Determinants of effectiveness of a novel community health workers programme in improving maternal and child health in Nigeria

改善母亲和儿童健康仍然是一个国际优先事项，特别是对撒哈拉以南非洲国家而言。有证据表明，社区卫生工作者参与的计划可以有效地改善母亲和儿童的健康。虽然这类计划在孟加拉国等一些发展中国家得到了实施，但为了指导进一步的发展，需要更好地了解是什么使CHW计划成功，以及在什么情况下成功。在尼日利亚，尽管取得了重大进展，但妇幼保健仍然是一个令人关切的问题，特别是在最脆弱群体居住的农村地区。2012年，尼日利亚联邦政府设立了补贴再投资和赋权方案（SURE-P），将减少燃料补贴的收入投资于一项社会保障方案，以改善最弱势群体的生活。在每个州的选定设施中实施的一个SURE-P组成部分侧重于孕产妇和儿童健康（SURE-P/MCH）。我们的想法是，招募卫生保健员，同时发展基础设施，改善用品和药品的供应，将改善获得优质卫生服务的机会，并最终改善母亲和儿童的健康。自2012年12月起，有条件现金转移（CCT）也在选定的站点（“SURE-P/MCH+CCT”）增加。这些奖励与孕妇在不同阶段使用保健服务有关：例如产前保健检查和设施分娩。该项目的目标是为加强和扩大社区卫生工作者（CHW）方案提供信息。这将通过调查尼日利亚卫生保健方案的两项执行情况（即有条件现金转移和无条件现金转移）来实现，以了解在什么条件下，哪些因素促进公平获得优质服务，并改善孕产妇和儿童健康结果。我们将这样做：1。1 .深入了解实施干预措施的背景和过程，包括卫生人力与基础设施和供应品之间的关系；2 .确定、评估和比较干预产出（如卫生保健员的技能和做法以及初级卫生保健设施的效率）和成果（如公平获得优质妇幼保健服务和实现妇幼保健成果目标）；3 .建立一个以经验为基础和理论为基础的模型，分析干预措施的相关人员、背景、实施过程、产出和结果之间的复杂关系；为干预措施的可扩展性（在大致相似的上下文中扩展）和可泛化性（扩展到不同的上下文中）开发可转移的最佳实践。这个为期五年的研究和发展项目将在尼日利亚的两个州——北部的尼日尔州和南部的阿南布拉州实施，这两个州是在与联邦卫生部和SURE-P国家方案官员协商后选定的。选择来自该国不同地区的两个州将为更好地阐明影响方案实施和结果的不同背景因素提供机会，并确保调查结果可推广到整个国家。在每个州，我们将选择三个地方政府区域（lga）集群：一个是SURE-P/MCH集群，一个是SURE-P/MCH+CCT集群，一个是不进行干预的集群。在每个国家，将对这两种干预措施进行相互对照和对照（即不实施）的评估。我们将与地方、州和联邦的政策制定者和实践者密切合作，得出可以用来为他们的政策决策提供信息的答案。我们希望，更好地了解尼日利亚CHW项目的绩效，将为进一步加强现有项目、在尼日利亚和其他考虑实施CHW项目的类似国家复制该项目提供信息。

Improved mother and child health (MCH) continues to be an issue of international priority, particularly for sub-Saharan African countries. Evidence suggests that schemes involving Community Health Worker (CHWs) can be effective in improving the health of mothers and children. Although such schemes are implemented in some developing countries such as Bangladesh, to guide further developments, much better understanding is needed on what makes CHW programmes successful and under what circumstances. In Nigeria, despite significant improvements, mother and child health remains an issue of concern, particularly in rural areas where most vulnerable groups live. In 2012, the Federal Government of Nigeria established the Subsidy Reinvestment and Empowerment Programme (SURE-P) to invest the revenue from fuel subsidy reduction into a social security programme to improve lives of most vulnerable populations. One SURE-P component, implemented in selected facilities in each State, focuses on maternal and child health (SURE-P/MCH). The idea is that recruitment of CHWs, combined with infrastructure development, and improved availability of supplies and medicines, will improve access to quality health services, and ultimately, improve mother and child health. Since December 2012, Conditional Cash Transfers (CCT) have also been added at selected sites ('SURE-P/MCH+CCT'). These incentive payments to pregnant mothers are linked to use of health services at different stages: e.g. for antenatal care visits and facility deliveries. The AIM of this project is to inform strengthening and scaling up of community health worker (CHW) programmes. This will be achieved by investigating two implementations (i.e. with and without conditional cash transfers) of a Nigerian CHW programme, to understand what factors, under what conditions, promote equitable access to quality services, and improve maternal and child health outcomes. We will do so by:1.Developing an in-depth understanding of the context and the process of implementation of the interventions, including relations between health workforce and infrastructure and supplies;2.Identifying, assessing and comparing the intervention outputs (e.g. skills and practices of CHWs and efficiency of primary health care facilities) and outcomes (e.g. equitable access to quality MCH services and attainment of MCH outcome targets);3.Developing an empirically-based and theoretically-grounded model of complex relations between the people involved, context, implementation process, outputs and outcomes of the interventions;4.Developing transferable best practices for scalability (expansion within a broadly similar context) and generalizability (expansion to different contexts) of the interventions.This five-year research and development project will be implemented in two States in Nigeria - Niger State in the North and Anambra State in the South, which were selected in consultation with the Federal MOH and SURE-P national programme officer. Selecting two states from different parts of the country will provide an opportunity for different contextual factors that affect the implementation and outcome from the programme to be better elucidated and ensure that the findings are generalisable to the entire country. Within each State we will select three Local Government Areas (LGAs) clusters: one with SURE-P/MCH, one with SURE-P/MCH+CCT and one with no intervention. In each State the two interventions will be assessed against each other and against the comparison (i.e. no implementation) site. We will work closely with local, State and Federal policymakers and practitioners, to generate answers that can be used to inform their policy decisions. We expect that better understanding of performance of the CHW programme in Nigeria will inform further strengthening of the existing programme, its replication within Nigeria, and other similar countries considering the implementation of CHW initiatives.