While maternal and newborn deaths has been decreasing since 2008 in Rwanda, there is room for improvement to meet its sustainable development goals. The maternal and newborn health care program needs to be monitored to ensure its effective implementation. This study therefore aimed to explore stakeholder’s perceptions of the Rwandan maternal and newborn health care program to identify areas for improvement.The convergent, parallel, mixed method study used quantitative and qualitative data in a single phase. The quantitative data was obtained from 79 health care workers, ranging from maternal community health care workers to program supervisors. The 10 areas of the Project Implementation Profile (PIP) instrument checklist with a five-point Likert scale were used to indicate their perceptions (strongly disagree to strongly agree). The qualitative interviews of five nurse managers used a manifest inductive content analysis, directed approach that entailed using existing theory and prior research to develop the initial coding scheme before starting data analyse.n = 14/79) indicating that they did not agree that this was adequately provided for; urgent solutions for unexpected problems was regarded as an areas of concern by 46.8% (n = 36/79). Top management support weakness were inadequate support training, materials, money for home visits, supervision and leaderships, and training of newly recruited maternity health care workers. For human resources, there were insufficient trained staff to take care of mothers and newborns due to the shortages of health providers. The management of unexpected problems was also an area of concerns and related to getting patients to health facilities during pregnancy emergencies and the lack of qualified birth attendants at health facilities.There was disagreement about the level of top management support, human resources was regarded as an area of concern, with 18.7% (The study identified three areas for improvement: top management support, human resources and urgent solutions for unexpected problems, as they may be affecting the provision of maternal and newborn health care program services. Using the PIP enable managers to improve the country’s maternal and newborn health care program, and to provide ongoing monitoring and evaluation of with respect to the desired outcomes of reducing maternal and neonatal mortality.The online version contains supplementary material available at 10.1186/s12913-021-06824-3. Globally, the number of annual neonatal deaths decreased from 5.0 million in 1990 to 2.5 million in 2018 . Sub-SahOf the women who die from causes relating to pregnancy, childbirth or postpartum , 99%  ranges from 266 to 1667 per 100,000 live births (LB) . A studyIn Kenya, the maternal mortality ratio was 362 deaths per 100,000 live births and neonatal mortality rate 22/1000 live births in 2017 , with frIn Rwanda, the rates of newborn mortality have been slow to decline, and constitute approximately one-third of all child mortality , 13, witNewborn deaths remain higher than desired  in Rwanda , 17. MNCPinto and Slevin  identifiThe maternal and newborn health program targets are in line with Rwandan Health Sector Strategic Plan 4 to address the maternal, neonatal and child challenges facing the country. The program started in 2008, when the National Roadmap was adopted to campaign for the accelerated reduction of maternal, newborn and child mortality in Africa (CARMMA), an initiative by the African Union (AU) Commission to address the associated challenges. The CARMMA is derived from the key priority areas enshrined in the AU policy framework for promoting sexual and reproductive health and rights in Africa (2005) and the Maputo plan of action (2006). In May 2009, the AU launched the CARMMA during the 4th session of the conference of AU Ministers of Health held in Addis Ababa, Ethiopia, to trigger concerted and increased action towards improving maternal and newborn health and survival across the continent. At the 5th conference of Ministers of Health in 2011 it was agreed that the CARMMA should be expended to address newborn and child health .In Rwanda, the maternal and the newborn health program includes the roadmap  that outlines approaches to reduce mortality, as well as strategies for improving the quality of facility-based primary and referral care, provide kangaroo mother care  and community-based services for women during and after pregnancy. The home-based maternal and neonatal health care package (HB-MNCP) was adapted as a strategy to reduce maternal and neonatal deaths, and is a part of the program .Pinto and Slevin  identifiThe project mission and goals need to be clear, specific, operational, and understandable . Rwanda’This is required to gain the necessary resources to adequately support a project through to completion . In RwanAll the activities needed to ensure successful program implementation should be scheduled, and the necessary people, money, time and other resources allocated. Furthermore, it must include a workable plan and assess the implementation process against the scheduled expectations . In RwanThis entails including persons who will be the project recipient or participant, and could be persons outside or within a related health department . In thisIt is important to include adequate personnel in a program, ensure their training, associated infrastructure and continuing professional development (CPD). There need to be criteria for selecting, recruiting, developing and retaining MCHWs and trained health providers . Sliven Successful project implementation needs to be managed by skilled people who understand the program and are able to implement or use the required technology . The RapThe use of the health facility services needs to be negotiated with the clients , these bThis refers to the project control processes, and entails keeping abreast of how a project is progressing compared to initial projections at each stage of its implementation and thereafter. Monitoring and feedback refers not only to observing project schedules, processes and budgets, but to the performance of members of the project team, and providing feedback about what works and what does not to enable changes to be made as needed . This enTwo-way communication is essential within and between the project teams, the organization and the client, and requires information about the project being available to all levels of operation. Communication must be clear within the project team, and in accordance with the goals and objectives of the project. The team members need to have formal channels of communication and regularly provide written status reports . In RwanThis is the ability to urgently address any unexpected problems that might arise that requires each team to have technically competent people with specific roles that are supported by effective systems and processes . In RwanThese 10 critical success factors were investigated in this study to establish the health workers perception of the effectiveness of its implementation, and could be adapted for the maternal and newborn health care program and used as the routine tool of monitoring and evaluation.This study entailed the use of quantitative and qualitative techniques within a convergent, parallel mixed method methodology that requires both quantitative and qualitative data to be collected during a single phase of research . Mixed m: Kibogora District Hospital, Kibogora and Nyamasheke Health facility .The Rwandan public health system consist of four levels: community, health facilities, district hospitals and national level hospitals being the final referral point, with the health system being decentralized to the district level. Rwanda has five provinces, with three public sector districts hospitals being purposively selected from 30 within the three of the provinces of Kigali City, Eastern Province and Western Provinces, and two each of their urban, semi-urban and rural associated health facilities being selected for inclusion. The health facilities were select based on their accessibility, these being: Kigali City Province: Muhima District Hospital, Muhima and Butamwa Health facility (urban); Eastern Province: Nyamata District Hospital, Nyamata and Mayange health facilities (semi-urban); Western ProvinceThe participants consisted of maternal community health workers (MCHWs) and all staff working in the maternal and newborn health care programs at health facilities and district hospitals, namely: nurses and data managers, the nurses and midwives in the maternity ward and immunization services, and the district-based community health worker supervisors. The nurse managers provide information about the implementation and integration of maternal and newborn health care program and are responsible for the MCHW training and overall supervision. The data managers are responsible for patient records kept and training the MCHWs to record and send data to the health facilities. The nurses and midwives provide PNC, delivery and ANC services to the women in their catchment communities. The district level supervisors MCHW supervisor are community coordinators who oversee the health facility-based MCHW supervisors.Non-probability convenience sampling was used to identify 100 individuals to participate in the quantitative PIP questionnaire. The staff at each of the six sites consisted of those working in the program  with 30% of the MCHWs being included out of a total of 224 in the three selected districts. The team in charge of the maternal and newborn health care program was purposively selected from each health facility or district hospital according to their availability during working hours. These consisted of 30% of the MCHWs, one nurse manager, one data manager, and two nurses and/or midwives in the maternity wards, and one district hospital level community supervisor. All those who provided informed consent completed the PIP questionnaire.Qualitative research typically involves purposeful sampling to enhance the understanding of the information–rich case . It is oA meeting was held with the selected staff at each of the six health facilities to outline the project, establish their willingness to participate and complete a written informed consent form, which they were given a copy of for their records, with standard ethical considerations being observed throughout the study. Those who provided consent were asked to complete the questionnaires, which took approximately 30 min, and were provided with assistance where required.Three data collection tools were used, the first being to obtain their demographic details on a standardized questionnaire, the second being the Project Implementation Profile (PIP) instrument to monitor the current perceived state of each of the 10 successes areas with all the participants , with permission to use the instrument being given by the Project Management Institute (PMI). The PIP instrument was initially validated as a useful diagnostic tool for practicing manager and adapted according to the program under investigation in this study . In the The trustworthiness of a qualitative study can be increased by maintaining high credibility and objectivity . This waThe participants provided demographic data from a questionnaire and indicated their opinions about the critical success factor of the Maternal and Newborn health care program through the PIP questionnaire. The quantitative data was analysed using various statistical measures that included a needs assessments and empowerment analysis. It provided an opportunity for a mixed methods study to contribute to learning about what worked regarding the implementation of the program as well as to explore its effectiveness in achieving the desired maternal and newborn health outcome .The participants were asked to indicate their perceptions about the 10 key performance areas of the PIP regarded as important in maternal and newborn health care programs. The five-point Likert scale answers ranged from 1 = strongly disagree [SD], to 5 = strongly agree [SA]. The mean of each statement was out of 5, with the scales being grouped into three categories of (1) disagree, (2) Neutral (3) and agree. The data was analysed using the statistical package for Social Sciences (SPSS 25.0), with a mean value of four being required to be regarded as an indicator .. The quThe qualitative analysis entailed content analysis, which required identifying codes, with the initial categories being revised and refined with ongoing analysis. A directed approach was used for the 10 PIP areas in the context of study, hence that used for qualitative data being directed content analysis . This prThe qualitative analysis entailed the following analysis processes:(1) Transcribing interviews and sorting field notes: a combination of audio-taping of participants responses and field notes for observations were used during the individual interviews.