B. Fakunle, M. A. Okunlola, A. Fajola, U. Ottih & A. O. Ilesanmi To cite this article: B. Fakunle, M. A. Okunlola, A. Fajola, U. Ottih & A. O. Ilesanmi (2014) Community health insurance as a catalyst for uptake of family planning and reproductive health services: The Obio Cottage Hospital experience, Journal of Obstetrics and Gynaecology, 34:6, 501-503 To link to this article: http://dx.doi.org/10.3109/01443615.2014.902044
Published online: 11 Apr 2014.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [Washington University in St Louis]
Date: 05 November 2015, At: 13:34
Journal of Obstetrics and Gynaecology, August 2014; 34: 501–503 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.902044
GYNAECOLOGY
Community health insurance as a catalyst for uptake of family planning and reproductive health services: The Obio Cottage Hospital experience B. Fakunle1, M. A. Okunlola2, A. Fajola1, U. Ottih3 & A. O. Ilesanmi1 1Department of Community Health, Shell Petroleum Development Company, 3Obio Cottage Hospital, Port Harcourt, Rivers State and
Downloaded by [Washington University in St Louis] at 13:34 05 November 2015
2Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria
Health service delivery in the Niger Delta region of Nigeria has suffered many setbacks. Community participation may help break the barriers limiting access to health services, especially those associated with family planning and reproductive health services. This is a two-year review of family planning and reproductive health services records offered by the Obio Cottage Hospital from the onset of the Community Insurance Scheme (2010–12). Since the inception of the Community Insurance Scheme, there has been an increase in the uptake of family planning methods of more than 50%; 1,274 women in 2011 vs 3,140 in 2012. An increase in number of women seeking reproductive health services was also observed. The Community Health Insurance Scheme (CHIS) at the Obio Cottage Hospital provides evidence for expansion, as seen in the improvement in patronage for family planning and reproductive health services. Keywords: Community health insurance, family planning, reproductive health
Introduction Government services in sub-Saharan Africa are generally perceived as being resource-poor and providing poor quality services (Atherton et al. 1999). Nigeria constitutes less than 2% of the world population but contributes 10% of the world’s maternal deaths (SOGON 2000). Health service delivery in Nigeria, especially in the Niger Delta region, has over the years suffered setbacks, such as a lack of skilled health professionals, particularly doctors, midwives, medical assistants, general nurses, laboratory staff and community health nurses at all levels especially in rural areas. This is mainly as a result of the locations of these facilities in rural communities leading to professionals refusing postings for lack of attractive working conditions. This complex interplay may result in delays in women seeking care and delays in women receiving care during pregnancy and delivery (Obiechina et al. 2013). This situation can however, be resolved through community participation and mobilisation. Involving communities is now known to be crucial in improving health equity, healthcare service delivery and uptake (Draper et al. 2010). Community participation can be made possible through community-based health insurance (CBHI) which is a not-for-profit type of health insurance that has been used by poor people to protect themselves against the high costs of seeking medical care and treatment for illnesses (Uzochukwu et al. 2010).
Community participation may help break the barriers limiting access to health services, especially those associated with maternal, child health and family planning services in Nigeria. This review was carried out to assess the benefits of community participation, through a local insurance scheme, on improving uptake of antenatal services, prevention of mother-to-child transmission of HIV (PMTCT) and family planning services, in a secondary-level health facility the Obio Cottage Hospital. The facility, is located in the city of Port Harcourt Nigeria, and is utilised by individuals from all areas of the city. The facility is owned by the Rivers State government and has been in existence since the 1980s. It was initially a health centre offering primary-level health services. It was upgraded to a Cottage Hospital in 2010. The upgrade was propelled by the launch of the Community Health Insurance Scheme (CHIS) initiated by Shell Petroleum Development Company (SPDC) in conjunction with Rivers State Government and the Obio/Akpor Local Government, to increase the provision and utilisation of health services. The scheme was designed primarily to provide greater financial access to healthcare for the indigenes of Rumuobiakani, Oginigba, Rumuomasi and Rumuozuolu communities and secondarily, other members of the society. Indigenes of the four communities pay a yearly premium of ͘ 3,600 (Nigerian Naira) while non-indigenes pay ͘7,200 (at an average conversion rate of US$1 to 160 Naira). The commencement of the health insurance scheme has resulted in a significant increase in the utilisation of the facility due to the abolishment of out-ofpocket payment, which has been known to hinder health service utilisation. Similar findings were found in a recent multivariate analysis on healthcare financing by Riman and Akpan (2012), as seen in another area in the Niger delta region (Calabar), where high predominance of out-of-pocket payment was associated with high levels of infant mortality and morbidity, A tri-partite partnership, consisting of the SPDC, River State Government and Obio/Akpor Local Government, provides governance and guidance to the facility through a governing board. The SPDC is responsible for provision of equipment; the state government is responsible for provision of personnel, while the local government is responsible for infrastructure. Since the upgrade of the cottage hospital through the introduction of the community insurance scheme, there has been an enhancement in service delivery for both clients and service providers. The community insurance scheme has enabled clients to access multiple services at the facility and this is evident in the increase in the number
Correspondence: M. O. Okunlola, Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria. E-mail: [email protected]
