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Objective To explore the equity implications of insecticide-treated nets (ITN) distribution programmes that are based on user charges.

Removal of exhaled air from total body emanations or artificially standardising carbon dioxide (CO2) outputs has previously been shown to eliminate differential attractiveness of humans to certain blackfly (Simuliidae) and mosquito (Culicidae) species. Whether or not breath contributes to between-person differences in relative attractiveness to the highly anthropophilic malaria vector Anopheles gambiae sensu stricto remains unknown and was the focus of the present study. The contribution to and possible interaction of breath (BR) and body odours (BO) in the attraction of An. gambiae s.s. to humans was investigated by conducting dual choice tests using a recently developed olfactometer. Either one or two human subjects were used as bait. The single person experiments compared the attractiveness of a person's BR versus that person's BO or a control (empty tent with no odour). His BO and total emanations (TE = BR+BO) were also compared with a control. The two-person experiments compared the relative attractiveness of their TE, BO or BR, and the TE of each person against the BO of the other. Experiments with one human subject (P1) as bait found that his BO and TE collected more mosquitoes than the control (P = 0.005 and P < 0.001, respectively), as did his BO and the control versus his BR (P < 0.001 and P = 0.034, respectively). The TE of P1 attracted more mosquitoes than that of another person designated P8 (P < 0.021), whereas the BR of P8 attracted more mosquitoes than the BR of P1 (P = 0.001). The attractiveness of the BO of P1 versus the BO of P8 did not differ (P = 0.346). The BO from either individual was consistently more attractive than the TE from the other (P < 0.001). We demonstrated for the first time that human breath, although known to contain semiochemicals that elicit behavioural and/or electrophysiological responses (CO2, ammonia, fatty acids) in An. gambiae also contains one or more constituents with allomonal (~repellent) properties, which inhibit attraction and may serve as an important contributor to between-person differences in the relative attractiveness of humans to this important malaria vector.

Initial Working Theories. (DOCX 37Â kb)

Background Understanding the extent that different modern contraceptives are acceptable to different populations groups and where they get the commodities from will help in developing specific interventions that will help to scale-up the availability of the contraceptives. Methods The study took place in urban and rural sites in six states across Nigeria. Data on acceptability and sources of the contraceptives was collected from at least 770 randomly selected mostly female householders from each state respectively using a questionnaire. Acceptability of the different contraceptives was scored by the respondents on a scale of 1 (lowest) to 10 (highest). The relationships between acceptability and sources of the contraceptives with socio-economic status and geographic location of the respondents were examined. Results The use of modern contraceptives in general was acceptable to 87% of the respondents. Male condom was the most acceptable means of contraceptive with an average score of 5.0. It was followed by implants with and oral contraceptive pill with average scores of 4.0, whilst IUD was the least acceptable with an average score of 2.9. The private sector was the major source of contraceptives to different population groups. Both male and female condoms were mostly procured from patent medicine dealers (PMD) and pharmacy shops. Intra Uterine Devices (IUDs) and implants were mostly sourced from public and private hospitals in the urban areas, whilst injectibles were mostly sourced from private hospitals. Oral contraceptives were mostly sourced from pharmacy shops and patent medicine dealers. There were SES and geographic differences for both acceptability and sources of the contraceptives. Also, the sources of different contraceptives depended on the type of the contraceptive. Conclusion The different contraceptives were acceptable to the respondents and the major source of the contraceptives was the private sector. Hence, public-private partnership arrangements should be explored so that universal coverage with contraceptives could be easily achieved. Interventions should be developed to eliminate the inequities in both acceptability and sources of different contraceptives. The acceptability of all the contraceptives should be enhanced with relevant behaviour change communication interventions especially in areas with the lowest levels of acceptability.

Project workplan. (DOCX 22Â kb)

Assessment of ITS design against quality criteria. (DOCX 29Â kb)

Initial Working Theories. (DOCX 37Â kb)

Assessment of ITS design against quality criteria. (DOCX 29Â kb)

Background Improvement of utilization of malaria treatment services will depend on provision of treatment services that different population groups of consumers prefer and would want to use. Treatment of malaria in Nigeria is still problematic and this contributes to worsening burden of the disease in the country. Therefore this study explores the socio-economic and geographic differences in consumers' preferences for improved treatment of malaria in Southeast Nigeria and how the results can be used to improve the deployment of malaria treatment services. Methods This study was undertaken in Anambra state, Southeast Nigeria in three rural and three urban areas. A total of 2,250 randomly selected householders were interviewed using a pre tested interviewer administered questionnaire. Preferences were elicited using both a rating scale and ranking of different treatment provision sources by the respondents. A socio-economic status (SES) index was used to examine for SES differences, whilst urban-rural comparison was used to examine for geographic differences, in preferences. Results The most preferred source of provision of malaria treatment services was public hospitals (30.5%), training of mothers (19%) and treatment in Primary healthcare centres (18.1%). Traditional healers (4.8%) and patent medicine dealers (4.2%) were the least preferred strategies for improving malaria treatment. Some of the preferences differed by SES and by a lesser extent, the geographic location of the respondents. Conclusion Preferences for provision of improved malaria treatment services were influenced by SES and by geographic location. There should be re-invigoration of public facilities for appropriate diagnosis and treatment of malaria, in addition to improving the financial and geographic accessibility of such facilities. Training of mothers should be encouraged but home management will not work if the quality of services of patent medicine dealers and pharmacy shops where drugs for home management are purchased are not improved. Therefore, there is the need for a holistic improvement of malaria treatment services.

