Ward Development Committees as 4th Level Governance of Primary Health Care in Nigeria: The Rivers State Model
by Ibama AS1*, Green KI2, Wihioka JT2, Babbo DM1, Jaja E2, Ogbonna C3, Onawola RM4, Ugwuoke A3, Ibulubo RI5, Ibulubo TG5, Afonja OD6, Fagbamigbe AO6, Jaja BM5
1School of Public Health, University of Port Harcourt, Port Harcourt, Nigeria
2Rivers State Primary Health Care Management Board, Port Harcourt, Nigeria
3Imo State College of Health and Management Sciences, Owerri, Nigeria
4Community Health Practitioners Registration Board of Nigeria, Abuja, Nigeria
5Rivers State College of Health Sciences and Management Technology, Port Harcourt, Nigeria
6University College Hospital, Ibadan, Nigeria
*Corresponding author: Ibama AS, School of Public Health, University of Port Harcourt, Port Harcourt, Nigeria
Received Date: 18 August, 2024
Accepted Date: 05 September, 2024
Published Date: 20 September, 2024
Citation: Ibama AS, Green KI, Wihioka JT, Babbo DM, Jaja E, et al. (2024) Ward Development Committees as 4th Level Governance of Primary Health Care in Nigeria: The Rivers State Model. J Community Med Public Health 8: 473. https://doi.org/10.29011/2577-2228.100473
Abstract
Background: Ward Development Committee (WDC) is a component of Ward Health System, framed in accordance with the Political Wards as the fourth level of governance of Primary Health Care in Nigeria. This operational research paper sought to explore the extent to which supportive supervision as a means of building capacity and reorientation of WDC members on their roles and responsibilities, foster the community component of health care delivery drive towards ownership of the health system. Methods: The method used was supportive supervision focused model checklist to guide and access performance and review of relevant literature from open-access journals and google scholar data base, research reports and policy document on variables of the subject across the globe. Results: A total of 14 (60.8%) LGAs; 44 (21.7%) WDC cluster health facilities and 96 (30%) wards were supervised. Strengths were identified, described and elaborated on ways and means of sustainability as well as formed the basis of discussion in this paper. While challenges were highlighted and grouped into what the WDC members should work on to improve the situation, whereas those within the scope and responsibility of the LGHA and RSPHCMB should also be addressed appropriately. The recommendations were continuous orientation/capacity building of WDC members during monthly Supportive Supervision and provision of manual for reference, selection of persons residing within the WDC clusters to replace non-residence persons, regular and prompt payment of monthly logistic stipend to WDC members. Conclusion: The model is unique in the drive towards community ownership of the health system. More importantly, adoption and implementation of the recommendations, will overtime go a long way in optimally improving utilization and uptake of essential interventions for health gains in Rivers State and indeed Nigeria.
Keywords: Ward Development Committee; Supportive Supervision; Governance, River State Model, Primary Health Care, Community Participation; Essential Interventions
Introduction
There are different levels in the governance of Primary Health Care (PHC) in Nigeria, namely; National Primary Health Care Development Agency (NPHCDA), State Primary Health Care Board/Agency, Local Government Health Authority (LGHA) and Ward Development Committees (WDCs). Amongst these levels, the WDC is the most vital, because it touches the grassroots/ communities directly, where about 70% of the population reside and earn a living.
Ward Development Committee is a group of influential men and women who are charged with the responsibility to oversee the health needs of their people. The WDC is a component of the Ward Health System and fourth level of governance of Primary Health Care. It is adopted in line with the Political Wards as the operational units for the implementation of Primary Health Care programmes [1]. This is because, the Wards provide a nationally acceptable targeted area of operation with clearly defined boundary, political representation and population. The wards also, enables citizen participation in the political economy through a councillor [2].
The WDC is equally a strategic framework for effective delivery of interventions in the Basic Minimum Package of Health Services (BMPHS) and vital in the management of the Basic Health Care Provision Fund (BHCPF) [1]. WDC as a community component, provides the platform for active participation of communities in Primary Health Care, via identification of peculiarities of health system issues, service utilization issues, belief and practice issues among others associated with poor indicators in health care delivery. These issues mentioned, provide direction for contextual capacity building/orientation during engagement and supportive supervision in addressing them to improve the health status of the people overtime.
