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["Major themes","Description","Codes","Description","Conceptual framework","Quotes","Sub-codes","Description","Sub-codes 2","Description","Main findings","Literature search","Sussan's comments","Rejoice's comments","Rifkatu's comments","Dr. Charity's comments","Dr. Iwu's comments","Combined comment"]
["Roles/responsibilites",null,"Roles/responsibility"]
["POLICY CONTENT",null,"Allocation of resources","provision of human resources, equipment, infrastructure, financing, supplies and commodities. The three Ms - man, material, money.","Process",{"$nulls":5},"In terms of allocation of resources; One respondent agreed that there are resources allocated to the health sector, while the second respondents differ in opinion. He argues that specific resources even though not allocated can be sourced and used when needed to cater for MNH services. The CSOs that responded to this differ in their opinions even though belonging to the same category. This could be as a result of level of interaction with the different levels of policy makers and implementers, which results in inappropriate allocation of resources."]
[null,null,"Financial decision makers","1. In your experience or knowledge, who makes financial decisions about how funding is distributed for health services in Yobe State?","Actors",{"$nulls":5},"In terms of financial decision makers, respondents state that financial decisions are being made at the state levels by the ministry of budget and planning, ministry of finance, national assembly, and state government, where budget is allocated to health sectors which is controlled centrally and strictly followed while at the health facility level, only the management staff like the Primary Health Center (PHC) coordinator, and the Medical Directors (MDs) make financial decisions after the budget must have been allocated. However, it is not clear whether there are mechanisms in place to find out if the funds allocated is sufficient.We recommend that healthcare workers be more involved in financial decision making especially at the state level. Also, feedback from the service providers be explored to find out if these funds are accessible by the healthcare workers."]
[null,null,"Feedback mechanisms","If improvement is sought, an opportunity for the client to express themselves on services rendered. For the policymakers to know the challenges of the clients who patronize the facility. Channels - for healthcare seekers to air concerns and can be through suggestion boxes, whatsapp groups, apps, other physical places for clients to go and make complains in person etc. Customer/client satisfaction survey forms about expriences at facilities. Awareness about feedback mechanisms key. Different level of feedback: 1. Grassroot up - client to facility. 2. From facility to policymaker.","Process",{"$nulls":5},"In terms of feedback mechanisms on MNH services, the respondents mentioned that both the policymakers, NGOs and HCW agreed that feedback on service deliveries exists between the policy makers and the service users. Suggestion boxes, hotlines, and Gender Based Violence (GBV) referral pathways and organisations such as Ward Development Committee (WDC) are used as channels to receive feedback. We recommend that more research should be done on client’s awareness of the feedback channels, its accessibility and effectiveness given that the respondent think funding is the issue.","Feedback mechanism improve MNH service delivery when used to guide program implementation, responsive feedback results in improved program outcomes, increased ownership, and sustainability of solutions. As observed in a study conducted in Kano State. Before the used of responsive feedback mechanism to improve the quality of antenatal care services in health facilities, few pregnant women knew of and used the MNH services9."]
[null,null,"Routine policies and guidelines","2. Can you please describe the policies and guidelines that are used in your line of work to guide the provision of MNH services, including community MNH services?\n PROBE;\n a. Are there existing laws and policies affecting gender and social inclusion in relation to MNH?\n b. Based on your experience/knowledge, please describe a typical planning process for the implementation of a new maternal health policy or guide at the health facility level. \n \n c. In your experience, what specific policies/guidelines have been the most difficult to implement and why?","Context",{"$nulls":5},"In terms of routine policies and guidelines, all respondents, which include policymakers, NGOs, CSOs, and HCW except for a few CSOs, agreed that various policies and guidelines are being used in the implementation of MNH services in the state. Most of these policies and guidelines are Nationally generated and adopted by the state with some adjustments to suit the peculiarities and needs of the state. These cut across guidelines/policies used in the recruitment of MNH workforces, program implementation, and penalties for non-adherence to the set guides and policies. These policies include; national strategic plan, national health policy (i.e Human resource for health, Financing, commodities, and infrastructures), task shifting and sharing policy, National quality of care strategic plan, national quality of care monitoring and evaluation framework, national surgical, obstetric and aesthetic, and newborn plan, national guideline on catheterization, national maternal, perinatal and child death surveillance and response, verbal autopsy and social autopsy (VASA), guidelines on the use of PPE, nursing and midwifery curriculum, midwifery service scheme, basic health care provision fund (provides free healthcare for pregnant women and under 5 children, elderly, persons with sickle cell, physically challenges persons), policy on social equity program that caters for the poor and vulnerable population, contributory health scheme, national policy on the implementation of HIV, TB, malaria response and immunization, policies on ANC, management of stages of labor and prevention of PPH, etc. All mentioned policies guide the provision of MNH services and their implementation. It targets pregnant women during ANC, labor and delivery, and postpartum. It also targets vulnerable populations like those under 5, the elderly, and persons with disabilities. Though these policies exist, implementation is not without challenges, as some of the respondents observed that not all facilities offer the said services, and even though various policies are trying to reach most populations, not all needing such services are covered (for example, only 185 persons are registered under the social equity fund per ward in the state)\n \n A few CSOs disagreed with the existence of policies and guidelines used to implement MNH services were referring to guidelines for the operation of women leaders at the community level, but one CSO mentioned that there is a printable guideline for the operations of women leaders at the emirate council.\n \n We recommend Implementation of guidelines and policies should be a priority for the state. Modalities for scaling down, monitoring, and evaluating these guides should be clearly spelt out and followed for maximum results."]
[null,null,"GESI Policies","a. Are there existing laws and policies affecting gender and social inclusion in relation to MNH?",{"$nulls":6},"The findings on Gender Equity and Social Inclusion (GESI) policies showed that all the respondents were CSOs. Two in five of respondents mentioned that there are no policies while three agreed that even though there are no policies, women are included in Maternal and Newborn Health (MNH) decision making table incidentally, however, respondents reported progress in terms of women inclusion, but the structure is not well defined. Awareness of GESI laws and policies is minimal in Yobe state even though they exist at the national level. We recommend that laws/policies on GESI be disseminated among stakeholders and implementers at the state level."]
[null,null,"Existing policies and guidelines","Creation of demand for services, things that will make client patronize the facility. In the airwaves, community to target and alert consumers on what is available. what clients really want and if the facility has them.",null,null,"New policies and guideline","Have any new policies/guidelines been introduced in the past three years? State/ federal? Note: refers to renewal of policies",null,null,"In terms of existing policies and guidelines for MNH services, all respondents agreed that there are existing policies and guidelines guiding the provision of MNH services, except for one who does not seem to know if these policies and guidelines are in existence. However, the indices of those policies available could not be clearly spelt out by the respondents. We would recommend that when scaling down policies implementers need to understand the best practices of policy dissemination to enable easy adoption."]