Background Out-of-pocket spending (OOPS) is the major payment strategy for healthcare in Nigeria. Hence, the paper assessed the determinants socio-economic status (SES) of OOPS and strategies for coping with payments for healthcare in urban, semi-urban and rural areas of southeast Nigeria. This paper provides information that would be required to improve financial accessibility and equity in financing within the public health care system. Methods The study areas were three rural and three urban areas from Ebonyi and Enugu states in South-east Nigeria. Cross-sectional survey using interviewer-administered questionnaires to randomly selected householders was the study tool. A socio-economic status (SES) index that was developed using principal components analysis was used to examine levels of inequity in OOPS and regression analysis was used to examine the determinants of use of OOPS. Results All the SES groups equally sought healthcare when they needed to. However, the poorest households were most likely to use low level and informal providers such as traditional healers, whilst the least poor households were more likely to use the services of higher level and formal providers such as health centres and hospitals. The better-off SES more than worse-off SES groups used OOPS to pay for healthcare. The use of own money was the commonest payment-coping mechanism in the three communities. The sales of movable household assets or land were not commonly used as payment-coping mechanisms. Decreasing SES was associated with increased sale of household assets to cope with payment for healthcare in one of the communities. Fee exemptions and subsidies were almost non-existent as coping mechanisms in this study Conclusions There is the need to reduce OOPS and channel and improve equity in healthcare financing by designing and implementing payment strategies that will assure financial risk protection of the poor such pre-payment mechanisms with government paying for the poor.

Project workplan. (DOCX 22Â kb)

Background The national health insurance scheme of Nigeria recently proposed a national premium for community based insurance scheme. This study determined the capacity of households in the rural and urban areas in Nigeria to pay for the premium and different hypothetical health insurance schemes namely national health insurance scheme, national urban health insurance scheme, national rural health insurance scheme and regional health insurance schemes. It determined the likely impact of different premiums on membership across socio-economic status quintiles, and then determined the threshold premium affordable to rural and urban households. Results The results show that the mean capacity to pay for the households in different regions ranged from US$194 ± 100 to US$986 ± 907. The threshold premiums of the national health insurance scheme, urban national health insurance and rural health insurance schemes were US$66, US$154 and US$53 respectively. Conclusions Overall, the threshold premium for rural national health insurance scheme and national health insurance schemes were affordable to the lowest socio economic group. Hence, it is recommended that threshold premium for rural national health insurance scheme be adopted as the maximum premium not to be exceeded in the proposed national health insurance scheme.

Background There is need for new information about the socio-economic and geographic differences in health seeking and expenditures on many health conditions, so to help to design interventions that will reduce inequity in utilisation of healthcare services and ensure universal coverage. Objectives The paper contributes additional knowledge about health seeking and economic burden of different health conditions. It also shows the level of healthcare payments in public and private sector and their distribution across socioeconomic and geographic population groups. Methods A questionnaire was used to collect data from randomly selected householders from 4,873 households (2,483 urban and 2,390 rural) in southeast Nigeria. Data was collected on: health problems that people had and sought care for; type of care sought, outpatient department (OPD) visits and inpatient department (IPD) stays; providers visited; expenditures; and preferences for improving access to care. Data was disaggregated by socio-economic status (SES) and geographic location (urban versus rural) of the households. Results Malaria and hypertension were the major communicable and non-communicable diseases respectively that required OPD and IPD. Patent medicine dealers (PMDs) were the most commonly used providers (41.1%), followed by private hospitals (19.7%) and pharmacies (16.4%). The rural dwellers and poorer SES groups mostly used low-level and informal providers. The average monthly treatment expenditure in urban area was 2444 Naira (US$20.4) and 2267 Naira (US$18.9) in the rural area. Higher SES groups and urbanites incurred higher health expenditures. People that needed healthcare services did not seek care mostly because the health condition was not serious enough or they could not afford the cost of services. Conclusion There were inequities in use of the different providers, and also in expenditures on treatment. Reforms should aim to decrease barriers to access to public and formal health services and also identify constraints which impede the equitable distribution and access of public health services for the general population especially for poor people and rural dwellers.