According to Federal Ministry of Health [2], WDC exists at the community level to enable mobilization and governance of community resources, furthermore, going by NPHCDA’s minimum standards for Primary Health Centres (PHCs) in Nigeria, WDCs are involved alongside health workers and local government primary health care department officials in co-managing PHCs at the ward level. Quite important to note also, is that via collaborative effort, Breakthrough Action-Nigeria guided 289 WDCs within Bauchi, Kebbi, Sokoto and Ebonyi States as well as Federal Capital Territory to define and resolve priority challenges related to Reproductive Maternal Newborn Child Health + Nutrition and address barriers in particular to maternal health care by helping them develop Community Health Action Resource Plans, which offers them a blueprint to action and follow-up on their initiatives [3].
Rationale or Purpose of WDCs
It aims to address previous failures in the development of functional Primary Health Care System via:
- Capacity building of communities.
- Harnessing of grassroots political participation in the health of the people.
- Providing the platform for active participation towards ownership of the primary healthcare system.
- Using the platform for the delivery of essential interventions as a response to health care need to safeguard the health of the community.
- Development of effective systems of financing and comanagement of the Primary Health Care thus making it community based as possible.
- Serving as the apex body for the functions of the Primary Health Centre and other development activities carried out in the Ward.
- Linking directly with the Local Government Health Authority (LGHA) through a representative of the WDC.
- Representation in the Health Facility Management Committee (FMC), for purposes of coordination and support.
- Quite importantly, members of the committee are participating on a voluntary and merit basis with transport and refreshment allowances only provided [1].
The Nigeria’s Health Promotion Policy, stated that, the WDC was designed and developed as a social strategy for encouraging community participation and access to primary health care services, ... It is a group consisting of religious, traditional leaders and other prominent persons across the communities that make up the ward [4].
Objectives of WDCs
The key objectives are to:
- Improve the organizational structure of PHC operations at the Ward/Community level.
- Facilitate integrated PHC service delivery with improvement in referrals.
- Ensure improved skilled, motivated and supervised human and material resources for health.
- Ensure increased collaborative mechanism with related sector (education, agriculture, environment, water etc) to health care delivery.
- Meet at least once a month and regularly as decided by members.
- Recording of minutes of meetings.
- Minutes should be duly signed by the Chairman and Secretary after adopting at subsequent meetings.
- Treasurer should record and keep all monies.
- Treasurer should record all expenditure.
- Treasurer should spend money subject to the approval of the committee.
- Minutes of meetings should be sent to LGHA
- Continuous Education and Sensitization activities to promote health within the Ward.
- To undertake tour of villages/Settlements and Communities in the Ward to discuss issues of Health and Development [2].
- Conduct of Situational Analysis of recorded data of essential interventions of minimum service package to obtain baseline data related to objectives of the WDC Activities.
- Number of planned and conducted Integrated PHC service delivery at outreach sites with referrals.
- Number of planned and conducted supervisions of Integrated PHC service delivery at outreach sites.
- Number of planned and conducted collaborative meetings with related sectors to health care delivery.
Operational Guidelines for WDCs
Processes and Indicators for Measurement of Objectives of WDCs
What WDCs Cannot Do
According to Federal Ministry of Health [2], the WDCs cannot do the following:
- Manage the health facility, but provide only oversight of the running of the facility.
- Take unilateral decisions concerning the health facilities.
- Claim money in the health facilities’ account.
Aim of the Paper
The paper aims to explore the extent to which supportive supervision as a means of capacity building and reorientation of the WDC members on their roles and responsibilities, to foster the community component of health care delivery drive towards ownership of the health of the people.
Methodology
The method used was basically supportive supervision focused operational research model checklist to guide and access performance within the framework of roles and responsibilities of WDC and review of relevant literature from open-access journals and google scholar data base, research reports and policy document on variables of the subject across the globe, to form the basis of discussion of findings.
The Rivers State Model of Ward Development Committees
Rivers State is comprised of 319 political wards, spanning across the 23 Local Government Areas, but practically impossible to have standard Primary Health Facility sited in these Wards as stipulated in the National guideline for Ward Health System, in Nigeria, due to the traditional, cultural and political formulation of communities and Local Government Areas. This provided the fulcrum, for the domestication of the National Framework for formation and operationalization of WDCs in Rivers State.