502
B. Fakunle et al.
of women seeking both antenatal care, PMTCT and family planning services, since the commencement of the scheme.
Materials and methods Both quantitative and qualitative methods were used for this study. Hospital management records from January 2010 to December 2012 were reviewed to extract utilisation data for family planning services, antenatal care, number of deliveries, number of caesarean sections and number of women receiving PMTCT services. Key informant interviews were carried out to elicit information on the governance of the facility, operating guidelines and challenges experienced since service provision began.
Downloaded by [Washington University in St Louis] at 13:34 05 November 2015
Results Since the inception of the community insurance scheme, records for antenatal care show that of the 33,864 women who sought antenatal care between 2010 and 2012, 19.8% sought antenatal care in 2010, 29.1% in 2011 and about half (51.1%) in 2012. This was also the case for number of deliveries, with 2012 accounting for more than half (56.8%) of total deliveries between 2010 and 2012. There was also an increase in the number of caesarean deliveries, as well as women receiving PMTCT services, since the inception of the community insurance scheme (Table I). There has also been an increase in the uptake of family planning services between 2011 and 2012. A total of 4,414 women patronised at least one family planning method at the facility with more than half in 2012 (71.1%), while the rest (28.9%) were in 2011. As at August 2013, 2,623 women had already utilised a method of family planning at the health facility. Of the various methods of family planning assessed by the women, more than half of the women used short-term methods such as condoms (68.1%); the use of long-term methods was low, with 21.6% using injectables (Depo-Provera and Noristerat), 4.8% using IUCDs and 5.5% using oral contraceptive pills (Table II).
Discussion Since the inception of CHIS in 2010, there has been a steady rise in the number of women attending antenatal clinics – 6,699 women presented for antenatal care visits in 2010; 9,857 women in 2011; 17,308 women in 2012 and 6,904 women as at April 2013. This steady rise in antenatal care attendance is an indication of the influence the scheme has played in improving antenatal care services uptake. There has also been a steady rise in the total number of deliveries at the hospital since the inception of the scheme from 512 in 2010 to 1,087 in 2011; 2,100 in 2012 and 832 as at April 2013. However, there still exists a large difference in the number of antenatal care visits and total number of deliveries at the Table I. Summary distribution of patronage of the Obio Cottage Hospital (2010–12). 2010 Year Family planning ANC Deliveries CS PMTCT
n NA 6,699 512 NA NA
NA, no data available.