[null,null,"Community based service policy","1. Can you please describe if the current policies and guidelines also support the implementation of community-based services and if so how?",{"$nulls":6},"In terms of community service policy that supports the implementation of community-based services, findings from all policy makers who responded revealed that there are policies that support community-based service delivery such as recruitment of community midwives, placement of midwives to improve human resource for health especially at the rural communities, Yobe State Contributory Scheme (YOCHMA), Yobe State Drug Management Agency (YODMA), and Yobe State Emergency Medical Ambulance Service (YEMABUS), to aid in the provision of quality access to healthcare services. Other community engagement strategies and agencies such as Voluntary Community Health Mobilizers (VCM), also help to facilitate these policies. However, one of the respondents was concerned about the sustainability of these policies due to the unstable political system. We recommend that there should be sustainable system of governance especially in terms of continuity of policies and programs at the political space. Also, government should collaborate with other institutions to increase human resource for health through provision employment opportunities for midwifery students to dispense the MNH services across hard to reach communities.","Yobe State Contributory Healthcare Management Agency (YOCHMA): The Scheme is an institutional framework for improving advance healthcare financing through contributions, premiums or taxes paid into a common pool to make access to healthcare services easier by all residents of Yobe State toward achieving universal health coverage. Yobe State Emergency Medical Ambulance Service (YEMABUS) was launched by the State Governor, (Hon. Mai Mala Buni) to provide effective and efficient healthcare delivery across the State. YEMABUS supports the provision of Emergency Medical Treatment (EMT) to all residents of the State. “The policy is intended to address the missing link in the health sector as reiterated by the World Health Organization (WHO)”. YEMABUS started its operation with nine ambulances and two hundred and seventy customized Keke ambulances for rural areas. The agency is designed to provide 24/7 emergency health services to anyone who needs it, anywhere in the State at no cost to the patient for the first 48 hours at the dial 112 toll-free number. Yobe State Drugs and Medical Consumables Management Agency (YODMA) was launched by the State Governor to provide effective and efficient qualitative health care delivery to the people of Yobe State through the supply of quality and affordable as well as accessible medicines and other health care related commodities to all health facilities in Yobe State. Volunteer Community Mobilizers (VCMs) are “agents of change,” who are predominantly females hired from local settlements to conduct house-to-house awareness-raising activities on immunization and basic health and hygiene practices. The VCMs also accompanied vaccination teams during Immunization Plus Days to encourage participation by eligible households. They coordinated with community influencers, such as religious leaders and traditional community leaders, to tackle existing misconceptions about immunization and resolve any religious and social barriers4."]
[null,null,"laws/policy/guidelines gaps","1. What do you think are key gaps or issues with the laws, policies, and operational guidelines that exist to cater to maternal and newborn health needs in Yobe State?",null,null,"Level of implementation of policies and guidelines","a) What do you think about the level of implementation of policies for MNH in Yobe State?\n OR\n b) What specific policies/guidelines have been the most difficult to implement? What has made these policies/guidelines difficult to carry out?",null,null,"In terms of gaps in laws, policy and guideline gaps, the respondents who were all policymakers, majorly agreed that there are gaps in the existing laws, policies and guidelines in the state, the gaps are related to political and administrative issues. The implementation of policies, guidelines and laws as indicated by the respondents is also affected by security challenges leading to facilities being attack and valuables stolen, financial constraint which affects the rate of employment, inadequate human resource for health, Misplacement of priority on the part of the health workers, inadequate dissemination and implementation of policies and guidelines by the policy makers. We recommend that security majors be put in place by the government to protect lives and properties especially maternal and newborns in the health facilities living in the affected communities, policy makers should ensure dissemination, and implementation of policies, and guidelines through timely distribution of established guidelines/policies and training of implementers."]
[null,null,"influence policymaker's attitude","1. What do you think influences policymakers’ attitudes toward the prioritization of MNH in Yobe State?","Context",{"$nulls":5},"In terms of factors that influences policymakers’ attitude, the respondents who are all policymakers mentioned that mostly their attitude towards MNH services can be influenced by increase in high maternal mortality and morbidity rate given that Yobe state is having one of the highest mortality rates in Nigeria. Their attitudes can also be influenced by political reasons, but this can be disadvantaged as a result of lack of continuity in governance and projects, economic growth in terms of maintaining the economy by having a healthy population, demands from community on the prioritization of health services and mandate of the politicians as one of the expected deliverables. The respondents also speak to high maternal mortality rate being a driver for political agenda, there was no mention of infant mortality and morbidity rate as an issue of concern in Yobe state by the respondents. Policy makers rely on maternal mortality data from Yobe State to make decisions, We recommend that on the policy makers should be more familiar with their infant mortality data in terms of national ranking and utilize the national and state data to advocate politicians to keep neonatal and newborn healthcare in the fore front. We also recommend that there should be Yobe state data for maternal and infant mortality and morbidity rate and continuity in viable government projects that prioritize MNH services be put in place for people in power to enable sustainability."]

{"sheet":"Compiled","index":1,"n_rows":89,"n_cols":15,"rows_kept":89}
["Major themes","Description","Codes","Description",null,"Sub-codes","Description","Sub-codes 2","Description","Sussan's comments","goo","Rifkatu's comments","Dr. Charity's comments","Dr. Iwu's comments","Combined comment"]
["Roles/responsibilites",null,"Roles/responsibility"]
["POLICY CONTENT","Types of MNH policies and guidelines available for implementation at health facility and community levels, as well as the gaps in policies and guidelines to support various components such as GESI and community-based service delivery.","Allocation of resources","provision of human resources, equipment, infrastructure, financing, supplies and commodities. The three Ms - man, material, money. ","Process"]
[null,null,"Financial decision makers","1. In your experience or knowledge, who makes financial decisions about how funding is distributed for health services in Yobe State?","Actors"," "]
[null,null,"Creation of demand","Creation of demand for services, things that will make client patronize the facility. In the airwaves, community to target and alert consumers on what is available. what clients really want and if the facility has them. ","Process"]
[null,null,"Feedback mechanisms","If improvement is sought, an opportunity for the client to express themselves on services rendered. For the policymakers to know the challenges of the clients who patronize the facility. Channels - for healthcare seekers to air concerns and can be through suggestion boxes, whatsapp groups, apps, other physical places for clients to go and make complains in person etc. Customer/client satisfaction survey forms about expriences at facilities. Awareness about feedback mechanisms key. Different level of feedback: 1. Grassroot up - client to facility. 2. From facility to policymaker. ","Process"]
[null,null,"MNH priority or not","If improvement is sought, an opportunity for the client to express themselves on services rendered. For the policymakers to know the challenges of the clients who patronize the facility. Channels - for healthcare seekers to air concerns and can be through suggestion boxes, whatsapp groups, apps, other physical places for clients to go and make complains in person etc. Customer/client satisfaction survey forms about expriences at facilities. Awareness about feedback mechanisms key. Different level of feedback: 1. Grassroot up - client to facility. 2. From facility to policymaker. ","context"]
[null,null,"Routine policies and guidelines","2.        Can you please describe the policies and guidelines that are used in your line of work to guide the provision of MNH services, including community MNH services?\nPROBE;\na.        Are there existing laws and policies affecting gender and social inclusion in relation to MNH?\nb.        Based on your experience/knowledge, please describe a typical planning process for the implementation of a new maternal health policy or guide at the health facility level. \n\nc.        In your experience, what specific policies/guidelines have been the most difficult to implement and why?\n","Context"]
[null,null,"GESI Policies","a. Are there existing laws and policies affecting gender and social inclusion in relation to MNH?"]
[null,null,"Existing policies and guidelines","Creation of demand for services, things that will make client patronize the facility. In the airwaves, community to target and alert consumers on what is available. what clients really want and if the facility has them. ",null,"New policies and guideline","Have any new policies/guidelines been introduced in the past three years? State/ federal? Note: refers to renewal of policies"]
[null,null,"Community based service policy","1. Can you please describe if the current policies and guidelines also support the implementation of community-based services and if so how?"]