The domestication produced an abridged composition of the WDC members, reflecting the political and essential community structure for optimal health services provision and governance. Each WDC in Rivers State is made of the following:
- Ward councillor
- Head of facility
- Community leader
- Youth leader
- Women leader
- Ward focal person
- Religious leader
- Education representative
It was recommended that women should form 30% of membership and a woman should be treasurer. The Chairman, should be from the community (Community leader) where the health facility is sited, while the Secretary, is the head of facility. This is for Wards with health facility, that met the standard for the Basic Health Care Provision Fund (BHCPF) implementation. Wards with more than one health facilities, the head/s of other facilities are also members. While wards without such facility, are represented in the facility covering their catchment area by the respective Women and Youth Leaders, making the WDC in Rivers State, formed in clusters around the BHCPF selected health facilities with all wards represented to suit its peculiarity and making the WDC membership ranging between eight (8) and thirty-three (33).
Currently, the number of persons in WDC operations as members in the 23 Local Government Areas, is One Thousand, Nine Hundred and Forty-four (1,944), organized in Two Hundred and Three (203) facilities/clusters. However, this number may increase or decrease, depending on approval of new health facilities or deregistration of poor performing health facilities within the policy guidelines of the BHCPF implementation. The Rivers State Primary Health Care Management Board is providing members with monthly logistics fund for their statutory meetings.
Similarly, an abridged roles and responsibilities of WDCs was adopted for more effective and efficient operations. These include:
- To identify health and social needs and plan for them.
- Grass root mobilization and stimulation of active involvement among prominent and other local people in primary health care activities.
- To ensure the implementation of developed work/business plans in collaboration with the Medical Officer of Health (MOH).
- To identify local human and material resources to meet identified needs.
- Forward all health/community/business development plans (village, facility and ward levels to LGHA).
- Take active role in the monitoring of health activities, within the framework of developed business plan.
- Liaise with government and other voluntary agencies in finding solution to health, social and other related problems in the ward.
What were the Notable Experiences of the Model?
The significant experiences were the introduction of routine supportive supervision process to WDCs as an intervention to observed role conflict between Facility Management Committee and Ward Development Committee in the Primary Health Care System from August, 2023. The observed gap was basically attributable to poor orientation and understanding of Ward Health System in Primary Health Care. Supportive supervision is a system strengthening mechanism, targeting skills of operators of the system (primary health care) to improve performance and quality of services. A three (3) section checklist was developed and used during the visits for orientation and basis for assessment of performance of the WDCs’ operation. In the process, a total of fourteen (14) [60.8%] LGAs; 44 (21.7%) WDC cluster health facilities and 96 (30%) wards were covered within the period under review (August, 2023 to January, 2024). Strength/ what worked well were identified from minutes of meetings and during interactive sessions of supportive supervision, and were described and elaborated on ways and means of sustainability. While challenges/what did not work well were highlighted and grouped into what the WDC members should work on to improve the situation, whereas those within the scope and responsibility of the LGHA and RSPHCMB should also be addressed appropriately.
S. No. |
LGA |
WDC Cluster Health Facility |
Ward/s |
Remarks |
1 |
Asari-Toru |
MPHC, Abalama MPHC, Buguma MPHC, Minama MPHC, Ido |
11 1 - 10 13 12 |
|
2 |
Obio/Akpor |
MPHC, Eliozu MPHC, Rumuepirikon MPHC, Mgbuosimini MPHC, Elelenwo MPHC, Rumuolumeni MPHC, Rumuokwuta MPHC, Rumuigbo |
1 9 10 5 17 13 12 |
2 Times SP |
3 |
Ogu/Bolo |
MPHC, Ogu H/C, Chukwuama |
4;1;2 & 5 3 |
|
4 |
Oyigbo |
CHC, Oyigbo MPHC, Mirinwanyi |
8 & 9 7 & 1 |
|
5 |
Port Harcourt City |
MPHC, Ozuboko MPHC, Elekehia MPHC, Orogbum MPHC, Bundu-Ama MPHC, Churchill Staff Clinic MPHC, Mgbundukwu |
20 19 2; 1; 3; 8 & 9 5 7 4 15;10;11;12;13;14; 16; 17 & 18 |
|
6 |
Opobo/Nkoro |
MPHC, Opobo MPHC, Nkoro MPHC, Kalaibiama |
7; 3; 4; 5 & 6 9; 10 & 11 1 |
|
7 |