(%)
19.8 13.8
2011
2012
n
(%)
n
(%)
Total (n)
1,274 9,857 1,087 152 94
28.9 29.1 29.4 22.7 45.4
3,140 17,308 2,100 518 113
71.1 51.1 56.8 77.3 54.6
4,414 33,864 3,699 670 207
Table II. Distribution of types of family planning services. OCP
Injectables
IUCD
Year
n
(%)
n
(%)
n
(%)
2011 2012 Total
113 129 242
8.9 4.1 5.5
340 610 940
26.7 19.4 21.6
139 75 214
10.9 2.4 4.8
Condom n
(%)
Total n
682 53.5 1,274 2,326 74.1 3,140 3,008 68.1 4,414
(%) 28.9 71.1
facility. This may be as a result of sociocultural preferences for home deliveries or with traditional birth attendants. The increase in antenatal care patronage at the facility has also led to an increase in PMTCT patronage. HIV Counselling and Testing (HCT) services began in September 2007, in partnership with the International Foundation for Education and Self Help (IFESH). At this time, HIV-positive pregnant women were referred to other facilities to access antiretroviral drugs during pregnancy and for the postpartum management of HIV. In October 2007, the Global Fund through its sub-recipient, Planned Parenthood Foundation Nigeria (PPFN) took over technical assistance of the Obio health centre in the provision of the HCT service. In March 2011, Family Health International provided technical support for HCT as well as antiretroviral drugs for HIV-positive mothers throughout the duration of their pregnancy. Since the provision of free PMTCT services in March 2011, the number of women receiving PMTCT service increased from 94 in 2011, to 113 in 2012. All pregnant women registering for antenatal care the first time during an index pregnancy are counselled and tested for HIV, with the option to opt out (according to National policy). Pregnant women who test positive for HIV receive further counselling on PMTCT, CD4 testing, antiretroviral medication for prophylaxis and treatment of their own disease, infant feeding and PMTCT support groups, before treatment commences. Compliance to management has been enhanced by the established PMTCT support group in the facility. Family planning services started in Obio Cottage Hospital in the early 1990s, when it was still a primary health centre. Obio Cottage Hospital is able to showcase how ‘the unmet need for contraception can be addressed through community participation’ and integration of family planning and antenatal care services. Results show a marked increase in the uptake of family planning methods from 2011 to 2012, especially the use of short-term methods (condoms). There was also an increase in the use of long-term methods. This increase may be an indication of willingness to patronise family planning services, as well as indicate the presence of unmet need for contraception among the women in the communities serviced by the health facility. One of the ways they were able to achieve this was through strong political will. Appropriate policies and intervention programmes were directed to facilitate the delivery of contraceptives to people who need them, irrespective of their capacity to pay for the services. The State government through the local government, at no cost, provides family planning commodities to these facilities. Contraceptives are provided every two months. Money is paid for consumables associated with provision of the services and not the contraceptives’ commodities, such as disinfectants, surgical gloves and swabs. The facility has also re-enforced local planning and evaluation capacity and has allowed other health workers to assume more responsibility in the provision of previously restricted family planning methods. In addition, they have extended family planning services to the communities through the direct involvement of community members. This is a major way to overcome the sociocultural and financial barriers to contraceptive up-take. It has also increased male involvement in family planning. The Community Health Insurance Scheme at the Obio Cottage Hospital provides evidence of the benefits of such interventions
The Obio Cottage Hospital experience 503
Downloaded by [Washington University in St Louis] at 13:34 05 November 2015
to rural communities, as seen in the improvement in patronage, especially for maternal and child health. This has gone a long way in breaking sociocultural, religious, economic and political barriers that had hindered the uptake of these services in Nigeria. Experience has shown that people are more likely to patronise programmes that they have helped plan. There should therefore be an expansion in the scope of the community health insurance scheme by integration of PMTCT and family planning services during the antenatal process as this can lead to a reduction of HIV/AIDS through prevention of mother-to-child transmission and transmission of HIV/AIDS to sexual partners. Its sustainability should therefore be upheld and strategies put in place to improve on the type of services the facility provides. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Atherton F, Mbekem G, Nyalusi I. 1999. Improving service quality: experience from the Tanzania Family Health Project. International Journal for Quality in Health Care 11:353–356. Draper AK, Hewitt G, Rifkin S. 2010. Chasing the dragon: developing indicators for the assessment of community participation in health programmes. Social Science and Medicine 71:1102–1109. Obiechina NJ, Okolie V, Okechukwu Z, Oguejiofor C, Udegbunam O, Nwajiaku L et al. 2013. Maternal mortality at Nnamdi Azikiwe University Teaching Hospital, Southeast Nigeria: a 10-year review (2003–2012). International Journal of Women’s Health 5:431–443. Riman HB, Akpan ES. 2012. Healthcare financing and health outcomes in Nigeria: a state level study using multivariate analysis. International Journal of Humanities and Social Science 2:296–309. SOGON. 2000. Policy handbook and strategic plan on women’s health (2000–2010). Benin City: Society of Gynaecology and Obstetrics of Nigeria, Ambik Press. Uzochukwu BSC, Onwujekwe OE, Eze S, Ezuma N, Obikeze EN, Onoka CA. 2010. Implementing community based health insurance in Anambra State, Nigeria. CREH Policy Brief. Available at: http://www. crehs.lshtm.ac.uk/downloads/publications/CBHI_brief.pdf.
ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20
Community health insurance as a catalyst for uptake of family planning and reproductive health services: The Obio Cottage Hospital experience B. Fakunle, M. A. Okunlola, A. Fajola, U. Ottih & A. O. Ilesanmi To cite this article: B. Fakunle, M. A. Okunlola, A. Fajola, U. Ottih & A. O. Ilesanmi (2014) Community health insurance as a catalyst for uptake of family planning and reproductive health services: The Obio Cottage Hospital experience, Journal of Obstetrics and Gynaecology, 34:6, 501-503 To link to this article: http://dx.doi.org/10.3109/01443615.2014.902044
Published online: 11 Apr 2014.
Submit your article to this journal
Article views: 43
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ijog20 Download by: [Washington University in St Louis]
Date: 05 November 2015, At: 13:34
Journal of Obstetrics and Gynaecology, August 2014; 34: 501–503 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.902044
GYNAECOLOGY
Community health insurance as a catalyst for uptake of family planning and reproductive health services: The Obio Cottage Hospital experience B. Fakunle1, M. A. Okunlola2, A. Fajola1, U. Ottih3 & A. O. Ilesanmi1 1Department of Community Health, Shell Petroleum Development Company, 3Obio Cottage Hospital, Port Harcourt, Rivers State and
Downloaded by [Washington University in St Louis] at 13:34 05 November 2015
2Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria
Health service delivery in the Niger Delta region of Nigeria has suffered many setbacks. Community participation may help break the barriers limiting access to health services, especially those associated with family planning and reproductive health services. This is a two-year review of family planning and reproductive health services records offered by the Obio Cottage Hospital from the onset of the Community Insurance Scheme (2010–12). Since the inception of the Community Insurance Scheme, there has been an increase in the uptake of family planning methods of more than 50%; 1,274 women in 2011 vs 3,140 in 2012. An increase in number of women seeking reproductive health services was also observed. The Community Health Insurance Scheme (CHIS) at the Obio Cottage Hospital provides evidence for expansion, as seen in the improvement in patronage for family planning and reproductive health services. Keywords: Community health insurance, family planning, reproductive health
Introduction Government services in sub-Saharan Africa are generally perceived as being resource-poor and providing poor quality services (Atherton et al. 1999). Nigeria constitutes less than 2% of the world population but contributes 10% of the world’s maternal deaths (SOGON 2000). Health service delivery in Nigeria, especially in the Niger Delta region, has over the years suffered setbacks, such as a lack of skilled health professionals, particularly doctors, midwives, medical assistants, general nurses, laboratory staff and community health nurses at all levels especially in rural areas. This is mainly as a result of the locations of these facilities in rural communities leading to professionals refusing postings for lack of attractive working conditions. This complex interplay may result in delays in women seeking care and delays in women receiving care during pregnancy and delivery (Obiechina et al. 2013). This situation can however, be resolved through community participation and mobilisation. Involving communities is now known to be crucial in improving health equity, healthcare service delivery and uptake (Draper et al. 2010). Community participation can be made possible through community-based health insurance (CBHI) which is a not-for-profit type of health insurance that has been used by poor people to protect themselves against the high costs of seeking medical care and treatment for illnesses (Uzochukwu et al. 2010).
Community participation may help break the barriers limiting access to health services, especially those associated with maternal, child health and family planning services in Nigeria. This review was carried out to assess the benefits of community participation, through a local insurance scheme, on improving uptake of antenatal services, prevention of mother-to-child transmission of HIV (PMTCT) and family planning services, in a secondary-level health facility the Obio Cottage Hospital. The facility, is located in the city of Port Harcourt Nigeria, and is utilised by individuals from all areas of the city. The facility is owned by the Rivers State government and has been in existence since the 1980s. It was initially a health centre offering primary-level health services. It was upgraded to a Cottage Hospital in 2010. The upgrade was propelled by the launch of the Community Health Insurance Scheme (CHIS) initiated by Shell Petroleum Development Company (SPDC) in conjunction with Rivers State Government and the Obio/Akpor Local Government, to increase the provision and utilisation of health services. The scheme was designed primarily to provide greater financial access to healthcare for the indigenes of Rumuobiakani, Oginigba, Rumuomasi and Rumuozuolu communities and secondarily, other members of the society. Indigenes of the four communities pay a yearly premium of ͘ 3,600 (Nigerian Naira) while non-indigenes pay ͘7,200 (at an average conversion rate of US$1 to 160 Naira). The commencement of the health insurance scheme has resulted in a significant increase in the utilisation of the facility due to the abolishment of out-ofpocket payment, which has been known to hinder health service utilisation. Similar findings were found in a recent multivariate analysis on healthcare financing by Riman and Akpan (2012), as seen in another area in the Niger delta region (Calabar), where high predominance of out-of-pocket payment was associated with high levels of infant mortality and morbidity, A tri-partite partnership, consisting of the SPDC, River State Government and Obio/Akpor Local Government, provides governance and guidance to the facility through a governing board. The SPDC is responsible for provision of equipment; the state government is responsible for provision of personnel, while the local government is responsible for infrastructure. Since the upgrade of the cottage hospital through the introduction of the community insurance scheme, there has been an enhancement in service delivery for both clients and service providers. The community insurance scheme has enabled clients to access multiple services at the facility and this is evident in the increase in the number
Correspondence: M. O. Okunlola, Department of Obstetrics and Gynaecology, University College Hospital, Ibadan, Oyo State, Nigeria. E-mail: [email protected]