(2) Ordering and organising the data: the recorded material was cross checked and labelled for final analysis, with the material being stored in appropriate files for later retrieval.(3) Analytical steps: this entailed a variety of analysis measures, such as listening to, viewing and gaining a holistic view of the data, as well as dividing them into units or segments of meaning. The analysis steps were: reflect on each transcript and search for significant statements; record all relevant statements; delete repetitive and overlapping statements; leave only invariant constituents of the phenomenon; organise, link and relate these into themes, including verbatim quotes from the data; integrate the themes into a description of the texture of the experience as told by the participants; reflect on this and their own experiences; and develop a description of the meanings of the experience .(4) After obtaining written meaning of their experiences, the researcher returned to the supervisor for a review of the analysis process.The point of interface for the mixed methods entailed the convergent parallel design collecting and analysing two independent strands of quantitative and qualitative data at the same time in a single phase. It prioritizes the methods equally, keeps the data analysis independent, combines the results during the overall interpretation in an effort to find convergence, divergence, contradictions, or relationships of the two sources of data .Triangulation, which can combine quantitative and qualitative methods, was used as some of the participants who completed the questionnaire were interviewed, with the answers from the two data sets being compared . Data trEthical considerations, which are related to the protection of the rights, dignity, safety and well-being of human subjects, underpinned this study. According to Brink (2006), a researcher is responsible for conducting research in an ethical manner and must have paid attention to all requirements . The mayAccording to Emmanuel, Wendler, Killen and Grady (2016), it is important to subscribe to ethical standards , with thThe anonymity of the target population was ensured by not having any personal identification attached to the data collection responses. Participants only agreed to volunteer if sensitive information was held in confidence. For the questionnaire, confidentiality was guaranteed by using coding and storing the completed forms in a locked cupboard in a locked room at the School of Nursing at the University of KwaZulu-Natal, which will be kept for a period of 5 years before being shredded. Only the researcher and the research supervisor have access to the data collected and copies of relevant review documents.The participants need to understand their contribution to the study and what the researcher is asking them to do. Thus, participation in this study was voluntary and details about the aims, research methods (what was done to collect data), objectives and the potential outcomes were explained. All participants completed a written informed consent form and each was given a signed copy for their personal records.During the research process, the participants were informed that participation was voluntary, they had the right to withdraw at any stage and not to answer any questions without this affecting their employment in any way ..The participants’ demographic details are followed by the results of the PIP questionnaire and the qualitative data from the semi-structured interviews of the five nurse managersn = 72) were women and 78.5% were from rural and semi-urban areas. Most  were aged 35–39 years, and 65.8% (n = 52) were MCHWs, while 7.7% (n = 6) were nurse managers, data managers and health facility MCHW supervisors (Table n = 71) had worked in the maternal and newborn health care program for more than 4 years, over half  had completed their primary schooling and 22.8% (n = 18) had a university qualification  felt that the program mission (No. 1) was adequately addressed, while there was disagreement about the level of top management support (No. 2) (Table n = 74/79) that the program’s scheduled plans (No. 3) were in place and that client consultation (No. 4) had occurred . Human resources (No. 5) was regarded as an area of concern, with 18.7% (n = 14/79) indicating that they did not agree that this was adequately provided for. A few respondents  did not agree that the technical tasks (No. 6) were adequately available, while 98.6% (n = 75/79) agreed that client acceptance (No.7) was satisfactory, as indicated by their attending the program services.The results of the quantitative PIP questionnaire with 10 success areas were responded to by 77 participants  agreed that monitoring and feedback (No.8) was done to monitor the progress of the program, while 97.4% (n = 75/79) agreed that adequate communication (No.9) was in place. Urgent solutions for unexpected problems (No. 10) was regarded as an areas of concern, with 46.8% (n = 36/79) indicating that they did not agree that there was a way to identify unexpected solution strategies. Three categories were below the mean value of 4 , these being top management support (No. 2) , human resources (No. 5)  and urgent solutions for unexpected problems (No. 10)   provision of guidelines about MNH care program, (2) regular meetings for MCHWs and health providers, (3) health facility delivery, (4) continuing professional development, (5) community work (umuganda) and (6) announcements in churches and markets.The Ministry of Health provided guidelines at all levels on how to take care of mothers and newborns. The staff and the MCHWs communicate all the required information to the mother. The country provides guidelines at all levels on how to take care of mothers and newborns. We hold regular meetings on a monthly basis … At the central level, the Ministry of Health  decentralized the MNH care guidelines to district hospitals, where relevant staff and community health supervisors implement programs that fall under their supervision. From the district hospitals, the supervisors have to distribute to the next level, the health facilities, and communicate with health facility management. The Health facility nurse managers communicate with the MCHWs by providing information and support. The health facility nurse managers described how the decentralized guidelines are disseminated to their staff and communities. The decentralization of maternal and newborn service guidelines and dissemination of information enables the health system to introduce material to all relevant staff down to the MCHWs, who are an important link for pregnant women, mothers and newborn community to access the health system at Health facility. The nurse managers explains:Then nurse managers indicated that the MNHC program mission is communicated to the MCHWs and health providers through (a) regular meetings held at health facilities and in communities, (b) educative talks during ANC appointments and (c) MCHWs meeting at health facilities.a. Regular meetings: at health facility, the nurse managers hold meetings once a month and communicates to the health providers any new programs or changes to existing ones. They may also hold short meetings in the morning before work starts, where they communicate instructions or information received from the upper health levels. The meetings are the channels of updating the health providers on maternal and the newborn health care program. The health facility nurse managers also update the community level service providers and recipients, including the MCHWs and families through the health education and campaign about new programs to reduce maternal and newborn deaths. The qualitative data supported these findings, with participants explaining:We communicate the program goal to the health providers of the program team, MCHWs, mothers and their family group through regular meetings … b. Educative talk or health education: health facility staff provide information to pregnant women attending ANC services while they visit the health facilities. There are also peer group discussion facilitated by health providers who convey relevant information, including any service changes. The health facility community health supervisors have a scheduled monthly agenda to visit the MCHWs in their communities to update them on new programs or changes to the MNH care program. These activities contribute to updating the community and evaluating the pregnant women’s practices as part of the program.. We hold educative talks with the pregnant women during their peer group antenatal care services. We hold a meeting each month with MCHWs on how to improve the services for our clients. Each month, we go to the community to explain the program to the mothersc. MCHWs meeting at Health facility: the MCHWs attend monthly meetings at health facilities and submit monthly reports about what services they provided in their communities. The monthly meetings and MCHWs reports are a way of updating the health facility and district managers and supervisors about what services are being provided, given the resource limitations, and how problems that arise are addressed, thereby enabling the system to be monitored.Regular meetings are held with MCHWs at the health facility and MCHWs provide information to the Health facility. MCHWs give us reports that contain necessary information; also, some explanations are provided to the staff regarding the importance of the program … We sensitize our clients every day before service provision. Health education talks are scheduled to explain the program to the mothers. Several times, we go in the community to explain the program to the mothers. The goal is explained to the community by the MCHWs; they explain the importance of delivering at the Health facility. We explain to the staff and the people the importance of the program. We explain to the MCHWs the importance of delivering at the health facility. Then the MCHWs mobilize the mothers to deliver at a health facility. The nurse managers explain to the MCHWs and health providers the importance of shifting delivery from home to health facilities to enable the women to access skilled birth attendants. The trained health providers on the MNHC program provide information to their colleagues and during community health education session. This is due to a concern about the high number of home delivery and the need to reduce the problems that could occur without the attendance of skilled health providers . One nurse manager said::Top management offer continuing professional development (CPD) to health providers to allow them to improve their knowledge and explain the program to people, and we have enough and appropriate materials provided to perform