Omuma |
MPHC, Oyoro MPHC, Obiohia PHC, Eberi PHC, Ohim-Oyoro |
4 3 1 & 2 4 |
8 |
Tai |
MPHC, Korokoro MPHC, Bare-Ale PHC, Ban-Ogoi |
3 8 10 |
|
9 |
Ikwerre |
MPHC, Omunwei-Igwuruta MPHC, Ipo |
12 10 |
|
10 |
Abua/Odual |
MPHC, Ayama MPHC, Ogbema |
4 & 3 1 |
|
11 |
Degema |
PHC, Usokun CHC, Degema |
13 11 & 12 |
|
12 |
Akuku-Toru |
MPHC, Abonnema MPHC, Obonoma |
1 - 13 14 |
|
13 |
Ahoada East |
MPHC, Ahoada PHC, Ihuaje |
3; 1 & 3 12 |
|
14 |
Okirika |
Island Maternity MPHC, Ogoloma |
4 & 3 10; 11 & 12 |
|
Total:14 (60.8%) |
44 (21.7%) |
96 (30%) |
||
Strength/What worked well Remarks |
||||
Oyigbo |
MPHC, Mirinwanyi (Wards 7&1): - Fund drive activities to augment infrastructural development (including access road) of the health facility to enhance optimal operation of the health facility. - Monitoring outreach health services and SIAs and resolving cases of hesitancy of vaccination uptake. CHC, Oyigbo (Wards 8&9): - Collaborative engagement with Port Harcourt Electricity Distribution Company (PHEDC), in working out optimal electricity bill to ensure effective operation of the health facility. - Mobilization of youths towards cleaning of newly completed staff residential quarters to improve access to essential services at odd hours. |
Community resources mobilization to enhance effective service delivery and improved coverage of community-based vaccinations. Spirit of collaboration to improve access to essential services at the health facility. |
||
Ogu/Bolo |
MPHC, Ogu (Wards 4;1;2 & 5): - Youths’ extension of monthly community sanitation activities to clearing of overgrown grasses in the health facility premises to enhance access to uptake of essential services at the health facility. |
Collaboration effort to improve access to essential interventions at the health facility |
Port Harcourt City |
MPHC, Elekehia (Ward 19): - Planned for fund raising activities towards procurement of mini vehicle to enhance referrals of cases. |
Community resource mobilization effort towards effective referrals |
|
Opobo/Nkoro |
MPHC, Nkoro (Wards 9; 10 & 11): - Sensitization activities on range of health services provided and utilization of services at the health facility in churches and women organizations. - Planned for Emergency Transport System (ETS), to facilitate access to health care services. MPHC, Kalaibiama (Ward 1): - Collaborative effort with NGO and provided some essential supplies (foot mats; Cotton blinds; Bed sheets etc) to enhance health service delivery. |
Community initiated awareness creation to increase uptake of essential interventions and efforts to addressing community delay in accessing care. Collaborative effort towards infrastructural development to enhance effective health care delivery. |
|
Tai |
MPHC, Bare-Ale (Ward 8): - Sensitization programme (Health Talk) on range of health services provided and utilization of services at the health facility in Sime market along East/West road. |
Community initiated awareness creation to increase uptake of essential interventions. |
|
Ikwerre |
MPHC, Omunwei-Igwuruta (Ward 12): - Tracking and identification of illegal private immunization service provision point of questionable status of vaccines. - Engagement/active participation in boundary synchronization to reducing missed opportunities in health service provision and uptake. |
Community initiated protection and promotion of health of the people and active participation to reduce missed opportunities in uptake of essential interventions |
|
Degema |
PHC, Usokun (Ward 13): - Planned youths’ sensitization of benefits of ANC registration, uptake of interventions and health facility delivery in youths’ forum. |
Youths stimulated efforts in increasing uptake of essential interventions at the facility. |
|
Akuku-Toru |
MPHC, Obonoma (Ward 14): - Community sensitization on range of health services provision at the health facility and MNCHW at monthly prayer meeting. MPHC, Abonnema (Wards 1 to 13): - Ward level sensitization on range of health services provision at the health facility, MNCHW and Malaria Impact project. |
Community initiated awareness creation to increase uptake of range of essential interventions at the health facility. |
|
Abua/Odual |
MPHC, Ogbema (Ward 1) - Ward Councillor, who is the political head of the Ward and WDC member promised to pay for first ten (10) pregnant women that will register for ANC at the health facility. - He also, promised and fulfilled on installation of solar light around the health facility, |
Political Will towards infrastructural development to enhance effective health service delivery and uptake of interventions. |
|
Challenges/What did not work well |
