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


Pregnant women and infants are at risk of dying from often preventable diseases and complications related to pregnancy and birth, particularly in sub-Saharan Africa. Evidence suggests that schemes involving Community Health Workers (CHWs) are effective in improving the health of mothers and their infants. Although an increasing number of CHW schemes are being implemented in developing countries, greater clarity is required on what makes CHW programmes successful and under what circumstances.

Despite cutting maternal and infant mortality by half between 1990 and 2008, maternal and child health (MCH) remains an issue of concern in Nigeria, particularly in rural areas where the most vulnerable groups live. In 2012, the Government of Nigeria started a 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.

SURE-P comprises supply and demand components. The first aims to broaden access to quality maternal health services and improve MCH outcomes through recruiting CHWs, improving infrastructure development and increasing the availability of supplies and medicines. The second aims to increase utilization of health services during pregnancy and at birth through the use of a conditional cash transfer (CCT) programme. CCTs are given to pregnant women who register at a primary health care (PHC) centre, where they get health check-ups while pregnant, deliver at a health facility, and take their baby for the first series of vaccinations.

Aims & Objectives

The aim of this project is to better understand to what extent, and under what conditions, the CHW programme (with or without CCT) contributes to achieving equitable access to quality services and MCH outcomes in Nigeria.

The specific objectives are to:

  1. Understand the context and the process of implementation of the interventions.

  2. Identify, assess and compare the intervention outputs and outcomes.

  3. Develop a model of complex relations between the actors, context, implementation processes, outputs and outcomes of the interventions.

  4. Develop transferable best practices for scalability and generalizability of the interventions.


This is a five-year multi-disciplinary and mixed methods study that makes use of four disciplines of health policy and systems research: realist evaluation, health economics, social sciences and statistics.

  1. Realist evaluation will provide an overall methodological approach to guide the development, testing and refining of middle-range programme theories and the analysis of the relationships between the context mechanisms and outcomes.
  2. Social science methods will be used to explore views of key actor groups to develop, test and refine the study hypotheses.
  3. Economic evaluation will be used to assess the programme benefits relative to costs, using incremental approach.
  4. Statistical analysis of quantitative data from the HMIS and SURE-P M&E system will enable us to determine the extent to which the interventions achieved improvements in MCH services and health outcomes.

The mixed methods design includes exploratory (qualitative methods followed by quantitative), explanatory (quantitative then qualitative), embedded (one dataset provides supportive secondary role) and convergent (both provide complementary datasets) models. This project shall deploy the convergent model, to allow continuous integration and triangulation between, quantitative and quantitative methods.

You can download the conceptual framework here.

The project uses an input-process-output-outcome continuum (see Figure above). We will explore how inputs lead to processes, how processes lead to outputs and how outputs determine outcomes. We will also identify and assess the relationships within each stage of this continuum: whether and how the different inputs complement each other; any catalysing or mutually negating effects between the processes (e.g., implications of staff absences due to training on availability and quality of MCH services); and any relations between the different outputs as well as between the different service outcomes. We recognise context as a key influence in achieving the intended results. Therefore, instead of attributing the change in health outcomes to programme only, we will explore the contribution of the interventions to achievement of desired effects, within the wider context. We will explore context not only at the macro level (e.g. political and resource environment) but, as literature suggests, also at the meso-level (e.g. organisations and their roles) and micro-level (e.g. capabilities, values and interests of individuals, shaping acceptability of the intervention). We will also assess the relationship between the supply and demand of programme components, which are recognised to provide the continuum of care.

The final policy brief has now been published and is available here

Project Partners


We will ‘embed’ the research strategy development and assessment into policy and practice, working with the Federal, State and local actors. This project will make a timely and important contribution to health systems strengthening, within Anambra State, Nigeria more generally and beyond. We will improve understanding of performance of complex interventions involving both supply and demand sides and will conduct an in-depth analysis of key contextual facilitators and barriers affecting achievement of outcomes. The study will also identify and assess spill-over effects from SURE-P on other programmes and, ultimately strengthen other health programmes at PHC level.

Lessons from this study will inform the integration of programmes at the PHC level through a greater use of CHWs and strengthening PHC more generally in Nigeria and wider. The study results can also inform strengthening the different components of the national health system e.g.: assessment of context will inform the best practices in PHC staff performance management; assessment of the added value of CCTs will inform further demand-side financing schemes.