[null,null,"laws/policy/guidelines gaps","1. What do you think are key gaps or issues with the laws, policies, and operational guidelines that exist to cater to maternal and newborn health needs in Yobe State?",null,"Level of implementation of policies and guidelines","a)        What do you think about the level of implementation of policies for MNH in Yobe State?\nOR\nb) What specific policies/guidelines have been the most difficult to implement? What has made these policies/guidelines difficult to carry out?\n"]
[null,null,"stakeholder prioritization of MNH ","1. Do you think MNH is a priority for stakeholders in your department/organization? Why or why not?","Context"]
[null,null,"regional prioritization of MNH","1. In your opinion, how does the prioritization of MNH in Yobe compare to other regions in the country?","Context"]
[null,null,"influence policymaker's attitude","1. What do you think influences policymakers’ attitudes toward the prioritization of MNH in Yobe State?","Context"]
[]
["GENDER AND SOCIAL INCLUSION",null," Decision makers composition","a. In your view are women and women-led organizations/groups adequately involved in the decision-making process at the health facility level? Please elaborate.",null,"Policy for gender equity","a. How, in your opinion, are existing policies/reforms accommodating gender equity in leadership and MNH decision-making space?"]
[]
["CONTEXT/EVENTS","sociocultural and political factors (e.g effect of crises, geographical inequalities, religious and cultural issues, inclusiveness) as well as health system factors (e.g leadership capacity, human resources capacity, HCW attitudes, emergency preparedness) that influence MNH policy and practice in humanitarian settings.","Political leadership","Politics that influence MNCH, it could positive or negative. The extent of political support from key decision makers. Also resource distribution and allocation. political interests and leaders attitudes toward MNH influencing attention on it; political transitions affecting the continuity of implementation of policies"]
[null,null,"Poor leadership capacity","competencies and capacities of selected leaders and managers not matched to priorities/the work to be done; "]
[null,null,"human resources capacity","availability and efficiency of available manpower (attrition, replacement, skills/ right skills mix,  weak capacity for technical functions like M&E/health information systems etc); · lack of implementation at subnational levels due to lack of capacity (mentorship, supportive supervision)."]
[null,null,"Effect of crises","1. Do you think crises in your area {describe it/them, may include covid} may influence how much MNH services are prioritized in policies and funding? Please elaborate.  Crisis conditions or insecurity affecting service access; geographical location; environment - rains and geographical access"]
[null,null,"Religious and Cultural issues","competencies and capacities of selected leaders and managers not matched to priorities/the work to be done; "]
[null,null,"HCW attitudes","Attitudes affecting program implementation - leading to client indicators dropping, mistreatment of clients, access to companions during labour. "]
[null,null,"Inclusiveness","eg. for persons living with disabilities – lack of accommodative facilities ; involvement of women at decision making level incl. PLWD; marginalized/vulnerable people "]
[null,null,"Global disparities","· burden in low income areas, funders from high income areas, which affects allocation of resources.","Actors"]
[null,null,"Location/environment","poor infrastructure eg. road, telecommunications, transport ; affecting personnel motivations to work in certain areas"]
[]
[]
[null,null,"Emergency Plans","Availability of ambulances, healthcare workers and referral directories in hard-to-reach areas. Contacts of security agencies to fastract movement during crisis and emergencies"]
[null,null,"Recovery from Crises","Facilities might not have needed human resources due to attrition and displacement by crisis, and services might not be available, causing a reduction in the utilization of healthcare facilities. "]
[null,null,"Current event/notable initiatives","1. Are there any current major, notable initiatives ongoing around MNH (at the national level, at the state level)? Any momentum for Community based maternal and newborn care (CBMNC) in particular?","Content"]
[null,null,"Important events","1. What do you think are the important events, inside or outside of the health system that has shaped how MNH services are being carried out currently in your facility?"]
[]
["STAKEHOLDERS","the position and influence of decision-makers among government and non-governmental organizations in MNH services, quality of coordination, and collaboration between the health facility and decision-makers in health research and policy influencing at all levels.","Alliances in health","1. Are there any existing alliances or coalitions (formal or informal networks) that are influential in health research and policy influencing, particularly for MNH issues?"]
[null,null,"Influencial decision makers","1. Who are the most influential decision-makers in the MNH space and why do you consider them influential?"]
[null,null,"Analysis by stakeholders/organisation","Capacity building, frequent trainings, support system for service providers "]
[null,null,"Prioritization organisational role","1. What role does your institution have to prioritize MNH, whether as a service provider or influencing the ministry of health (e.g. creating laws/policies, budgets, operational guidance, etc.)?",null,"Limitations in authority","a. What limitations in authority do you face in prioritizing MNH?"]
[null,null,"Current behaviour and perception","1. What do you think are the factors that influence/motivate a health provider to give good quality care to a mother? You may also elaborate on the challenges a health provider may face. 2. What do you think are the important behaviors and practices that health providers must undertake to provide good quality care to a mother in your context?"]
[null,null,"Intersectoral collaboration","What do you think about the quality of coordination and collaboration between\ndifferent health-providing sectors (NGOs, Civil society organizations)/actors\nand the government health system?"]
[null,null,"Facilities/ policy makers collaboration","1. In your view, what is the quality of coordination and collaboration between the health facility level and decision-makers at higher levels?",null," "]
[null,null,"Facilities/ other organisations collaboration","1. Are there other service agencies/organizations that you work with closely and rely on to be able to provide MNH services to clients? What do you think about the quality of the coordination and collaboration between you and these agencies/organizations?",null," "]
[null,null,"Drivers of stakeholders behaviour and decision","1. What do you think influences policymakers’ attitudes toward the prioritization of MNH in Yobe State?"]
[null,null,"Acceptance (Beliefs, incentives, external influence)","Acceptance can be influenced by religious belief and culture (e.g restriction of access to male healthcare providers at the MNH unit). Familirization with existing practices might affect acceptance."]
[null,null,"MNH priority (provider)","1. Do you think MNH is a priority for health providers in this area (Yobe state/Northeast)? Provide reasons and typical examples.",null,"Locational prioritization","a. How would you characterize prioritization in this area in comparison to other locations in the country?"]
[null,null,"MNH priority (community)","1. What, in your opinion, influences whether different actors support or resist certain policy recommendations related to community delivery of MNH services?"]
[null,null,"MNH priority (decision maker)","1. Do you think MNH is a priority for stakeholders in your department/organization? Why or why not?"]
[null,null,"Perception of providers on CSD","1. What in your opinion, are the main perceptions service providers have around community delivery of Maternal and Newborn care? { Prompts; willingness to serve at the community level, security, finance, housing, infrastructure, and needed commodities/equipment}",null," "]
[null,null,"Policymakers attitude on prioritization","1. What do you think influences policymakers’ attitudes toward the prioritization of MNH in Yobe State?"]
[null,null,"MNH prioritization compared to other regiond","1. In your opinion, how does the prioritization of MNH in Yobe compare to other regions in the country?"]
[null,null,"Limitation/challenges in prioritizing","1. What limitations/challenges to authority or influence does your department face in prioritizing MNH?"]
[null,null,"Organizational technical capacity","Please comment on the technical capacity of your organization to deliver and prioritize MNH services"]
[null,null,"Role of research in organisation","1. Please describe the role and use of research in your organization for implementing MNH interventions. What are the processes for reviewing/utilizing evidence?"]
[null,null,"Organizational policy role","1. Based on your experience, please describe your organization and/or similar organizations’ role in the creation of new laws/policies and what that typical process may look like."]
[null,null,"Quality/access action","1. What, in your opinion, are the actions your organization is taking to ensure that access to quality MNH services is improved and expanded for women in your context?"]
[null,null,"Gender mix ","a. What do you think about the level of diversity in the composition of health service provider staff, especially managers and policymakers in terms of, for instance, gender mix?"]