502
B. Fakunle et al.
of women seeking both antenatal care, PMTCT and family planning services, since the commencement of the scheme.
Materials and methods Both quantitative and qualitative methods were used for this study. Hospital management records from January 2010 to December 2012 were reviewed to extract utilisation data for family planning services, antenatal care, number of deliveries, number of caesarean sections and number of women receiving PMTCT services. Key informant interviews were carried out to elicit information on the governance of the facility, operating guidelines and challenges experienced since service provision began.
Downloaded by [Washington University in St Louis] at 13:34 05 November 2015
Results Since the inception of the community insurance scheme, records for antenatal care show that of the 33,864 women who sought antenatal care between 2010 and 2012, 19.8% sought antenatal care in 2010, 29.1% in 2011 and about half (51.1%) in 2012. This was also the case for number of deliveries, with 2012 accounting for more than half (56.8%) of total deliveries between 2010 and 2012. There was also an increase in the number of caesarean deliveries, as well as women receiving PMTCT services, since the inception of the community insurance scheme (Table I). There has also been an increase in the uptake of family planning services between 2011 and 2012. A total of 4,414 women patronised at least one family planning method at the facility with more than half in 2012 (71.1%), while the rest (28.9%) were in 2011. As at August 2013, 2,623 women had already utilised a method of family planning at the health facility. Of the various methods of family planning assessed by the women, more than half of the women used short-term methods such as condoms (68.1%); the use of long-term methods was low, with 21.6% using injectables (Depo-Provera and Noristerat), 4.8% using IUCDs and 5.5% using oral contraceptive pills (Table II).
Discussion Since the inception of CHIS in 2010, there has been a steady rise in the number of women attending antenatal clinics – 6,699 women presented for antenatal care visits in 2010; 9,857 women in 2011; 17,308 women in 2012 and 6,904 women as at April 2013. This steady rise in antenatal care attendance is an indication of the influence the scheme has played in improving antenatal care services uptake. There has also been a steady rise in the total number of deliveries at the hospital since the inception of the scheme from 512 in 2010 to 1,087 in 2011; 2,100 in 2012 and 832 as at April 2013. However, there still exists a large difference in the number of antenatal care visits and total number of deliveries at the Table I. Summary distribution of patronage of the Obio Cottage Hospital (2010–12). 2010 Year Family planning ANC Deliveries CS PMTCT
n NA 6,699 512 NA NA
NA, no data available.
