Abstract
ABSTRACTBackground: Studies examining how the capacity of health facilities affect implementation of free healthcare policies in low and middle-income countries are limited.Objective: This study describes how the context and institutional capacity of health facilities influenced implementation of the free maternal and child health programme (FMCHP) in Enugu state, South-east Nigeria.Methods: We conducted a qualitative case study at the state level and in two health districts (Isi-Uzo and Enugu Metropolis) in Enugu State. Data were collected through document review and semi-structured, in-depth interviews with policymakers (n = 16), healthcare providers (n = 16) and health facility committee leaders (n = 12) guided by an existing capacity framework and analysed using a thematic framework approach.Results: The findings reveal that active health facility committees, changes in provider payment process, supportive supervision, drug revolving fund, availability of medical equipment, electronic data transmission and staff sanction system enhanced the capacity of health facilities to offer free healthcare. However, ineffective decentralisation, irregular supervision and weak citizen participation limited this capacity. Uncertain provider payment, evidence of tax payment policy and a co-existing fee-exempt scheme constrained health facilities in following the FMCHP guidelines. Poor recording and reporting skills and lack of support from district officials constrained providers’ adherence to claims’ submission timeline. Poor funding, weak drug supply system, inadequate infrastructure and lack of participatory decision-making constrained delivery of free healthcare. Insufficient trained workforce, mission-inconsistent postings and transfers, and weak staff disciplinary system limited the human resource capacity.Conclusions: Effectiveness of FMCHP at the health facility level depends on the extent of decentralisation, citizen participation, concurrent and conflictive policies, timely payment of providers, organisation of service delivery and human resources practices. Attention to these contextual and institutional factors will enhance responsiveness of health facilities, sustainability of free healthcare policies and progress towards universal health coverage.
Highlights
Studies examining how the capacity of health facilities affect implementation of free healthcare policies in low and middle-income countries are limited
Many low and middle-income countries (LMICs) have adopted free healthcare policies to mitigate the negative impact of user fees on the poor, improve access to health services and accelerate progress towards universal health coverage and the sustainable development goals (SDGs) [1,2,3]
Organisational culture of public service bureaucracy constrained the constitution of district-level free maternal and child health programme (FMCHP) committees, posting and transfer, staff disciplinary mechanisms and payment of salaries through the District Health Boards (DHBs)
Summary
Studies examining how the capacity of health facilities affect implementation of free healthcare policies in low and middle-income countries are limited. Many low and middle-income countries (LMICs) have adopted free healthcare policies to mitigate the negative impact of user fees on the poor, improve access to health services and accelerate progress towards universal health coverage and the sustainable development goals (SDGs) [1,2,3]. In. Nigeria, despite adoption of free maternal and child healthcare policies in 2006 [5], reduction in maternal and childhood mortality rates have been lower than expected [6]. Capacity of health facilities, referred to as ability to perform appropriate tasks effectively, efficiently and sustainably [7,8], affect the effectiveness of free healthcare policies, theory-driven studies examining the effect of capacity of health facilities on implementation of user fee removal policies are limited
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