[null,null,"Religious belief/sociocultural","Influence service uptake and how services delivered; involvement of women at decision making level either locally or nationally; inclusion of women with disabilities; Male involvement in MNH."]
[null,null,"Selection of leaders/decision makers","5.        Please describe how managers/leaders/decision makers at your level are chosen, and mention any factors that you think help with their success/power/influence at the management/decision-making level. ",null," "]
[null,null,"Inclusiveness","Discriminatory attitudes/ marginalization. Consideration of persons with disabilities in service provision, eg. for persons living with disabilities – lack of accommodative facilities; involvement of women at decision making level incl. PLWD"]
[null,null,"Inclusion of female staff","1. In your view are female staff involved in the decision-making process at the health facility level? Please elaborate.",null," "]
[null,null,"Gender dynamics","Patriarchal dominance of men. Please comment on the diversity of the staff composition for the delivery of MNH services (gender, ethnicity, etc.)."]
[null,null,"Competencies","1.  What do you think is needed to ensure that people in your facility are competent and able to deliver effective MNH services?",null," "]
[]
["PROCESSES","the processes for policy making, dissemination of policies, and implementation planning at all levels of the system, client feedback mechanisms, and accountability for service delivery by healthcare workers in MNH.","Awareness about new policies/guidelines","Change in governance can mean change of priority and ability to continue activities related to programs and reduce ownership/championship of programs by leaders. Have any new policies/guidelines been introduced in the past three years? State/ federal?"]
[null,null,"Dissemination of policies","Lack of resources for dissemination; TOT are organized for key people for scaling down to health facility level (not everyone benefits from the dissemination- “inadequate transmission”, lack of awareness – disparity between policymakers and implementers/providers); how learning disseminates in the system."]
[null,null,"Donor driven policies","Stakeholders are invited from different regions to discuss policies, using donor resources - health committee - dissemination. Bottlenecks – funding for distribution. Authority/power dynamics related to communication/information dissemination about the policies that have been developed."]
[null,null,"Administration issues at facility level","Bureaucracy at facility level (protocols, approvals etc), client navigation of services (incl. acquiring consumables), provision of services (processes for preparing procedures) and client experience of care. Managerial nature of government"]
[null,null,"Federal and state level governance","Coordination for making decisions about programs/policies. Administrative level hierarchies at facility levels – ‘decision flows’"]
[null,null,"Bureaucracy","Bureaucratic nature of the policy process in the sense that all the stakeholders or policy makers have to come together and consent or agree on certain issues. This could affect the process"]
[null,null,"Planning at facility level","Based on your experience/knowledge, please describe a typical planning process for the implementation of a new maternal health policy or guide at the health facility level."]
[null,null,"Planning (Policy makers)","1. What is the typical planning process/decision-making process in Yobe state?",null," "]
[null,null,"Most difficult guidelines","In your experience, what specific policies/guidelines have been the most difficult to implement and why?"]
[null,null,"Implementation support","1. Please what kind of support or steps does your Organization provide/take when health center staff have difficulty meeting MNH service requirements? If no support is given, can you explain why, in your opinion?"]
[null,null,"Accountability service provider","1. In your experience or view, how are service providers held accountable to ensure that they implement policies and guidelines?"]
[null,null,"Feedback mechanisms for PLWD","1. Are there mechanisms for women, girls, and people living with disability to provide feedback on satisfaction with services received?"]
[]
[null,null,"Organisational support in MNH services","1. Are there other service agencies/organizations that you work with closely and rely on to be able to provide MNH services to clients? What do you think about the quality of the coordination and collaboration between you and these agencies/organizations?","Actors"]
[null,null,"Accountability ","1. How do we ensure that all the actors that are responsible for implementing various aspects of policies and guidelines, from administrators/finance to health providers, are accountable for that goal?"]
[null,null,"The mechanism for feedback on satisfaction","a. Are there mechanisms for mothers to provide feedback on satisfaction with services received? What happens with the feedback? How does that influence the program?"]
[null,null,"Planning/decision-making process","1. What is the typical planning process/decision-making process in Yobe state? a.        At what level are decisions made? \nb.        Is the process typically being followed? \n"]
[null,null,"Coordination/ collaboration among health systems","1. What do you think about coordination and collaboration between different levels of the health system during decision-making processes? a.        Where is this strongest? Why? b.        Where is it weakest? Why? ","Actors "]
[null,null,"Collaboration among service providers","a. What about coordination between the government health system and NGOs/UN?","Actors "," "]
[null,null,"Challenges faced in implementing policies","1. What limitations/challenges to authority or influence does your department face in prioritizing MNH?","Actors "]
[null,null,"Funding for MNH","1. Based on your knowledge, please describe the financing mechanisms (i.e. sources of funding and budget allocations) in your context and how those mechanisms influence the prioritization of MNH by the health system.","Actors ","Programs with most funding","a. Which programs get the most funding within MNH in Yobe State and why?","Programs with least funding","Participants mentions programs that did not get as much funding/with the least funding. Related to the question on funding for MNH and which programs get the most funding.  "]
[null,null,"Provider behaviour/practices","1. What do you think are the important behaviors and practices that health providers must undertake to provide good quality care to a mother in your context?",null,"Provider motivation","a. What do you think are the factors that influence/motivate a health provider to give good quality care to a mother? You may also elaborate on the challenges a health provider may face."]
[null,null,"Support or resistance for CBMNC","1. What, in your opinion, influences whether different actors support or resist certain policy recommendations related to community delivery of MNH services?","Actors"]
[null,null,"Guidelines on Community Midwifery","a.  Are there policies/guidelines that exist for the support of community-based midwifery? What is your opinion about implementation so far in Yobe State?","Content"," "]
[]
["SUGGESTIONS FROM EXPERIENCE","1. From your experience, what would most help the provision of effective MNH services in this area? Please explain your answer."]

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["Major themes (Questionnaire)","Description","Codes","Description","Framework realignment","Pattern Coding"]
["Roles/responsibilites",null,"Roles/responsibility",null,null,"Initial Codes","Pattern Code","Description"]
["POLICY CONTENT","Types of MNH policies and guidelines available for implementation at health facility and community levels, as well as the gaps in policies and guidelines to support various components such as GESI and community-based service delivery.","Allocation of resources","provision of human resources, equipment, infrastructure, financing, supplies and commodities. The three Ms - man, material, money. ","Process","Current event/notable initiatives","Percecption/events/roles of research","Provider perception on CSD, events or initiatives on CBMNC as well as the role of research in implementing MNH interventions"]
[null,null,"Financial decision makers","1. In your experience or knowledge, who makes financial decisions about how funding is distributed for health services in Yobe State?","Actors","Perception of providers on CSD",null,null,"CONTENT"]
[null,null,"Creation of demand","Creation of demand for services, things that will make client patronize the facility. In the airwaves, community to target and alert consumers on what is available. what clients really want and if the facility has them. ","Process","Role of research in organisation"]
[]
[null,null,"MNH priority or not","If improvement is sought, an opportunity for the client to express themselves on services rendered. For the policymakers to know the challenges of the clients who patronize the facility. Channels - for healthcare seekers to air concerns and can be through suggestion boxes, whatsapp groups, apps, other physical places for clients to go and make complains in person etc. Customer/client satisfaction survey forms about expriences at facilities. Awareness about feedback mechanisms key. Different level of feedback: 1. Grassroot up - client to facility. 2. From facility to policymaker. ","Context","Guidelines on Community Midwifery","Existing policies and guidelines","All policies and guidelines, laws that exist to support MNH in general, CBMNC, and GESI."]