our work correctly. A nurse manager revealed that the national Ministry of Health offers, promotes and authorises ongoing training for health providers in their working place to improve their knowledge about maternal and newborn health care programs, and to ensure that they have the appropriate skills to provide the required services. This also takes the form of continuing professional development, with programmes being developed and provided by Ministry appointed staff. This requires the provision of training materials to enable instruction to be provided at the work place, including updating the health providers on MNHC guidelines, policies and program tools. A manager explainsWe communicate and explain the goal of the program in community administrative work (Umuganda). We use advertisements in churches and markets explaining the goals. The nurse manager emphasized that the MNHC program mission is communicated to enable community sensitization (Umuganda), which is scheduled by the Rwanda Government once a month on the last Saturday at meetings, as well in churches and at market events. In Rwanda, umuganda is done once each month, where the local government administration ensure that work done by the community, such as hygiene around the households. After the activities, there is a talk about health or issues that the local administration wants to raise with the community. The church leaders also make announcements at the request of government, and allow a brief talk about the MNH program to be given during the service. In open markets, once agreed by the local government authority, public announcements are made using a microphone to communicate information about a relevant subject, such as the MNHC. The participant explains:The issues identified by the informants as part of top management support were training the MCHWs and health providers, and providing materials, money for the MCHWs to make home visits, supervision and leadership..Top management support us in the MNH care program by providing training for staff in order for them to improve their knowledge. Money for visits is provided, but not enough. Supervision and leadership on field are ensured. However, although everything is provided or supported, it seems not enough; we need more trainings, supervision, leadership, and money for home visits .We received training to improve the knowledge of the staff, and some materials are provided to perform the work, but still materials and training are not enough, especially training for newly recruited MCHWs The nurse managers revealed that the MCHWs and health providers received support from the Rwanda Ministry of Health in terms of training, materials, money for home visits and supervision. While these was support from top management, the nurse managers indicated that it was inadequate and inconsistent, making providing ongoing services difficult. The distribution of money depends on the Ministry of Health and its partners’ budgets, or what was made available for each program. They indicated the need to address issues related to training programs and materials, money for the MCHWs home visits and supervision in order to improve maternal and newborn health. The absence of this support made it difficult to provide the services, as indicated by a nurse manager:In the program, the following categories of activities were identified: (1) MCHWs visits to communities, (2) health facility staff visits to communities, (3) antenatal care service and (4) immunization scheduled.We have a daily plan for MCHWs. For every activity done by MCHWs for mothers in the community, an SMS is sent to inform the health facility. We have a plan for community visits; it is once per months, and we give mothers advice about the Maternal and Newborn Health Care program. The MCHWs visit the mothers throughout their area to make sure the advice is followed. The nurse manager noted that the MCHWs are required to visit community members, with specific appointment schedules needing to be followed when a woman is pregnant and once she had delivered. This required them to have daily plans to follow-up and advise the women in their communities. The MCHWs also need to submit their monthly reports to the health facilities to enable them to be analysed and reported on. Communication between the MCHWs and health facility occurs via SMS using cell phones that are provided to enable them to have quick access to support. Health facility community staff in the MNCH program have a community visit once a month when information is shared and problems addressed. The villages consist of 50–100 households, with each MCHW providing services to approximately 30 households. While mother in their catchment areas should be seen once a month, it can be difficult for the MCHWs to keep to their schedules as they work voluntary and do not always received the financial support to visit the women and neonates who need their care. Nurse Manager explains:, with the MCHWs making up to 150 visits to the mothers per month in their catchment areas, with one pregnant women and mother being visited by a MCHWs at least once per month. They are required to provide a report once a month to the health facility, and are supervised by the health facility supervises once a semester. The schedule of looking after the mothers in their communities is known by the MCHWs, who inform their supervisors at the health facilities. The participant explained:Manager 1, rural)The maternal community health workers’ schedule include visiting every mother once a month in her catchment area. MCHWs make a report once a month. The schedule for MCHWs supervision is once per semester. Each month, we go into the field to explain the program to the mothers. When the MCHWs know that a mother is pregnant, they do the follow-up and advise her to go for antenatal care service early at a health facility. The health facility is open 24 hours, ready for ANC services. We are available for pregnancy tests every day. Every month, we hold meetings to explain the maternal and newborn health care program to the mothers. The Community health workers visit mothers every day to make sure the advice is followed. The nurse manager noted that the MCHW are responsible for ANC maternal health within their communities to identify pregnant women, make regular follow-ups during the pregnancy and encourage delivery in health facilities where skilled health workers are available. Pregnant women are encouraged to attend the health facility for ANC services during the 12th weeks of gestation, with Rwandan culture often requiring that women hide their pregnancy until the 4th month, making it difficult to identify and address problems. The health facilities are open 24 h, where health providers work shifts to ensure continuous access to care. The health providers explain the ANC services they offers, and advise the mothers to access their services at any time to prevent complications and ensure a safe delivery. The nurse manager explains:We have a schedule of vaccination (immunization) and antenatal care services on different days throughout the week … The participant revealed that the health facilities offer child immunization and ANC services as part of the MNH care program, these being scheduled at different time during the week. The staff at the different levels are able to communication with and remind the pregnant women and mothers with newborns to attend the relevant services on the appropriate dates. The participant explains:Regarding how the staff consulted the program clients as program users to find out what they thought was required, the nurse managers indicated that this was done during the MCHWs home visits and by providing a suggestion box at the health facility.MCHWs visit the clients of our maternal and newborn health care program and send us a rapid SMS. We consult the clients of the program; we ask our stakeholders if they are satisfied with the services, we offer to them and ask them to tell us how to improve the services. In addition, they are free to use suggestions boxes to write to us telling us what they need for improvement. Home visit by MCHWs and a suggestion box were the channels of communication through which consultation occurred between the health facility, MCHWs and mothers. The participant revealed that the health facility staff communicate with clients  by home visit undertaken by MCHWs, and at the health facilities, where suggestion boxes were provided for users to put their comments or recommendation about to the services received or required. This included issues related to the quality of services received by mother, pregnant women and their family as part of ongoing monitoring. The participant explains:The data obtained from the participants revealed the presence of MCHWs, A2 nurses, A1 and A0 midwives, MCHWs supervisors and data managers, but that there were shortages of some categories and additional training was needed..The participants revealed that the MNHC program had insufficient professionals and nonprofessional health workers, including A2 nurses, A1midwives, MCHWs and inadequate trainingWe have A2 nurses, and MCHWs who can read and write, and some of them hold at least 3 year secondary school certificate, and the MCHWs supervisor hold an A1 … In the MNH care program, we have maternal community health workers who have all the required materials, they are always provided with the materials that are needed. The maternal community health workers need to be trained … The people in this area move too much, change their dwelling too much; maternal community health workers cannot follow up on them. We don’t have any midwife; we are waiting for his or her appointment. Manager 1, rural)We have one A1 midwife, two A2 nurses well trained and very competent … We do not have enough trained staff to take care of mothers and newborns; we have one midwife (A1) and nurses but their number is not enough … The Rapid SMS system uses a cell phone: the MCHWs send a message to the Ministry of Health, then feedback from Ministry of Health is provided through an SMS alerter, We use a telephone to send a rapid SMS to the Ministry of Health and the Ministry of Health sends feedback to acknowledge receipt. The MCHWs use a telephone to send a rapid SMS to the Ministry of Health providing information on pregnant women. When there is a danger, the MCHW sends a message to the Ministry of Health and the system informs the sector concerned. The system indicates to the MCHWs how to intervene in the case of difficulties. The nurse managers described how the use of the RapidSMS works, which is a platform that channels communication between community health workers, the ambulance system, health facilities staffs, and the central level . Mobile phones, a charging device and airtime are provided for the MCHWs, the technology enabling message to be sent from them to the health facility staff, who send feedback with relevant information, with skilled staff being available to provide training on any changes to the RapidSMS system. However, there have been a number of challenges to its effective use, these being network problems and uncharged batteries, which can affected communication during emergencies, when information or ambulances need to be requested. The participants explains:The nurse managers felt that the clients had accepted the program services, specifically the MCHWs in their communities, who were trusted and respected members and offered useful and relevant advice. Regarding the interaction between the mothers, MCHWs and health providers, the informants identified the following category as being important: (1) communication between mother and MCHWs and (2) referrals between community, health facility and district hospitals.. When a problem arises in relation to the MNH care program, the MCHWs