- Some WDC members residing outside their assigned location/LGA, particularly in LGAs far away from the State capital, making effective operations of WDC difficult. - Scattered settlements within cluster of Wards, making transport to attend meetings as provided, difficult in the present economic hardship in the country and so affecting smooth operation of WDC activities. - Poor understanding of concept of WDC roles and responsibilities among members, due to little or no orientation (capacity building) prior commencement of duty. -Absence of Situational Analysis on essential interventions at the focal/ cluster health facility to form baseline data to measure improvement in utilization/uptake of interventions attributable to WDC activities. - Delayed submission of minutes and attendance of meetings as evidences as provided for by the Accountability Frame Work. - Delayed and or non-release of logistics money as requested, approved and released by RSPHCMB to WDC members in some clusters, thereby dampening the zeal of WDC members in performing their volunteer work. |
|||
Recommendations |
|||
- Continuous orientation/capacity building of WDC members during monthly Supportive Supervision and provision of manual for reference. - Selection of persons residing within the WDC clusters to replace nonresidence persons. - Regular and prompt payment of monthly logistic stipend to WDC members. |
|||
Source: [5] |
Goal and Objectives of the Supportive Supervision
Goal: This is to nip in the bud, unwarranted conflict between Facility Management Committee and Ward Development Committee in the operations of the PHC system.
Objectives
- To make WDC members, understand the Roles of Facility Management Committee and Ward Development Committee within the BHCPF framework.
- To make WDC members, understand simple techniques of sensitization, encouragement and mobilization of their people toward uptake of interventions at the health facility and during community-based intervention programmes.
- To make WDC members, understand techniques of mobilization for resources in their community’s context to augment government’s infrastructural provision to ensure optimal operation of the health facility’s service delivery.
Supportive Supervision Focused Methodology
The focus of the Supportive Supervision was basically:
- To obtain WDC meeting schedules from the cluster health facility through the LGHA.
- Composition, orientation and posting of State Supportive Supervision Team.
- Scheduling 5 LGAs and 2 WDC Clusters per LGA on rotation for the Monthly Supportive Supervision with Obio/Akpor and Port Harcourt City LGAs (State Capital LGAs) reoccurring.
- To make WDC members understand the concept of fourth (4th) level governance of primary health care system and active participation towards ownership of the health of the people.
- Orientation on thematic areas of performance assessment to bring to bear the community components for improved uptake of interventions at the health facility and outreach sites, covering Management Supervision; Facility Reports; and MOH and LGA Reports. See attached checklist.
Outcome of Supportive Supervision (SP) Visits for 6 Months (August, 2023 to January, 2024)
Some Pictorial Evidences
Discussion
Community initiated awareness creation to increase uptake of essential interventions by WDCs in Tai, Opobo/Nkoro and AkukuToru LGAs is monumental and goes to bring out the practical intent of Clause IV of the Alma-Ata Declaration of Primary Health Care in USSR, 1978. The import of this was also highlighted in the polio-free declaration in Nigeria on August, 25, 2020, by the World Health Organization (WHO), wherein it brought joy to many persons, particularly the drivers of the health sector, due to huge milestone after years of hard work eventually paid off. Hence, with much attention on the availability of vaccines, but little given to community engagement and mobilization as well as enlightenment and sensitization. However, this was therein after championed by the Ward Development Committees (WDCs) at community levels [6].
Collaborative effort towards infrastructural development to enhance effective health care delivery as palpably pronounced in MPHC, Kalaibiama, Opobo/Nkoro LGA, WDC, cluster is a key paid-off primary health care strengthening mechanism and this corroborate with the declaration in Dalaram ward, Jere LGA, Borno State, where the WDC was first drawn with support from Infrastructure Concession Regulatory Commission (ICRC) and WHO, that implemented a few health projects in the ward via them. Even, when the health clinic in the community was newly renovated and equipped with support from the state government, the WDC also supports the mobilization of funds for providing hospital supplies and other services required for the smooth running of the health facility [6].