[null,null,"Routine policies and guidelines","2.        Can you please describe the policies and guidelines that are used in your line of work to guide the provision of MNH services, including community MNH services?\nPROBE;\na.        Are there existing laws and policies affecting gender and social inclusion in relation to MNH?\nb.        Based on your experience/knowledge, please describe a typical planning process for the implementation of a new maternal health policy or guide at the health facility level. \n\nc.        In your experience, what specific policies/guidelines have been the most difficult to implement and why?\n","Content","Routine policies and guidelines",null,null,"CONTENT"]
[null,null,"GESI Policies","a. Are there existing laws and policies affecting gender and social inclusion in relation to MNH?","Content","GESI Policies"]
[null,null,"Existing policies and guidelines","Creation of demand for services, things that will make client patronize the facility. In the airwaves, community to target and alert consumers on what is available. what clients really want and if the facility has them. ","Content","Existing policies and guidelines"]
[null,null,"Community based service policy","1. Can you please describe if the current policies and guidelines also support the implementation of community-based services and if so how?","Content","Community based service policy"]
[null,null,"Feedback mechanisms","If improvement is sought, an opportunity for the client to express themselves on services rendered. For the policymakers to know the challenges of the clients who patronize the facility. Channels - for healthcare seekers to air concerns and can be through suggestion boxes, whatsapp groups, apps, other physical places for clients to go and make complains in person etc. Customer/client satisfaction survey forms about expriences at facilities. Awareness about feedback mechanisms key. Different level of feedback: 1. Grassroot up - client to facility. 2. From facility to policymaker. ","Process","Most difficult guidelines","Laws/policy/guideline gaps","What the challenges are in terms of implementation and awareness about policies, as well gaps percieved"]
[null,null,"laws/policy/guidelines gaps","1. What do you think are key gaps or issues with the laws, policies, and operational guidelines that exist to cater to maternal and newborn health needs in Yobe State?","Content","laws/policy/guidelines gaps"]
[null,null,"stakeholder prioritization of MNH ","1. Do you think MNH is a priority for stakeholders in your department/organization? Why or why not?","Context","Awareness about new policies/guidelines"]
[null,null,"regional prioritization of MNH","1. In your opinion, how does the prioritization of MNH in Yobe compare to other regions in the country?","Context","MNH priority (provider, community, decisionmakers)","MNH prioritization/limitation & challenges","MNH prioritization by providers, community and decisionmakers as well as limitation and challenges in prioritizing MNH"]
[null,null,"influence policymaker's attitude","1. What do you think influences policymakers’ attitudes toward the prioritization of MNH in Yobe State?","Context","MNH priority or not",null,null,"CONTEXT"]
["GENDER AND SOCIAL INCLUSION",null," Decision makers composition","a. In your view are women and women-led organizations/groups adequately involved in the decision-making process at the health facility level? Please elaborate.","Actors","stakeholder prioritization of MNH "]
[{"$nulls":5},"regional prioritization of MNH"]
["CONTEXT/EVENTS","sociocultural and political factors (e.g effect of crises, geographical inequalities, religious and cultural issues, inclusiveness) as well as health system factors (e.g leadership capacity, human resources capacity, HCW attitudes, emergency preparedness) that influence MNH policy and practice in humanitarian settings.","Political leadership","Politics that influence MNCH, it could positive or negative. The extent of political support from key decision makers. Also resource distribution and allocation. political interests and leaders attitudes toward MNH influencing attention on it; political transitions affecting the continuity of implementation of policies","Actors","MNH prioritization compared to other regiond"]
[null,null,"Poor leadership capacity","competencies and capacities of selected leaders and managers not matched to priorities/the work to be done; ","Actors","Limitation/challenges in prioritizing"]
[null,null,"human resources capacity","availability and efficiency of available manpower (attrition, replacement, skills/ right skills mix,  weak capacity for technical functions like M&E/health information systems etc); · lack of implementation at subnational levels due to lack of capacity (mentorship, supportive supervision).","Actors","Effect of crises","Religious and cultural issues/beliefs, important belief","Issues around religious and culture that hinders prioritization of MNH services in Yobe state Nigeria"]
[null,null,"Effect of crises","1. Do you think crises in your area {describe it/them, may include covid} may influence how much MNH services are prioritized in policies and funding? Please elaborate.  Crisis conditions or insecurity affecting service access; geographical location; environment - rains and geographical access","Context","Religious and Cultural issues"]
[null,null,"Religious and Cultural issues","competencies and capacities of selected leaders and managers not matched to priorities/the work to be done; ","Context","Location/environment",null,null,"CONTEXT"]
[null,null,"HCW attitudes","Attitudes affecting program implementation - leading to client indicators dropping, mistreatment of clients, access to companions during labour. ","Actors","Emergency Plans"]
[null,null,"Inclusiveness","eg. for persons living with disabilities – lack of accommodative facilities ; involvement of women at decision making level incl. PLWD; marginalized/vulnerable people ","Actors","Recovery from Crises"]
[null,null,"Global disparities","· burden in low income areas, funders from high income areas, which affects allocation of resources.","Actors","Important events"]
[null,null,"Location/environment","poor infrastructure eg. road, telecommunications, transport ; affecting personnel motivations to work in certain areas","Context","Religious belief/sociocultural"]
[null,null,"Emergency Plans","Availability of ambulances, healthcare workers and referral directories in hard-to-reach areas. Contacts of security agencies to fastract movement during crisis and emergencies","Context"]
[null,null,"Recovery from Crises","Facilities might not have needed human resources due to attrition and displacement by crisis, and services might not be available, causing a reduction in the utilization of healthcare facilities. ","Context"]
[null,null,"Current event/notable initiatives","1. Are there any current major, notable initiatives ongoing around MNH (at the national level, at the state level)? Any momentum for Community based maternal and newborn care (CBMNC) in particular?","Content","influence policymaker's attitude","Attitudes of influential decisionmakers","Decisionmakers attitudes and composition within the political spaces"]
[null,null,"Important events","1. What do you think are the important events, inside or outside of the health system that has shaped how MNH services are being carried out currently in your facility?","Context"," Decision makers composition",null,null,"ACTORS"]
[{"$nulls":5},"Political leadership"]
["STAKEHOLDERS/ACTORS","the position and influence of decision-makers among government and non-governmental organizations in MNH services, quality of coordination, and collaboration between the health facility and decision-makers in health research and policy influencing at all levels.","Alliances in health","1. Are there any existing alliances or coalitions (formal or informal networks) that are influential in health research and policy influencing, particularly for MNH issues?","Actors","Influencial decision makers"]
[null,null,"Influencial decision makers","1. Who are the most influential decision-makers in the MNH space and why do you consider them influential?","Actors","Policymakers attitude on prioritization"]
[null,null,"Analysis by stakeholders/organisation","Capacity building, frequent trainings, support system for service providers ","Actors"]
[null,null,"Prioritization organisational role","1. What role does your institution have to prioritize MNH, whether as a service provider or influencing the ministry of health (e.g. creating laws/policies, budgets, operational guidance, etc.)?","Actors","Intersectoral collaboration","Collaboration among servive providers, intersectorial and among other organisations","Impact of collaboration among various sectors and between the facilities and other organisation or policy makers"]
[null,null,"Current behaviour and perception","1. What do you think are the factors that influence/motivate a health provider to give good quality care to a mother? You may also elaborate on the challenges a health provider may face. 2. What do you think are the important behaviors and practices that health providers must undertake to provide good quality care to a mother in your context?","Actors","Coordination/ collaboration among health systems"]
[null,null,"Intersectoral collaboration","What do you think about the quality of coordination and collaboration between\ndifferent health-providing sectors (NGOs, Civil society organizations)/actors\nand the government health system?","Actors",{"$nulls":3},"ACTORS"]
[null,null,"Facilities/ policy makers collaboration","1. In your view, what is the quality of coordination and collaboration between the health facility level and decision-makers at higher levels?","Actors","Facilities/ policy makers collaboration"]
[null,null,"Facilities/ other organisations collaboration","1. Are there other service agencies/organizations that you work with closely and rely on to be able to provide MNH services to clients? What do you think about the quality of the coordination and collaboration between you and these agencies/organizations?","Actors","Facilities/ other organisations collaboration"]
[null,null,"Drivers of stakeholders behaviour and decision","1. What do you think influences policymakers’ attitudes toward the prioritization of MNH in Yobe State?","Actors","Collaboration among service providers"]