send us information by phone. Then, the staff works with the MCHWs who has sent the information and share the information with us (HF manager). The health facility sends back the information required to the maternal community health workers advising them on how to solve the problemsWhen mothers experience problems in the community, they inform the MCHW on duty who has been selected in the village; then MCHW intervenes, solves the problem and communicates with the health facility. However, when the problem is hard for them to solve the MCHW sends the mother to the health facility. The managers revealed how the users of the maternal and newborn health care program, especially mothers, had accepted the services and found that communication with the MCHWs was an important link to their use at higher levels. The mothers communicate with MCHWs when they have a problem, which the MCHWs relay to higher level health providers for advice, which they feed back to the women. For those in rural areas who cannot easily access health services, the MCHWs provide an important intermediary step through which services and information can be accessed, as noted by a respondent:n = 65/79) of pregnant women were given referral notes from the MCHWs to present at health facilities, while 53.2% (n = 42/79) are given referral notes to give back to the MCHWs when they returned home. There is a need to improve the number of referral notes provided by the health facilities to the MCHWs for continuous of care to be ensured.The staff work closely with MCHWs who deal with the problem; if they cannot solve the problem, a document is written and sent to the health care center. The health center sends required information to the MCHWs. The mothers inform MCHWs who deal with the problem. Sometimes the MCHWs send the mother to a health facility with a document explaining the case. The health facility provides care to the mother and sends required information to the MCHW. This means that the mother may come to the center so that we deal with the problem. In case the problem cannot be resolved at health facility level, the health facility sends the mother to the hospital. The nurse managers described the acceptance of health facility services through the use of referral forms as a means of communicating information, problems and solution between the different levels of care. The referral form support the transfer of patients to higher levels of care, from the MCHWs to the health facility and district hospital when more specialized input is needed. The results of the larger study found that 82.3%  MCHWs, staff and executive managers.We conduct regular meeting to monitor the progress and improve the feedback to the program team at the health facility. The monthly meeting with all MCHWs is chaired by the HF manager. The health facility helps the maternal community health workers to monitor the progress. We hold monthly meetings with the staff and monthly meetings with executive community general assembly. We hold a meeting every month with maternal community health workers to discuss the progress of the program, and a monthly meeting with the staff to talk about the activities running in health facility and find a solution to any problem raised. We hold regular meetings with health providers; we can update them on the program as well as the importance of the program … The participants commented on the regular meetings conducted to monitor program progress and improve feedback to the program team to enhance the MNH care services at all levels. The MCHWs were required to attend monthly meetings to raise problems, address areas of concern, and obtain feedback from previous discussions. Meetings were held monthly with all the health facility-based staff involved in the program to address local issues and those related to referrals between the MCHWs and district hospitals. The managers from the district hospitals and health facilities held executive meetings to address system and process issues, as well as those raised during the MCHW and staff meetings. All the meetings were focused on monitoring the implementation of the program, and providing feedback to all health providers in the team to ensure overall coordination of activities and information, and to address problems as they arose. The participant explains:Regarding communication between the program teams and their clients, the following issues were identified by the informants: (1) refer and accompany mothers to health facilities, in emergency cases, the ambulance is called, and the Rapid SMS system is a rapid and effective method.MCHWs refer pregnant women for ANC, accompany women to health facilities for delivery, and refer mothers and newborns for PNC … Another participant said… the MCHWs do the follow-up of mothers and babies at community level, with the health facilities, and in case of emergency, the ambulance is called … MCHWs were given mobile phones that enabled them to collect and receive real-time data on maternal, neonatal … in their catchment areas by SMS When pregnant women, mothers and newborn have issues that cannot be addressed by the MCHWs, they inform the health facility by sending an SMS or calling the nurse manager, who assists with advice or information. The health facility may sends an ambulance or the MCHWs refer and accompany mothers to health facilities. This often occurs when emergencies arise in communities that the MCHW cannot solve on their own, or do not have the authority to make decisions about. Most health facilities in Rwanda do not have ambulances, these being located at the district hospitals, with the former having to call the latter to access this service, which may be in use in anther district and results in long delays and people having to find other means of transport.Regarding managing unexpected problems that arise in the program, the nurse managers indicated the importance of communication between the MCHWs, mothers and managers at health facility and district levels, and where possible, to collaborate with community leaders.When an unexpected problem arises in the program, the MCHW supervisor at health facility level follows it up and inform us (nurse managers). Also, the District hospital MCHWs supervisor can help us when we have a problem. Emergency problems are dealt with at District hospital level. People may bring the mother at Health facility using the traditional transportation mode. If possible, and in case of emergency, we call for an ambulance. Manager 2, rural)The health facility resolves the problem, but when it is difficult to resolve the problem, we refer the mother to a higher level, the district hospital.  among existing maternal and newborn health care program in Rwanda were applied: (1) project mission, (2) top management support, (3) program schedule/plan, (4) client consultation, (5) human resource, (6) technical tasks, (7) client acceptance, (8) monitoring and feedback, (9) communication and (10) urgent solutions for unexpected problem.The convergent parallel mixed methods entailed the use of both quantitative and qualitative data, with the two data sets being analysed separately but combined for the interpretation and discussions of the results. The findings of the quantitative results from the PIP questionnaire showed that the three of the 10 areas need attention, these being top management support, human resource and urgent solutions for unexpected problem to improve the programs’ implementation and reduce maternal and newborn deaths, these being discussed further.While the quantitative data indicated the number of participants and the extent of their dissatisfaction with top management, the qualitative data provided the details of the components that they were dissatisfied with. Further research is required to establish if there are differences in the issues that need to be address between rural, semi-urban and urban areas. As most district hospitals are located in urban areas, the urban health facilities relying on them for support may have better access to services than rural ones.No. 2), with almost one fifth  indicating their dissatisfaction. In this study, the satisfaction was based on the key performance requirements for top management support, which were allocating adequate money; quantifying total resources required for implementation, especially for the program activities, and providing training, MCHWs equipment and supplies.In this study, top management support relates to the willingness of senior health services management to provide the necessary resources and exercise their authority/power to ensure that the maternal and newborn health care program is implemented effectively. The findings showed diverse opinions about the level of top management support  to implement this program. They were aware of the need to provide adequate and appropriate training for staffs, health providers and MCHWs; distribute money for home visits and materials, and ensure supervision and leadership in order to reduce maternal and newborn mortality. While such support was offered, the questionnaire indicated that the participants felt that it was insufficient. The interviews indicated that having only one ambulance for emergency transfers per district hospital, which included several health facilities, and only one delivery room in each health facility, was inadequate to meet the needs of those requiring such services.The Rwandan maternal and newborn health care program was initiated with the costs being shared between the MOH and development partners for various aspects, including training. Likewise, in many low- and middle-income countries, non-government organizations (NGOs) supplement the formal health system. These agencies are often relatively new, have unstable funding streams, inadequate ratios of staff members to the number of family served, and the donor /funder priorities guide the local programming, which results in many programs not being effective . This fiA theme identified in this study, the need for more training, materials, money for home visits, supervision and leadership, has been identified elsewhere in Rwanda . In addi(No. 5) was regarded as an area of concern, with 18.7% (n = 14) indicating that they did not agree that this was adequately provided for. A study conducted in Rwanda showed that health facility and community staff had insufficient training [In this study, insufficient human resources was identified as an area needing improvement by the participants, their responsibilities being recruitment, selection and training of the necessary personnel for the maternal and newborn health care program. Human resources training , which ctraining . This watraining . Aside ftraining .The Rwanda Maternal Newborn and Child Strategic Plan 2018–2024 noted the human resources challenges relating to enabling women to giving birth in health facility and being assisted by skilled providers, with quality of care being an ongoing problem. A focus on training additional skilled, competent providers, especially midwives, is an issue that needs to be addressed . The finDue to country–specific issues related to MCHWs, the selection of community health workers is often based on nomination rather than professional competence or capacity, and therefore requires extensive training. Organizations tend to identify socially competent and committed individuals who are good problem solvers and train them in the specific skills needed. Having likable, committed, smart staff who are invested in the MCH’s mission makes daily operations easier and offers the opportunity to deliver a high–quality program . High quThe nurse managers raised the issues of a shortage of suitably qualified health care providers in the program, with each health facility having only one midwife with an A1 qualification, while some nurses had A2 