Background Information about quality of malaria treatment services of different healthcare providers is needed to know how to improve the treatment of malaria since inappropriate service provision leads to increased burden of malaria. Hence, the study determined the technical and perceived quality of malaria treatment services of different types of providers in three urban and three rural areas in southeast Nigeria. Methods Questionnaire was used to interview randomly selected healthcare providers about the technical quality of their malaria treatment services. Exit polls were used to obtain information about perceived quality from consumers. A socio-economic status (SES) index and comparison of data between urban and rural areas was used to examine socio-economic status and geographic differences in quality of services. Results The lowest technical quality of services was found from patent medicine dealers. Conversely, public and private hospitals as well as primary healthcare centres had the highest quality of services. Householders were least satisfied with quality of services of patent medicine dealers and pharmacy shops and were mostly satisfied with services rendered by public and private hospitals. The urbanites were more satisfied with the overall quality of services than the rural dwellers. Conclusion These findings provide areas for interventions to equitably improve the quality of malaria treatment services, especially for patent medicine dealers and pharmacy shops, that are two of the most common providers of malaria treatment especially with the current change of first line drugs from the relatively inexpensive drugs to the expensive artemisinin-based combination therapy, so as to decrease inappropriate drug prescribing, use, costs and resistance to artemisinin-based combination therapy.

Background Policy-making can be described as a complex decisionmaking process involving different actors engaged in negotiating their interests [1] and promoting different types of evidence. Policy informed by research evidence is widely seen as a good thing. However Monaghan [2] indicated that ‘Policy-makers may fish for evidence, select the beneficial bits and throw back those that are un-required’. This discretion in evidence and policy (EaP) processes and the selected participation of policy actors is inherently political. Our research analyses the participation of actors in EaP processes in India and Nigeria.

INTRODUCTION: Ensuring equitable coverage of appropriate malaria treatment remains a high priority for the Nigerian government. This study examines the health seeking behaviour, patient-provider interaction and quality of care received by febrile patients of different socio-economic status (SES) groups. METHODS: A total of 1642 febrile patients and caregivers exiting public health centres, pharmacies and patent medicine dealers were surveyed in Enugu state, South-East Nigeria to obtain information on treatment seeking behaviour, patient-provider interactions and treatment received. Socioeconomic status was estimated for each patient using exit survey data on household assets in combination with asset ownership data from the 2008 Nigeria Demographic and Health Survey. RESULTS: Among the poorest SES group, 29% sought treatment at public health centres, 13% at pharmacies and 58% at patent medicine dealers (p

Background Malaria in pregnancy (MIP) is a major disease burden in Nigeria and has adverse consequences on the health of the mother, the foetus and the newborn. Information is required on how to improve its prevention and treatment from both the providers’ and consumers’ perspectives. Methods The study sites were two public and two private hospitals in Enugu, southeast Nigeria. Data was collected using a pre-tested structured questionnaire. The respondents were healthcare providers (doctors, pharmacists and nurses) providing ante-natal care (ANC) services. They consisted of 32 respondents from the public facilities and 20 from the private facilities. The questionnaire elicited information on their: knowledge about malaria, attitude, chemotherapy and chemoprophylaxis using pyrimethamine, chloroquine proguanil as well as IPTp with sulphadoxine-pyrimethamine (SP). The data was collected from May to June 2010. Results Not many providers recognized maternal and neonatal deaths as potential consequences of MIP. The public sector providers provided more appropriate treatment for the pregnant women, but the private sector providers found IPTp more acceptable and provided it more rationally than public sector providers (p Conclusions There is sub-optimal level of knowledge about current best practices for treatment and chemoprophylaxis for MIP especially in the private sector. Also, IPTp was hardly used in the public sector. Interventions are required to improve providers’ knowledge and practices with regards to management of MIP.

Background At primary care facilities in Nigeria, national treatment guidelines state that malaria should be symptomatically diagnosed and treated with artemisinin-based combination therapy (ACT). Evidence from households and health care providers indicates that many patients do not receive the recommended treatment. This study sought to determine the extent of the problem by collecting data as patients and caregivers leave health facilities, and determine what influences the treatment received. Methods A cross-sectional cluster survey of 2,039 respondents exiting public health centres, pharmacies and patent medicine dealers was undertaken in urban and rural settings in Enugu State, south-eastern Nigeria. Results Although 79% of febrile patients received an anti-malarial, only 23% received an ACT. Many patients (38%) received sulphadoxine-pyrimethamine (SP). A further 13% of patients received an artemisinin-derivative as a monotherapy. An estimated 66% of ACT dispensed was in the correct dose. The odds of a patient receiving an ACT was highly associated with consumer demand (OR: 55.5, p < 0.001). Conclusion Few febrile patients attending public health facilities, pharmacies and patent medicine dealers received an ACT, and the use of artemisinin-monotherapy and less effective anti-malarials is concerning. The results emphasize the importance of addressing both demand and supply-side influences on malaria treatment and the need for interventions that target consumer preferences as well as seek to improve health service provision.