[null,null,"Acceptance (Beliefs, incentives, external influence)","Acceptance can be influenced by religious belief and culture (e.g restriction of access to male healthcare providers at the MNH unit). Familirization with existing practices might affect acceptance.","context"]
[null,null,"MNH priority (provider)","1. Do you think MNH is a priority for health providers in this area (Yobe state/Northeast)? Provide reasons and typical examples.","context","Prioritization organisational role","Technical capacity/role","Level of organisational capacity, role and competencies\n\n\n","ACTORS"]
[null,null,"MNH priority (community)","1. What, in your opinion, influences whether different actors support or resist certain policy recommendations related to community delivery of MNH services?","context","Organizational technical capacity"]
[null,null,"MNH priority (decision maker)","1. Do you think MNH is a priority for stakeholders in your department/organization? Why or why not?","context","Organizational policy role"]
[null,null,"Perception of providers on CSD","1. What in your opinion, are the main perceptions service providers have around community delivery of Maternal and Newborn care? { Prompts; willingness to serve at the community level, security, finance, housing, infrastructure, and needed commodities/equipment}","Content","Gender mix "]
[null,null,"Policymakers attitude on prioritization","1. What do you think influences policymakers’ attitudes toward the prioritization of MNH in Yobe State?","Actors",null,"Inclusiveness, Competencies/ perception/ Acceptance\n\n\n\n\n","Inclusion of women, PWD as well as leadership selection to  prioritize MNH services in Yobe state"]
[null,null,"MNH prioritization compared to other regiond","1. In your opinion, how does the prioritization of MNH in Yobe compare to other regions in the country?","Context","Inclusion of female staff"]
[null,null,"Limitation/challenges in prioritizing","1. What limitations/challenges to authority or influence does your department face in prioritizing MNH?","Context","Inclusiveness"]
[null,null,"Organizational technical capacity","Please comment on the technical capacity of your organization to deliver and prioritize MNH services","Actors","Selection of leaders/decision makers",null,null,"ACTORS"]
[null,null,"Role of research in organisation","1. Please describe the role and use of research in your organization for implementing MNH interventions. What are the processes for reviewing/utilizing evidence?","Content","Acceptance (Beliefs, incentives, external influence)"]
[null,null,"Organizational policy role","1. Based on your experience, please describe your organization and/or similar organizations’ role in the creation of new laws/policies and what that typical process may look like.","Actors","Competencies"]
[null,null,"Quality/access action","1. What, in your opinion, are the actions your organization is taking to ensure that access to quality MNH services is improved and expanded for women in your context?","Process","Current behaviour and perception"]
[null,null,"Gender mix ","a. What do you think about the level of diversity in the composition of health service provider staff, especially managers and policymakers in terms of, for instance, gender mix?","Actors"]
[null,null,"Religious belief/sociocultural","Influence service uptake and how services delivered; involvement of women at decision making level either locally or nationally; inclusion of women with disabilities; Male involvement in MNH.","Context","Funding for MNH","Funding/support for MNH","Availabity of funding for delivery of MNH services"]
[null,null,"Selection of leaders/decision makers","5.        Please describe how managers/leaders/decision makers at your level are chosen, and mention any factors that you think help with their success/power/influence at the management/decision-making level. ","Actors","Support or resistance for CBMNC",null,null,"ACTORS"]
[null,null,"Inclusiveness","Discriminatory attitudes/ marginalization. Consideration of persons with disabilities in service provision, eg. for persons living with disabilities – lack of accommodative facilities; involvement of women at decision making level incl. PLWD","Actors"]
[null,null,"Inclusion of female staff","1. In your view are female staff involved in the decision-making process at the health facility level? Please elaborate.","Actors","Drivers of stakeholders behaviour and decision","Stakeholders behaviour/ decision/challenges","What are the drivers of stakeholders decision and behaviour, what are the challenges faced in policy implementation"]
[null,null,"Gender dynamics","Patriarchal dominance of men. Please comment on the diversity of the staff composition for the delivery of MNH services (gender, ethnicity, etc.).","Context","Challenges faced in implementing policies",null,null,"ACTORS"]
[null,null,"Competencies","1.  What do you think is needed to ensure that people in your facility are competent and able to deliver effective MNH services?","Actors","Gender mix ","Processes of accountability and the perspectives of key decisiom-makers"]
[{"$nulls":5},"Feedback Mechanism"]
["PROCESSES","the processes for policy making, dissemination of policies, and implementation planning at all levels of the system, client feedback mechanisms, and accountability for service delivery by healthcare workers in MNH.","Awareness about new policies/guidelines","Change in governance can mean change of priority and ability to continue activities related to programs and reduce ownership/championship of programs by leaders. Have any new policies/guidelines been introduced in the past three years? State/ federal?","Content","The mechanism for feedback on satisfaction"]
[null,null,"Dissemination of policies","Lack of resources for dissemination; TOT are organized for key people for scaling down to health facility level (not everyone benefits from the dissemination- “inadequate transmission”, lack of awareness – disparity between policymakers and implementers/providers); how learning disseminates in the system.","Process","Feedback mechanisms for PLWD",null,null,"PROCESS"]
[null,null,"Donor driven policies","Stakeholders are invited from different regions to discuss policies, using donor resources - health committee - dissemination. Bottlenecks – funding for distribution. Authority/power dynamics related to communication/information dissemination about the policies that have been developed.","Process"]
[null,null,"Administration issues at facility level","Bureaucracy at facility level (protocols, approvals etc), client navigation of services (incl. acquiring consumables), provision of services (processes for preparing procedures) and client experience of care. Managerial nature of government","Process","Accountability "]
[null,null,"Federal and state level governance","Coordination for making decisions about programs/policies. Administrative level hierarchies at facility levels – ‘decision flows’","Process","Accountability service provider"]
[null,null,"Bureaucracy","Bureaucratic nature of the policy process in the sense that all the stakeholders or policy makers have to come together and consent or agree on certain issues. This could affect the process","Process","Provider behaviour/practices"]
[null,null,"Planning at facility level","Based on your experience/knowledge, please describe a typical planning process for the implementation of a new maternal health policy or guide at the health facility level.","Process","Administration issues at facility level"]
[null,null,"Planning (Policy makers)","1. What is the typical planning process/decision-making process in Yobe state?","Process","Planning (Policy makers)"]
[null,null,"Most difficult guidelines","In your experience, what specific policies/guidelines have been the most difficult to implement and why?","Content","Planning at facility level"]
[null,null,"Implementation support","1. Please what kind of support or steps does your Organization provide/take when health center staff have difficulty meeting MNH service requirements? If no support is given, can you explain why, in your opinion?","Process","Planning (Policy makers)",null,null,"PROCESS"]
[null,null,"Accountability service provider","1. In your experience or view, how are service providers held accountable to ensure that they implement policies and guidelines?","Process","Planning/decision-making process"]
[null,null,"Feedback mechanisms for PLWD","1. Are there mechanisms for women, girls, and people living with disability to provide feedback on satisfaction with services received?","Process","Bureaucracy"]
[null,null,"Organisational support in MNH services","1. Are there other service agencies/organizations that you work with closely and rely on to be able to provide MNH services to clients? What do you think about the quality of the coordination and collaboration between you and these agencies/organizations?","Actors","Federal and state level governance"]
[null,null,"Accountability ","1. How do we ensure that all the actors that are responsible for implementing various aspects of policies and guidelines, from administrators/finance to health providers, are accountable for that goal?","Process","Donor driven policies"]
[null,null,"The mechanism for feedback on satisfaction","a. Are there mechanisms for mothers to provide feedback on satisfaction with services received? What happens with the feedback? How does that influence the program?","Process","Dissemination of policies"]
[null,null,"Planning/decision-making process","1. What is the typical planning process/decision-making process in Yobe state? a.        At what level are decisions made? \nb.        Is the process typically being followed? \n","Process"]
[null,null,"Coordination/ collaboration among health systems","1. What do you think about coordination and collaboration between different levels of the health system during decision-making processes? a.        Where is this strongest? Why? b.        Where is it weakest? Why? ","Actors "]
[null,null,"Collaboration among service providers","a. What about coordination between the government health system and NGOs/UN?","Actors "]
[null,null,"Challenges faced in implementing policies","1. What limitations/challenges to authority or influence does your department face in prioritizing MNH?","Actors "]
[null,null,"Funding for MNH","1. Based on your knowledge, please describe the financing mechanisms (i.e. sources of funding and budget allocations) in your context and how those mechanisms influence the prioritization of MNH by the health system.","Actors "]