(%)
19.8 13.8
2011
2012
n
(%)
n
(%)
Total (n)
1,274 9,857 1,087 152 94
28.9 29.1 29.4 22.7 45.4
3,140 17,308 2,100 518 113
71.1 51.1 56.8 77.3 54.6
4,414 33,864 3,699 670 207
Table II. Distribution of types of family planning services. OCP
Injectables
IUCD
Year
n
(%)
n
(%)
n
(%)
2011 2012 Total
113 129 242
8.9 4.1 5.5
340 610 940
26.7 19.4 21.6
139 75 214
10.9 2.4 4.8
Condom n
(%)
Total n
682 53.5 1,274 2,326 74.1 3,140 3,008 68.1 4,414
(%) 28.9 71.1
facility. This may be as a result of sociocultural preferences for home deliveries or with traditional birth attendants. The increase in antenatal care patronage at the facility has also led to an increase in PMTCT patronage. HIV Counselling and Testing (HCT) services began in September 2007, in partnership with the International Foundation for Education and Self Help (IFESH). At this time, HIV-positive pregnant women were referred to other facilities to access antiretroviral drugs during pregnancy and for the postpartum management of HIV. In October 2007, the Global Fund through its sub-recipient, Planned Parenthood Foundation Nigeria (PPFN) took over technical assistance of the Obio health centre in the provision of the HCT service. In March 2011, Family Health International provided technical support for HCT as well as antiretroviral drugs for HIV-positive mothers throughout the duration of their pregnancy. Since the provision of free PMTCT services in March 2011, the number of women receiving PMTCT service increased from 94 in 2011, to 113 in 2012. All pregnant women registering for antenatal care the first time during an index pregnancy are counselled and tested for HIV, with the option to opt out (according to National policy). Pregnant women who test positive for HIV receive further counselling on PMTCT, CD4 testing, antiretroviral medication for prophylaxis and treatment of their own disease, infant feeding and PMTCT support groups, before treatment commences. Compliance to management has been enhanced by the established PMTCT support group in the facility. Family planning services started in Obio Cottage Hospital in the early 1990s, when it was still a primary health centre. Obio Cottage Hospital is able to showcase how ‘the unmet need for contraception can be addressed through community participation’ and integration of family planning and antenatal care services. Results show a marked increase in the uptake of family planning methods from 2011 to 2012, especially the use of short-term methods (condoms). There was also an increase in the use of long-term methods. This increase may be an indication of willingness to patronise family planning services, as well as indicate the presence of unmet need for contraception among the women in the communities serviced by the health facility. One of the ways they were able to achieve this was through strong political will. Appropriate policies and intervention programmes were directed to facilitate the delivery of contraceptives to people who need them, irrespective of their capacity to pay for the services. The State government through the local government, at no cost, provides family planning commodities to these facilities. Contraceptives are provided every two months. Money is paid for consumables associated with provision of the services and not the contraceptives’ commodities, such as disinfectants, surgical gloves and swabs. The facility has also re-enforced local planning and evaluation capacity and has allowed other health workers to assume more responsibility in the provision of previously restricted family planning methods. In addition, they have extended family planning services to the communities through the direct involvement of community members. This is a major way to overcome the sociocultural and financial barriers to contraceptive up-take. It has also increased male involvement in family planning. The Community Health Insurance Scheme at the Obio Cottage Hospital provides evidence of the benefits of such interventions
The Obio Cottage Hospital experience 503
Downloaded by [Washington University in St Louis] at 13:34 05 November 2015
to rural communities, as seen in the improvement in patronage, especially for maternal and child health. This has gone a long way in breaking sociocultural, religious, economic and political barriers that had hindered the uptake of these services in Nigeria. Experience has shown that people are more likely to patronise programmes that they have helped plan. There should therefore be an expansion in the scope of the community health insurance scheme by integration of PMTCT and family planning services during the antenatal process as this can lead to a reduction of HIV/AIDS through prevention of mother-to-child transmission and transmission of HIV/AIDS to sexual partners. Its sustainability should therefore be upheld and strategies put in place to improve on the type of services the facility provides. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Atherton F, Mbekem G, Nyalusi I. 1999. Improving service quality: experience from the Tanzania Family Health Project. International Journal for Quality in Health Care 11:353–356. Draper AK, Hewitt G, Rifkin S. 2010. Chasing the dragon: developing indicators for the assessment of community participation in health programmes. Social Science and Medicine 71:1102–1109. Obiechina NJ, Okolie V, Okechukwu Z, Oguejiofor C, Udegbunam O, Nwajiaku L et al. 2013. Maternal mortality at Nnamdi Azikiwe University Teaching Hospital, Southeast Nigeria: a 10-year review (2003–2012). International Journal of Women’s Health 5:431–443. Riman HB, Akpan ES. 2012. Healthcare financing and health outcomes in Nigeria: a state level study using multivariate analysis. International Journal of Humanities and Social Science 2:296–309. SOGON. 2000. Policy handbook and strategic plan on women’s health (2000–2010). Benin City: Society of Gynaecology and Obstetrics of Nigeria, Ambik Press. Uzochukwu BSC, Onwujekwe OE, Eze S, Ezuma N, Obikeze EN, Onoka CA. 2010. Implementing community based health insurance in Anambra State, Nigeria. CREH Policy Brief. Available at: http://www. crehs.lshtm.ac.uk/downloads/publications/CBHI_brief.pdf.