certificates, which is regarded as an inadequate qualification to provide quality maternity services in the Rwandan health system, these nurses being advised to upgrade their certification. Furthermore, they indicated the need to increase the number of midwives at the health facilities, as one was not enough for both the day and night shifts. Another study conducted in Rwanda also recommended an equitable health workforce, with training being essential to address the determinants of poor health and reduce health inequalities . A revieThe quantitative data from the PIP questionnaire indicated that human resources were a problem, with the nurse manager interviews providing details about the areas of greatest concern, indicating what needs to be done to improve MNH services in Rwanda. The human resources issues were insufficient midwives and training, with a call for advocacy for maternal and newborn health of sufficient quality to meet the SDGs.No. 10) as an area of concern, with 46.8% (n = 36) indicating that they did not feel that the staff were equipped to address this adequately. The findings are similar to that of Rwanda’s Ministry of Health Strategic Plan 2018–2024, which showed that this may be due to the inadequate healthcare workforce, this being one midwife per 4064 women aged 5–49, one nurse per 1094 people, one doctor  per 10.055 people, while the SDGs recommended 4.45 nurses, midwives and doctor per 1000 population [In the current study, urgent solutions for unexpected problem was highlighted  delaFinding appropriate urgent solutions entailed collaborating with community leaders, using traditional transport and communicating with the mothers and their families to alert them to possible issues to find locally relevant ways to address them. Some solutions could be time-consuming and result in delays in getting to health facilities to address the emergencies. This was reported in a study in Rwanda, which noted an inadequate workforce at health facilities, which prevents the more experienced staff from being able to undertake home visits, and that when problems arose among the maternal and newborn staff at health facilities, the possible solutions were not discussed among the staff due to these shortages . Many maThis article has potential implications for the body of knowledge that shapes policies that direct evidence-based maternal and neonatal health care practice in Rwanda. The study had highlighted the need for ongoing monitoring and evaluation using a comprehensive and standardized tool, such as the PIP, to enable managers to effectively implement the maternal and newborn health care program across the country. Differences between rural and urban areas need to be identified and addressed, as well as the effect of limited resources and constraints that are beyond the control of the Ministry of Health. Once it has been implemented, ongoing monitoring is essential to ensure that the standards and systems are maintained, and against which any change in service use and maternal and neonate morbidity and mortality can be evaluated.Regarding its limitations, the sample size was small and the study was conducted in only three district hospitals, which means that the findings cannot be generalized to all settings. While many MCHWs participated, very few staff at the health facilities were included, which may have affected the findings. In addition, this is the first time that the PIP instrument was used in Rwanda, and it may need modifications to ensure that it is appropriate for the county’s health care context.Implementing an effective maternal and newborn health program in Rwanda is an essential part of reducing morbidity and mortality in the resource-constrained country. Since its roll-out in 2008, the MNH has been implemented with varying levels of success around the country, indicating the need for ongoing monitoring to ensure that its weaknesses are understood and addressed, and its strengths are acknowledged and replicated. While most of the participants generally agreed that the key areas were being adequately dealt with, the three areas of concern of top management support, human resources and urgent solutions for unexpected problems needs further investigation to establish the reasons for these responses, and to find ways to improve them, as they may well be affecting the provision and uptake of maternal and newborn health care program services.Additional file 1.Additional file 2.


To accelerate universal health coverage, Nigeria’s National Health Insurance Scheme (NHIS) decentralized the implementation of government health insurance to the individual states in 2014. Lagos is one of the states that passed a State Health Insurance Scheme into law, in order to expand the benefits of health insurance beyond the few residents enrolled in community-based health insurance programs, commercial private health insurance plans or the NHIS. Public and private healthcare providers are a critical component of the Lagos State Health Scheme (LSHS) rollout. This study explored the determinants and perception of provider participation in health insurance programs including the LSHS.This study used a mixed-methods cross sectional design. Quantitative data were collected from 60 healthcare facilities representatively sampled from 6 Local Government Areas in Lagos state. For the qualitative data, providers were interviewed using structured questionnaires on selected characteristics of each health facility in addition to the managers’ opinions about the challenges and benefits of insurance participation, capacity pressure, resource availability and financial management consequences.A higher proportion of provider facilities participating in insurance relative to non-participating facilities were larger with mid to (very) high patient volume, workforce, and longer years of operation. In addition, a greater proportion of private facilities compared to public facilities participated in insurance. Furthermore, a higher proportion of secondary and tertiary facilities relative to primary facilities participated in insurance. Lastly, increase in patient volume and revenue were motivating factors for provider facilities to participate in insurance, while low tariffs, delay and denial of payments, and patients’ unrealistic expectations were mentioned as inhibiting factors.For the Lagos state and other government insurance schemes in developing countries to be successful, effective contracting and quality assurance of healthcare providers are essential. The health facilities indicated that these would require adequate and regular provider payment, investments in infrastructure upgrades and educating the public about insurance benefit plans and service expectations. Nigeria’s National Health Insurance Scheme (NHIS), established in 1999 but operational since 2005, has been faced with numerous challenges including the failure to mandate enrollment for the entire population and the consequent lack of adoption at the state government level .In 2015, Lagos state was the first of the 36 states and Federal Capital Territory to pass the State-Based Health Insurance Scheme (SHIS) into law . The LagPublic and private healthcare providers are crucial to the rollout and success of this insurance program. Their ability to cooperate and participate in insurance importantly determines the extent and quality of care that population members would access . HoweverPrior to the passage of the LSHS, Lagos state rolled out three community-based health insurance (CBHI) schemes, which altogether enrolled close to 40,000 community members . A progrHMOs are a major part of health insurance in Nigeria . For theOn the provider side, there have been complaints in the public media suggesting widespread dissatisfaction about the low tariffs, delayed payments, increased administrative burden and the losses incurred from participating in government and private insurance plans . Some, aThe two-sided economic theory by Sloan and colleagues can be used in the analysis of health insurance markets and provider response to insurance . This thProviders can act as imperfect agents of patients, desire to maximize profit, and thus, prefer to serve patients in a market where they can generate more income . This suUnder the insurance program characteristics, the reimbursement fee, amount of paperwork, speed of processing payment, inappropriate claims reductions and denials can influence provider participation . For exaUnder the beneficiary characteristics, the difficulty of patients defined by health need or risk level of beneficiaries, ability of patients to understand insurance benefit package and income level of patients may influence provider participation in an insurance program . ProvideThe characteristics of a health facility may also influence provider participation in an insurance program . For exaFinally, the characteristics of the market that affect the productivity of a provider such as the ease for providers to access capital and labor in the market, and the associated costs of accreditation, recruiting and training of staff, may influence provider participation in an insurance program . For exaUsing the theoretical framework as a guide, this study aims to answer three main research questions. First, what are the characteristics of provider facilities that do, and do not, participate in insurance programs? Second, what are the drivers and barriers to provider participation in insurance? Lastly, what opportunities and challenges do facility managers anticipate from the rollout of the LSHS? The findings from this study will provide an evidence-based guide to Lagos state and governments of many other low- and middle-income economies on how to contract with providers and expand their participation in health insurance scheme in a phased manner.This study was conducted in Lagos state, the economic and business hub of Nigeria with an approximate population size of 24 million people. As shown in Health facilities for this study were sampled from the health facilities in the database of the Lagos State Healthcare Facilities Monitoring and Accreditation Agency (HEFAMAA) . The datLGAs were selected to get a range of population and health financing characteristics. From the 20 LGAs in Lagos state, 6 LGAs were purposively selected for the study. The purposive selection considered the differences in the size of the LGAs, urbanization, number of health facilities, likelihood of insurance participation, and income level of residents. These are Alimosho, Ibeju-Lekki, Oshodi-Isolo, Eti-Osa, Mushin and Ikeja LGAs. From the 6 LGAs, there were 1,142 health facilities in the combined database. In each LGA, health facilities were selected using a multi-stage stratified sampling technique . Strata In the end, 60 facilities were selected. This number represented 5% of the total number of health facilities in the six LGAs. The rationale for this sampling size was based on several considerations. First, the sample size took into consideration the objective of the data collection exercise, the timeframe, and resources available. The sample size is also consistent with what is adequate in the literature . As a reData collection and interviews for all the facilities were conducted between December 2017 and February 2018. Quantitative and qualitative data were collected at the selected health facilities to get an understanding of the facility’s capacity and perception of insurance participation. For the quantitative part, information was collected on the health facility characteristics including number of years of operation, workforce, HMO affiliation, bed size, service volume, and finances. However, not every manager was transparent with sharing the facility’s financial information. There was also no feasible way to double check the reliability of all the financial