[null,null,"Provider behaviour/practices","1. What do you think are the important behaviors and practices that health providers must undertake to provide good quality care to a mother in your context?","Process"]
[null,null,"Support or resistance for CBMNC","1. What, in your opinion, influences whether different actors support or resist certain policy recommendations related to community delivery of MNH services?","Actors"]
[null,null,"Guidelines on Community Midwifery","a.  Are there policies/guidelines that exist for the support of community-based midwifery? What is your opinion about implementation so far in Yobe State?","Content"]
[]
["SUGGESTIONS FROM EXPERIENCE","1. From your experience, what would most help the provision of effective MNH services in this area? Please explain your answer."]

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[]
["Initial Codes","Pattern Code","Description","Main findings","Quotes","Literature","Recommendation"]
["Current event/notable initiatives","Percecption/events/roles of research","Provider perception on CSD, events or initiatives on CBMNC as well as the role of research in implementing MNH interventions","In terms of providers perception on community service delivery of maternal and newborn care, the respondents who are all HCWs each mentioned their perceptions on CSD which includes instability in salary ranges especially for HCWs in the rural who should be paid higher but are not, educating and counselling the rural dwellers on the importance of immunization and facility delivery, difficulty in adjustment to facility and accommodation for HCWs, having the ability to ignore violent clients. We recommend additional policies to address the challenges especially at facility level mentioned by the respondents.\n\n","But the staff in the rural environment honestly should be highly paid than the ones in the urban areas because they are paid higher transportation fares and feeding too. In some villages, you cannot get food to eat until you come to the city. Honestly, they are facing these challenges"]
["Perception of providers on CSD"]
["Role of research in organisation"]
[]
["Guidelines on Community Midwifery","Existing policies and guidelines","All policies and guidelines, laws that exist to support MNH in general, CBMNC, and GESI.","In terms of existing policies and guidelines, the respondents mentioned that there are guidelines which includes provision of free education supported by NGOs and collaboration between ministries, signed MOU for the employment of graduates directly from school of midwifery from the communities. Various policies and guidelines are being used in the implementation of MNH services in the state. Most of these policies and guidelines are Nationally generated and adopted by the state with some adjustments to suit the peculiarities and needs of the state. These cut across guidelines/policies used in the recruitment of MNH workforces, program implementation, and penalties for non-adherence to the set guides and policies. These policies include; national strategic plan, national health policy (i.e Human resource for health, Financing, commodities, and infrastructures), task shifting and sharing policy, National quality of care strategic plan, national quality of care monitoring and evaluation framework, national surgical, obstetric and aesthetic, and newborn plan, national guideline on catheterization, national maternal, perinatal and child death surveillance and response, verbal autopsy and social autopsy (VASA), guidelines on the use of PPE, nursing and midwifery curriculum, midwifery service scheme, basic health care provision fund (provides free healthcare for pregnant women and under 5 children, elderly, persons with sickle cell, physically challenges persons), policy on social equity program that caters for the poor and vulnerable population, contributory health scheme, national policy on the implementation of HIV, TB, malaria response and immunization, policies on ANC, management of stages of labor and prevention of PPH, etc. All respondents mentioned that policies guide the provision of MNH services and their implementation. The policies target pregnant women during ANC, labor and delivery, and postpartum. It also targets vulnerable populations like those under 5, the elderly, and persons with disabilities. Though these policies exist, implementation is not without challenges, as some of the respondents observed that not all facilities offer the said services, and even though various policies are trying to reach most populations, not all needing such services are covered (for example, only 185 persons are registered under the social equity fund per ward in the state). Few of the respondents also mentioned that there are no policies, women are included in Maternal and Newborn Health (MNH) decision making table incidentally. A report on the progress in terms of women inclusion is available but the structure is not well defined. Awareness of GESI laws and policies is minimal in Yobe state even though they exist at the national level. For existing policies and guidelines for MNH services, respondents agreed that there are existing policies and guidelines supporting the provision of MNH services, except for a few HCWs who do not seem to know if these policies and guidelines are in existence. Most of the HCWs we talked to mentioned that even though they know there are policies, they do not have a documented policies and guidelines to follow. In terms of community service policy that supports the implementation of community-based services, the policy makers who responded revealed that there are policies that support community-based service delivery such as recruitment of community midwives, placement of midwives to improve human resource for health especially at the rural communities, Yobe State Contributory Scheme (YOCHMA), Yobe State Drug Management Agency (YODMA), and Yobe State Emergency Medical Ambulance Service (YEMABUS), to aid in the provision of quality access to healthcare services. Other community engagement strategies and agencies such as Voluntary Community Health Mobilizers (VCM), also help to facilitate these policies. However, a few of the respondents were concerned about the sustainability of these policies due to the unstable political system in terms of change in government positions, continuity of political tenure and changes in institutions/structures. ","I've said, many parts of the northern Nigeria have this law that we have about 3 maternal and child health which we fought for and they still exist, recently also we have gender policy in our state and within that agenda policy will also make sure the issue of MCH also comes out very clearly it has  that component and also recently with the birth act and the child right act and some of the human resource strategy is some of the northern state we work with they are all trying to capture all those things in one way or the other from different dimensions and I remember there are also some kind of package that entitles having something in writing or as you law is different from getting it implemented"," Yobe State Contributory Healthcare Management Agency (YOCHMA): [MM1] The Scheme is an institutional framework for improving advance healthcare financing through contributions, premiums or taxes paid into a common pool to make access to healthcare services easier by all residents of Yobe State toward achieving universal health coverage. Yobe\nState Emergency Medical Ambulance Service (YEMABUS) [MM2] was launched by the State Governor, (Hon. Mai Mala Buni) to provide effective and efficient healthcare delivery across the State. YEMABUS supports the provision of Emergency Medical Treatment (EMT) to all residents of the State. “The policy is intended to address the missing link in the health sector as reiterated by the World Health Organization (WHO)”. YEMABUS started its operation with nine ambulances and two hundred and seventy customized Keke ambulances for rural areas. The agency is designed to provide 24/7 emergency health services to anyone who needs it, anywhere in the State at no cost to the patient for the first 48 hours at the dial 112 toll-free number. Yobe State Drugs and Medical Consumables Management Agency (YODMA) was launched by the State Governor to provide effective and efficient qualitative health care delivery to the people of Yobe State through the supply of quality and affordable as well as accessible medicines and other health care related commodities to all health facilities in Yobe State.  Volunteer\nCommunity Mobilizers (VCMs[MM3] ) are “agents of change,” who are predominantly females hired from local settlements to conduct house-to-house awareness-raising activities on immunization and basic health and hygiene practices. The VCMs also accompanied vaccination teams during Immunization Plus Days to encourage participation by eligible households. They coordinated with community influencers, such as religious leaders and traditional community leaders, to tackle existing misconceptions about immunization and resolve any religious and social barriers4.","Recommendation: 1. We recommend more collaboration between the government and other partners for a sustainable implementation of programs to encourage potential midwives into the community midwifery school. 2. We recommend that laws/policies on GESI be disseminated among stakeholders and implementers at the state level. 3. We would recommend that when scaling down policies implementers need to understand the best practices of policy dissemination to enable easy adoption. 4. Also, government should collaborate with other institutions (NGOs, CSOs, UN) to increase human resource for health through provision employment opportunities for midwifery students to dispense the MNH services across hard-to-reach communities. There is community midwifery program designed to reach these issues, but the capacity is low, in order to have a grow you would need increase the number of graduate midwives, funding to build more classrooms and hostels, staffing (more teachers in the schools) and posting allowances. [MM1]Are there evaluations of its impact out there? [MM2]In the manuscript we will not go into this much detail but it is good to have here like this. For the manuscript we will move a bit beyond descriptions to a more critical analysis of how thing are working. [MM3]Think about the role of these different actors and institutions in advancing MNH and where the gaps could be."]