Spirit of collaboration to improve access to essential services at the health facility as fronted in CHC, Oyigbo and MPHC, Ogu clusters in Oyigbo and Ogu/Bolo LGAs are practical display of taking up responsibility of the health concerns of the people in their respective locality to promote health care seeking behaviour. This is supported by the study of [7], where various horizontal collaborations, including community-led, primary health facilityled and individual-led, foster increased use of PHC services and promoting community health, via advocacy, building and renovating PHC centres, equipping facilities and sensitization to educate community members on the essence of utilization of services at the PHC centres.
WDC initiation of protection and promotion of health of the people and active participation in the reduction of missed opportunities in uptake of essential interventions as proven in MPHC, OmunweiIgwuruta, Ikwerre LGA is quite significant in the prevention and control of diseases of public health concern, more so, vaccine preventable diseases. This is quite in line with [8], statement as thus “Beyond improving immunization coverage, the aim of reducing missed opportunities for vaccination (MOV) is to improve health services delivery and promote synergy between programmes”.
Community resources mobilization to enhance effective service delivery and improved coverage of community-based vaccinations as seen in MPHC, Mirinwanyi and MPHC, Elekahia clusters in Oyigbo and Port Harcourt City LGAs are further examples of intent and driving force toward ownership of primary health care by the community. This stance is equally supported by [9] as saying “…some countries have experience of information sharing and of involving communities through area development committees and boards, which are examples of community organizations supporting health action in the locality, furthermore, these findings indicate that experience in community mobilization exists in the Region and this can be built on to attain health for all with the full involvement of people” and also clearly stated the importance of guiding countries on how to promote and launch community participation to make communities become full partners in health action.
Youths stimulated efforts in increasing uptake of essential interventions targeting ANC and health facility delivery as shown in PHC, Usokun WDC cluster in Degema LGA, gave a clear indication of male involvement in reproductive and maternal health issues and assurance of value for family healthcare expenditure. This is corroborated by the study of [10], with the findings that descriptive and text mining analysis revealed male involvement has been conceptualised by focusing on two principal aspects - psychological and instrumental support for maternal health care utilization, with ANC attendance, the most used indicator (40%), followed by financial support (17%).
Political Will towards infrastructural development to enhance effective health service as recorded in MPHC, Ogbema, WDC cluster in Abua/Odual LGA, makes great meaning and typical example of citizen participation in the political economy through a councillor [2], noting that Ward Councillor is a member of WDC. This position was reechoed in the study of [11], 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.
Conclusion
From all indications, the model is indeed unique in enhancing the drive towards community ownership and achievement of health for All. More so, adoption and implementation of the recommendations will overtime, optimally improve the utilization and uptake of essential interventions to improve the health indices in Rivers State and indeed Nigeria.
References
- NPHCDA (2018) Ward Health System, 2nd Edition.
- Federal Ministry of Health (FMH) (2021) Basic Health Care Provision Fund, Training Manual on the BHCPF: A Guide for Facilitator.
- USAID (2023) Nigeria Ward Development Committees Drive Community Action by Helping Women get to Health Services.
- Federal Ministry of Health (FMH) (2019) Nigeria’s Health Promotion Policy.
- Field Report (2024) Supportive Supervision to WDC Meetings, August 2023 to January, 2024, Rivers State, Nigeria.
- Nigeria Health Watch (2022) Ward Development Committees: The Silver Lining to Primary Healthcare Delivery in Borno.
- Obi C, Ojiakor I, Etiaba E, Onwujekwe O (2024). Collaborations and Networks within Communities for Improved Utilization of Primary Healthcare Centers: On the Road to Universal Health Coverage. Int J Public Health 69: 1606810.
- WHO (2024) Essential Programme on Immunization. Reducing Missed Opportunities for Vaccination (MOV).
- WHO (1997) Technical Paper on Mobilization of the Community in Support of the Health for All. Regional Committee for the Eastern Mediterranean, forty-fourth session.
- Galle A, Plaieser G, Van Steenstraeten T, Griffin S, Osman NB, et al. (2021) Systematic review of the concept ‘male involvement in maternal health’ by natural language processing and descriptive analysis. BMJ Glob Health 6: e004909.
- Chukwuma A, Bossert TJ, Croke K (2019) Health Service Delivery and Political trust in Nigeria. SSM Popul Health 7: 100382.