information collected even though some facility managers gave us access directly to their financial statements through their account officers. As a result, we have omitted the financial variable from our analysis and results. For the qualitative part, 60 health facility managers were interviewed to get their perspectives on insurance participation, capacity pressure, resource availability and the Lagos State Health Scheme. The average length of each interview was one hour. The interviews were conducted in English Language, the official language of communication.The principal investigator (HOS) supported by two trained research assistants (RAs) conducted the field data collection. The RAs were both knowledgeable about healthcare delivery and survey administration, and both had a master’s degree. Both RAs were trained by the principal investigator on health research ethics, the procedure for data collection, and administration of informed consent. To ensure standardization in the data collection process, the principal investigator and RAs conducted the first two data collection and interviews together. Following the first two visits, each RA was randomly allocated to collect data from health facilities in each LGA.The survey instruments for both quantitative and qualitative were paper-based tools. See We used a convergent parallel mixed-methods design to collect, analyze and interpret both quantitative and qualitative data . FollowiTo analyze the quantitative data, descriptive statistics such as percentages, mean and median were used to summarize the demographic characteristics of the health facility managers. Similar descriptive statistics were used to describe the general characteristics of the health facilities and to examine any difference in insurance participation status based on location, ownership, level, type, volume of services provided, bed size, workforce, years of operation, and HMO affiliation.To understand the volume of service delivery in each facility, data on number of inpatients, outpatients, deliveries, and laboratory tests were collected for the years 2015 and 2016. Some of the facilities did not offer inpatient, delivery or laboratory services. However, all the facilities offered outpatient services. As a result, the number of outpatient services for each facility in 2016 was recoded and a new category of service delivery volume from very low to very high was created. Facilities with annual outpatient services less than or equal to 5,000 at the end of 2016 was labelled “very low” volume, less than or equal to 15,000 as “low” volume, less than or equal to 50,000 as “mid” volume, less than or equal to 100,000 as “high” volume and greater than 100,000 as “very high” volume.For the qualitative data, framework analysis, a qualitative research method that allows for theme-based analysis and is better suited for analyzing the specific questions facility managers were asked was used for the data analysis . In the The research protocol was approved by the Institutional Review Boards at the Nigerian Institute of Medical Research and Boston University Medical School. All respondents provided written informed consent.In all, 36 facilities accepted one or more type of health insurance: private health insurance (PHI), national health insurance scheme (NHIS) or community-based health insurance (CBHI). Based on facility ownership, 1 out of the 2 faith-based facilities, 26 out of 39 private facilities, and 9 out of 19 public facilities participated in an insurance program. Over half (20) of the facilities accepting insurance are medical centers or hospitals, representing 74% of all medical centers/hospitals sampled. All of the 9 specialist hospitals and the 1 teaching hospital participated in an insurance program. 77% of all health clinics/posts and 70% of all maternity homes visited did not accept insurance. 8 out of 25 facilities providing only primary care accepted insurance, while 24 out of 31 at the secondary level, and all the facilities  promised that the money will go directly to the facility. The local government may not be happy with it, so we are not sure how this will operate.” (Public Facility Manager)“Similarly, the facility managers highlighted as a potential unintended consequence of the scheme, a reduction in financial support from the LGA especially for services such as community outreach that would not be covered by the insurance scheme. The facility managers maintained that the state government intends to make a deduction from the LGA’s budget because of increased insurance collections, and this may disincentivize local government officials from providing continued support to the PHCs in the LGAs.Lagos state government plans to take money from source, meaning that they will be taking money directly from the LGA. It is going to affect services. There are services that are already free and there are other services like community outreaches that will not be under the health insurance, and the LGAs will no longer support these services since the state government is already deducting money from them. There will be malalignment between the health department and other departments in the LGA. As a result, lack of political will could worsen and if the capitation should go directly to them [LGA], we will be worse off and there will be a stand still.” (Public Facility Manager)“This study examined the characteristics of providers that participated in insurance programs, the factors that influenced their participation and the expectations of facility managers from the Lagos State Health Scheme.We observed that the number of years of operation, size, type, and ownership of facilities matter in insurance participation. A higher proportion of provider facilities participating in insurance relative to non-participating facilities were larger with mid to (very) high patient volume, workforce, and longer years of operation. In addition, a higher proportion of medical centers, specialist and teaching hospitals participated in insurance compared to health clinics and maternity homes. This could be because medical centers, specialist and teaching hospitals typically have higher service volume and workforce to accommodate any increase in the volume of patients associated with insurance participation than the health clinics and maternity homes, which are generally smaller in size and capacity. This could also be because the large facilities have the administrative capacity and the sophistication to understand the advantages of capitation paid for primary care.Conversely, the size and capacity of a facility could also be a key factor that HMOs consider before reaching out to the facility to join their insurance plans. Larger facilities are more likely than smaller facilities to have the capacity to train the workforce needed for insurance work, which could mean less contracting burden for the HMOs. In general, HMOs were more likely to deal with the medical centers, specialist and teaching hospitals than health clinics and maternity homes.In terms of ownership, a greater proportion of private facilities compared to public facilities participated in insurance. This could be because private facilities enjoy higher levels of autonomy in decision making about operations than public facilities. However, for the few public facilities participating, nearly all were large facilities with mid to very high volume of service delivery. The smaller public facilities were less likely to participate in insurance.Looking at insurance participation from the facility level, we observed that a higher proportion of facilities at the secondary and tertiary levels participated in an insurance program than primary level facilities. This was not surprising since most of the large facilities operated at the secondary and tertiary levels of care. However, the lack of participation at the primary level raises a wider concern for the role of primary care in achieving universal health coverage. If the primary facilities are not fully equipped to provide the first line of services that community members need, it means the population either would be unable to receive timely preventive care or would visit the secondary level facilities to receive primary care, overcrowding and overburdening these facilities, while the primary facilities remain underutilized.Regarding the drivers and barriers to insurance participation, we observed that high reimbursement fee, low amount of paperwork, short processing time for reimbursements and lower probability of claim reduction and denial were all motivating factors for facilities to join an insurance program. Conversely, at the patient level, patients poor understanding of their insurance plans and unrealistic expectations when they show up for care, as perceived by the facilities were barriers to insurance participation. Our findings are supported by many other studies that have examined determinants of provider participation in insurance programs , 36–41.From the results of this study, it is also clear that increase in patient volume, which could lead to increase in revenue, and additional cash to manage the operations of the facility and invest in facility upgrade is a key driver for facility insurance participation. Maximizing profit is also a key driver for private facilities and not for the public facilities. Private insurance was perceived to be more profitable than government insurance. This could be because the providers in the private market are price setters and are able to determine the amount charged to patients paying out of pocket or negotiate with HMOs based on their assessment of the cost and benefits, the amount charged to insured patients. On the other hand, in the public insurance market, providers are price takers, they do not have control over the amount charged to patients and the reimbursement received is well below the fees they charge. These findings therefore align with the two-sided economic theory by Sloan and colleagues that suggests that providers like every other firm in a dual market would gravitate towards the market that offers more benefits before considering the other .To that end, if providers perceive government insurance to be less profitable, it may have an unintended consequence on provider contracting and improved access to care. In the case of the LSHS, this could mean that providers may choose not to participate in the scheme, or when they do participate, ignore LSHS enrollees, while spending more time providing care to patients paying out of pocket or via private insurance. This may eventually lead to patients perceiving the quality of care received through the LSHS to be poor and discouraging future registration with the scheme.Ghana’s national health insurance program currently faced a similar challenge. In a study assessing the achievements and challenges of the national health insurance scheme in Ghana, many patients obtaining care through the national insurance program perceived their care to be poorer than patients who paid for care via private means . These pThe facility managers anticipate an increased volume of patients, revenue and opportunity to invest in facility upgrade as some of the benefits that the facilities would get from the Lagos State Health Scheme. However, they also anticipate, especially the private facilities, that low reimbursement fees without a guarantee of high patient volumes would be a major challenge to participate in the scheme.There is also a big capacity issue for the public facilities: inadequate infrastructure, shortage of skilled health workers, dearth of drugs and supplies, and poor access to finance for infrastructure upgrade that could pose a challenge to the successful implementation and scale-up of the scheme across the state. Many public facility managers lack the management and financial autonomy to address these capacity gaps in their facilities. These findings about the weak capacity at the public facilities and their managers’ lack of financial autonomy is consistent with the Nigerian study described earlier assessing the quality of care received by diabetic patients in public facilities under Nigeria’s NHIS program . The stuIn the public facilities also, facility managers for the primary health centers are concerned about the lack of transparency in the flow of funds and the possibility of a weak buy-in of the LSHS by some officials at the local government level. Primary health facilities are typically funded with fixed budgetary allocation from the local government, which facility managers do not have financial autonomy over. As a result, the facility managers at the primary care level are mostly worried that they may not receive the revenue earned from capitation if the payments go directly to the LGAs or Local Council Development Areas (LCDAs) instead of the primary health centers. These facility managers are also worried about the potential withdrawal of funding support from the LGAs/LCDAs for programs such as community outreaches and public health education programs that would not be covered under the state insurance program. The Lagos state government will need to pay particular attention to these issues since the success of the LSHS and the attainment of universal health coverage will be impossible to achieve if the population members do not have access to quality care at the primary health level.Finally, the LSHS should consider the associated administrative burden for providers that would need to work with multiple HMOs (if HMOs are being considered in the roll out of the scheme). The HMO model has been beneficial to the NHIS as a non-governmental system for paying capitations, approving secondary care, and a non-governmental system to process claims for that care. This model is valuable since some of the personnel needed to run an efficient claims payment system may be unavailable in the civil service system. Thus, for efficient claims processing, we would suggest that Lagos state considers selecting one HMO through a competitive process to perform this duty. However, we understand that one HMO across the state may create a monopoly, and as a result, we would suggest having one HMO in charge of each of the five senatorial zones in Lagos and for government to contract with each HMO for a maximum of 4 years, after which a competitive selection process would commence again. This is similar to what is done in the United States with the Medicare program, where private healthcare insurers compete to handle claims for exclusive geographic regions , 45. In This study has some potential limitations. First, only six LGAs were purposively selected for the study. This may limit the generalizability and transferability of the findings from the study. However, to improve the validity of the findings, the six LGAs were selected to reflect many of the differences in population size, income level, urbanization and insurance participation across the state. Secondly, some providers, particularly the large public teaching and general hospitals were purposively selected and may have overestimated some of the findings for the public facilities. However, given their large capacities and insurance participation insights, it was imperative to include them in the sample frame. Lastly, the sample size for this study was relatively small, and as a result, it was impossible to run a multivariable regression analysis to examine the statistical significance of the quantitative findings.This study used the two-sided economic theory by Sloan and colleagues to assess the determinants of provider participation in insurance. This theory hypothesizes that there are two markets, public and private, where providers sell their services, and that providers would naturally gravitate towards the market that offers more financial benefits. From this study, it is clear that the perceived benefits of participating in insurance in the private market currently outweigh its perceived costs, particularly for the big facilities, whereas this is likely not the case for the public insurance market. This is evident from the results showing that providers generally perceived private insurance to be more profitable than government insurance even though government insurance paid faster and more regularly. This could be, as explained by the two-sided economic theory, that providers in the private market are price setters and as a result can negotiate with HMOs the amount charged to insured patients. On the other hand, in the public insurance market, providers are price takers and do not have control over the amount charged to patients.Therefore, the key to success of the LSHS and other public insurance programs in low-and-middle income countries lies in the government’s ability to effectively manage and finance the scheme, and contract with healthcare providers. In its contracting with providers, governments must create policies that would ensure a reduction in the costs and an improvement in the benefits of insurance participation for the providers. We have suggested a model through alternating and potentially competitive time-limited contracts with HMOs that can help Lagos state and governments of other developing economies to achieve this and accelerate its progress towards universal health coverage. We have also found that smaller primary care facilities will need additional help to provide the level of resources required for insurance accreditation and to manage the process of collecting insurance payments. It is also vital that public facilities receive the funds earned through additional services provided to insured patients, and that public subsidies for outreach and other “uncovered” services are maintained.S1 AppendixObtained online from NHIS website, October 2017.(PDF)Click here for additional data file.S2 AppendixObtained online from NHIS website, October 2017.(PDF)Click here for additional data file.S3 Appendix(PDF)Click here for additional data file.S1 FileDataset containing variables used for analysis in Excel format.(XLSX)Click here for additional data file.


In recent decades, clinicians have developed the construct of ultra-high risk (UHR) for psychosis to characterize the prodromal phase of psychosis or classify people with weakly expressed psychotic symptoms. In this conceptual analysis, we have gathered up-to-date data about the clinical picture of neurocognition and social cognition in people at UHR for psychosis. We also discuss treatment options. A well-chosen therapeutic approach can help to deal with difficulties and delay or even prevent the development of full-blown psychotic disorders in the UHR group. Despite much evidence supporting the benefits of therapy, early interventions are still not as widely used as they should be. Thus, a better understanding of the UHR state is very important for all healthcare workers. In recent decades, clinicians have developed the construct of ultra-high risk (UHR) for psychosis states. This condition is associated with the risk of a diagnosis of schizophrenia or other psychotic disorder within 1-3 years of manifestation of symptoms and is sometimes considered the prodromal phase of psychosis , 3.Specific deficits in cognitive functioning in schizophrenia were reported a long time ago by the pioneers Kraepelin  and BleuDetailed study of the UHR state is important not only from the perspective of clinical knowledge, but also for the planning of interventions for people with early psychotic states. Fast diagnosis and well-chosen therapy can reduce suffering and slow down or even prevent the development of full-blown psychosis or other disorders in the UHR group. This group of patients requires an extremely delicate approach because of the risk of stigmatization and its negative consequences. Knowledge about different aspects of UHR for psychosis should be widespread among healthcare workers, as this would improve outcomes for people affected by this condition.Therefore, this article aims to present the primary characteristics of the UHR state, the associated neurocognition and social cognition, and possibilities for treatment, taking into consideration the controversy in this field. There is a need to set an unambiguous direction in thinking about people with the UHR state.Psychotic disorders are not binary conditions, but rather they occur on a spectrum. In the 19th and 20th centuries, clinicians and researchers focused on establishing proper criteria and treatment recommendations for people with severe and long-lasting psychotic symptoms. Detailed analysis of the medical history of many patients showed that specific prodromal symptoms occurred before the development of a full picture of the disease. Furthermore, young people with concurrent psychotic symptoms who did not fit in any particular unit in an institution were increasingly referred to specialists. Following the need to fully understand different stages of psychotic spectrum disorders, clinicians developed the construct of UHR for psychosis. Other definitions of UHR exist, though with some theoretical differences .For over 20 years, the criteria for UHR for psychosis have been used worldwide due to their predictive validity . HoweverProdromal symptoms may also include neurocognitive dysfunctions, but their presence is not necessary for the diagnosis. UHR criteria may be measured by different scales, most of which are based on detailed interviews, as for example: the Structured Interview for Prodromal Symptoms (SIPS), the Comprehensive Assessment of At-Risk Mental States (CAARMS), the Basel Screening Instrument for Psychosis (BSIP), and short screening methods such as the Prodromal Questionnaire - Brief version (PQ-B) or Prime Screen—Revised (PRIME) , 12, 14.Several studies have been conducted to estimate the risk of transition to psychosis in the UHR group. Different results have been obtained. Fusar-Poli et al.  in theirDespite meeting the criteria for UHR, an individual may never meet the criteria of any psychotic disorder or other psychiatric diagnosis. It is very important to be extra careful making a diagnosis to avoid stigmatization and iatrogenic effects in such a sensitive population. A recent study indicates that 43% of patients in the UHR sample recover or go into remission from UHR and 57% have no remission, transition, or relapse over 1 year . Some heThe criteria for transition are not clearly defined. Some of authors define them as the occurrence of at least 1 fully positive psychotic symptom which is present at least several times a week for more than 1 week or the presence of at least 1 full psychotic symptom for at least 1 day if this symptom is seriously disorganizing or dangerous , 16, 17.The precise prevalence of UHR for psychosis in populations is unknown because the diagnostic criteria were established based on research conducted on samples of people who had sought help . Data obDuring the course of schizophrenia, psychological testing or observation of the patient can reveal deficits in neurocognitive functions, varying in degrees of severity and range. Impairments in neurocognitive functions may be considered to be an indication of vulnerability for psychotic disorder . NeurodeA large longitudinal study conducted in America (NAPLS) on a UHR group and patients with FP suggested that people with prodromal symptoms are already dealing with neurocognitive difficulties, but they are less severe than in people with a diagnosis of FP . People A study conducted by a team from Switzerland found evidence of impairment in auditory working memory, verbal fluency, processing speed, and declarative verbal memory in a UHR group . A meta-Individuals who transitioned to full-blown psychosis had worse scores in verbal fluency, verbal and visual memory, and working memory . A generIt should be noted that impairments in general intelligence, attention, and visual and verbal memory are small to moderate in UHR, while they are moderate in FP, and deep in CHS , 23. ExeProcessing speed index, measured in neurocognitive tests by symbol or digit coding speed, is the most differentiating factor between a healthy control group and schizophrenia spectrum patients , 25. TheThe relationship between the onset of symptoms and the presence of different cognitive deficits can be two-sided. In the neurodegenerative model, psychotic symptoms cause typical brain dysfunctions. In this model, the severity and extent of cognitive impairments will increase with the duration and severity of clinical symptoms of UHR for psychosis. This also explains why we observe greater cognitive deficits at each stage of the schizophrenia continuum. But on the other hand, impairments in individual cognitive functions may have a significant impact on the development of psychotic and quasi-psychotic symptoms in UHR people. For example, impairments in attention and processing speed lead to an unrealistic perception of one's surroundings and strengthen the delusional attitude. Disturbances in cognitive functions can also have a negative impact on self-esteem and social relations. This can lead to social isolation and the development of negative symptoms.The findings of Bora et al.  suggest In order to thoroughly investigate the cause of cognitive deficits in the UHR group, numerous neuroimaging studies have been conducted. A systematic review and meta-analysis performed in 2018 by a research group from China showed that data collected in different studies reveals a specific neurophysiology in UHR people . StructuIn trying to understand the relationship between social cognition and UHR, we shall first briefly look at the specifics of psychotic disorders with particular attention devoted to schizophrenia. Studies indicate that patients with a diagnosis of schizophrenia score worse on tasks assessing emotion perception, theory of mind (ToM), adaptive attributional styles, social perception, and social knowledge . In addiResearchers, based on their knowledge of relationships between social cognition and psychotic disorders, have conducted several studies focused on social cognition in UHR. A meta-analysis of 17 studies showed that general impairments in social cognition are typical in the UHR group . They diThe inspiration to look for a relationship between social cognition deficits and UHR was reports suggesting that patients with autism spectrum disorders (ASD) are at greater risk of developing affective and nonaffective psychoses . ASD andAnother skill which is very important in social functioning is mentalizing, described in Theory of Mind (ToM) as the ability to be aware of the mental states of other people, such as moods or emotions, and their impact on behavior. There is evidence that impairments in metalizing are present at every stage of psychotic spectrum disorders, but it is still unknown whether the severity of these impairments increases at each stage . HoweverIt has also been shown that there is a correlation between atypical brain activation patterns during tasks involving monitoring the reality and perception of self and others and manifestation of sociotype in adolescence . RegardiAn interesting issue is the impact of UHR symptoms on social cognition. A study conducted by a team from the Netherlands found data suggesting that adolescents in a UHR state have problems identifying and verbalizing their own emotions and, furthermore, the level of difficulty was related to the severity of high risk symptoms . A studyDiagnostic criteria, evidence from research, brain mechanism models, case studies and other methods of gathering knowledge about specific psychiatric conditions are investigated, among other reasons, to find effective methods of treating people who seek help. As the prodromal phase of psychosis is not recognized as a disorder in ICD or DSM criteria, therapeutic interactions should be focused on prevention of conversion to psychosis or other disorders and should include actions which aim to improve quality of functioning.Taking into consideration the guidance for early detection, the European Psychiatric Association (EPA) has developed evidence-based recommendations for interventions for individuals at UHR for psychosis . Much reMany studies indicate that CBT is the most effective method of providing help to people at risk of psychosis. A study conducted in 2012 in the Netherlands indicated that CBT can reduce the transition to psychosis by about 50% . AnotherThe risk of transition to psychosis is highest in the first year after diagnosis of UHR . TherapeDespite the fact that the EPA recommendations indicate the use of CBT or CBT combined with pharmacotherapy, other treatment opportunities have been offered and tested for effectiveness in the UHR group. One such promising method is cognitive remediation (CR). CR is an intervention based on behavioral training composed of various tasks focused on improving cognitive functioning , 48. It In modern psychiatry, more and more time is being devoted to developing a detailed understanding of the different stages of the spectrum of mental disorders. There have been many reports on the ultra high risk (UHR) for psychosis state in recent years, giving us a better understanding of the cognitive and social functioning of people in this group. Knowledge about the difficulties faced by people at UHR enables us to tailor therapies appropriately. Due to the specificity and variability of prodromal symptoms and the sensitivity of patients, this issue should be treated with exceptional dedication and caution at the same time.Impairments in cognitive functions are described in the UHR state and some studies suggest their presence even before the onset of prodromal symptoms. From a clinical perspective, it seems appropriate to use cognitive training or remediation in patients with prodromal symptoms. This form of intervention can not only improve patients' quality of life, but also slow or prevent the development of symptoms. Based on the neurodegenerative model of psychotic disorders, future research should focus on the relationship between therapeutic interactions and the severity of cognitive deficits. When assessing cognitive functions in patients from the UHR group, it is worthwhile to conduct follow-up research.Some studies have suggested that social cognition impairments are characteristic of the UHR state, but data on specific skills are still limited. Research in this area should be continued. It seems particularly interesting to identify the specific relationships between difficulties in social cognition and global functioning. Knowledge about impairments in social cognition in the UHR state implies that therapeutic interactions should also address strengthening social competences.The UHR state is not included in any leading classification of psychiatric disorders. Nevertheless, the diagnostic criteria for UHR were chosen to identify people who are more likely to develop a psychotic disorder. On the one hand, early detection of UHR enables the monitoring of the patient's condition and the implementation of appropriate interventions to stop or slow down the development of symptoms. On the other hand, all clinicians should keep in mind the risk of stigmatization of UHR patients, which may have fatal consequences. The effects of stigmatization may include a decrease in self-esteem, social isolation, hopelessness, increased use of avoidance strategies, as well as depression and anxiety symptoms , 51. PatEvidence-based therapeutic methods, such as CBT or CBT combined with pharmacotherapy, are recommended by the EPA as the interventions for the UHR state. Research results suggest that this intervention might be effective in preventing transition to full-blown psychosis. However, it is worth mentioning that there is no clear agreement on these recommendations. Research in this area should definitely be continued. Clinical experience and a holistic view of people suggest a direction of research that focuses not on creating therapies specifically for UHR patients, but rather on adjusting interventions to the current needs of the patient. Therapy should focus on reducing subjective discomfort, teaching adaptive techniques for managing stress, improving social skills, and undermining cognitive biases. Even if it might sometimes be impossible to fully prevent the development of an illness, any delay could be very beneficial from the perspective of brain mechanisms, social functioning, and relations with others. Furthermore, early interventions include psychoeducation and provide the abilities necessary to deal with the disease, so they can ensure a milder course of the disorder.The efficacy of different methods and therapeutic techniques still needs to be tested in UHR patients. Current evidence is promising, but it is still worthwhile to investigate the effectiveness of other methods. Young people in an at-risk state can probably respond well to group therapy or modern forms of treatment using techniques such as computer training, virtual reality, or mobile applications. Despite the recommendations and evidence from research, early interventions are not as widely used as they should be. A study conducted in England showed that only 53% of 50 medical teams included these treatments in their service and provided them for at least 12 months (Despite knowledge about the UHR condition and the effectiveness of therapy, early interventions are still not as widely used as they should be. There is a pressing need to raise awareness about UHR symptoms and possible methods of treatment.To conclude, UHR for psychosis is the condition of being at risk of developing a psychotic disorder in which attenuated psychotic symptoms, frank, transient psychotic symptoms, or genetic risk and deterioration syndrome are present. It most often affects young people, and even when it does not lead to a transition to full-blown psychosis or some other psychiatric disorder, it impairs neurocognitive functions and social cognitive functioning. Deficits in cognitive functions such as general intelligence, memory, processing speed, attention, executive functions, and verbal fluency have been demonstrated by different studies. These impairments tend to be established before the appearance of prodromal symptoms, which supports the neurodevelopmental model of psychotic disorders. Structural and functional changes in brain activity in the prodromal phase of psychosis, such as gray matter volume, cortical thickness of the thalamocortical circuit, and prefrontal volume loss, have been shown by neuroimaging studies. UHR is also associated with difficulties in emotion perception based on face and voice recognition, mentalizing, and theory of mind. Early diagnosis, symptom monitoring, and early therapeutic interventions are key in people experiencing UHR. Avoiding stigmatization is extremely important during the diagnosis and treatment of people from the UHR group.KR-O and ET was involved in the paper design, managed literature searches and analyses, and wrote the first draft of the manuscript. JS and MM was a supervisor and corrected the manuscript. KW corrected the manuscript. All authors contributed to and have approved the final manuscript.This paper was funded by the Polish Minister of Science and Higher Education's program named Regional Initiative of Excellence in 2019–2022, grant number 002/RID/2018/2019 to the amount of 12 000 000 PLN.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling editor GD declared a past co-authorship with one of the authors.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.