["Routine policies and guidelines"]
["GESI Policies"]
["Existing policies and guidelines"]
["Community based service policy"]
["Most difficult guidelines","Laws/policy/guideline gaps","What the challenges are in terms of implementation and awareness about policies, as well gaps percieved","In terms of most difficult to implement guidelines, the respondents who are majorly NGOs and policy makers listed challenges faced in implementing guidelines which includes task shifting and sharing, maternal and perinatal death surveillance and response (MPDSR), policy on recruitment of health workers and implementation of delivery at facility-based delivery. According to the respondents, these guidelines are difficult to implement because of insufficient funding available for implementation, lack of understanding of the policies by some health workers due to improper dissemination, lack of human resources/manpower within the communities to care for MNH.\nThe respondents also mentioned the gaps in laws, policies and guidelines which are related to political like preferences in selecting candidates due to political power influence and administrative issues of institutions not implementing the curriculum in the right way. The implementation of policies, guidelines and laws as indicated by the respondents is also affected by security challenges leading to facilities being attack and valuables stolen, financial constraint which affects the rate of employment, inadequate human resource for health, Misplacement of priority on the part of the health workers, inadequate dissemination and implementation of policies and guidelines by the policy makers. \n","I think the task shifting and task sharing formula policy should come with commensurate human resources for help so that has been difficult. The second one is the maternal and perinatal death surveillance and response. That is because one, there is a human resource gap to do with it, it’s cumbersome, its time consuming, it’s not integrated to other activities like clinical audits or maternal mortality review meeting. In-fact the community NPDSR is even much more difficult and it has not also been tied to a quality measure. So right now at the Federal government they are trying to push that every facility getting the BHCPN fund must have demonstrated at least one quality improvement meeting interpreted into a NPDCSR meeting that has been a mission yet to be achieved.","Humanitarian contexts are often characterized by high mortality rates, poorly functioning health systems, lack of resources and trained health workers, and extreme political, economic, and social changes. As a result, the development of formal death reviews is often interrupted during times of insecurity, when health systems collapse, and trained health workers may leave the area. According to interviews, health workers who remain in such contexts may be overwhelmed with treating the living, and death reviews may be given less priority. \nAdditionally, the quality and leadership of death reviews may be compromised by a lack of trained or experienced staff. In this situation, national recommendations on the composition of large death review committees and extensive documentation requirements may be a barrier to conducting any reviews, especially when the guidance is over-interpreted, and the relevant staff are unavailable to conduct reviews. Furthermore, in challenging situations with high death rates, consistent identification of recommendations that healthcare providers feel powerless to implement may be demoralizing. A process with even a suggestion of blame may be unwelcome and unhelpful in a context of high levels of stress and potential psychological and moral distress.\n","1.\tWe recommend clear strategy for adherence to policies and guidelines, increased human resources and capacity building, increased funding to make resources required available, community awareness and advocacy at the facility level, monitoring and evaluation to ensure quality assurance.\n2.\tWe recommend that security measures be put in place by the government to protect lives and properties especially maternal and newborns in the health facilities living in the affected communities, policy makers should ensure dissemination, and implementation of policies, and guidelines through timely distribution of established guidelines/policies and training of implementers\n"]
["laws/policy/guidelines gaps"]
["Awareness about new policies/guidelines"]
["MNH priority (provider, community, decisionmakers)","MNH prioritization/limitation & challenges","How the providers, community and decisionmakers prioritize MNH, as well as limitations and challenges in prioritizing MNH in Yobe state","In terms of priority for maternal and neonatal health (MNH) the respondents (NGOs, CSOs and HCW) mentioned some level of priority among service providers to reduce maternal mortality and morbidity rates and ensuring the well-being of mothers and newborns by increasing manpower through provision of employments for the midwives. \nService providers think that priority is given to MNH because there was a policy, there is an initiative, but the funding to continue with the implementation is limited. For instance, Midwifery Service Scheme (MSS) and the free services for pregnant and under 5 years of age even though they maintained that MNH is a priority for service providers, funds are still needed to implement some of these schemes and priorities may change with change in governance. \n\nMost of the policymakers mentioned how the government is focusing on schools to produce more nurses and midwives to assist in the rural communities, sensitization sermons by the religious leaders on MNH services, free MNCH service delivery scheme in the state which is also giving free care and free medication to pregnant mothers, children of under 5- and 24-hours accident victims, renovation in some facilities across the state by the saving one million lives partners, IRC, and WHO. \n\nThe NGO respondents we interviewed mentioned some of the factors that influences whether different actors support or resist certain policy which includes employment of unskilled workers due to corrupt practices which has a negative effect on MNH services, lack of sustainability of intervention programs due to funding issues, poor quality of MNH services rendered, absence of frequent sensitization and awareness programs on MNH services.\n\n\nFor MNH prioritization compared to other regions, the respondents majorly policymakers talked about MNH being very much prioritized in Yobe state and the government is involved especially in prioritizing budget allocation for MNH services, upgrading Health colleges, prompt payment of staff salaries to motivate and enhance performance, employment of qualified manpower, and deployment of staff, mentoring and supervision of new staff, and providing suitable work environment. \n","I believed the government has lost focus on this, because they are the financers of this particular program and there is nothing the health workers will do, but recently this particular giant structure at the teaching hospital have been but in place, I was told it was about 200 bed space capacity now they are saying it is one of the largest in the country, and also probably one of the largest in west Africa, and I hope all these are true and the government will live up to their expectations by providing all that is needed to take care of people in that place and also take care of the facility.                                                                                                                                                                                              In terms of limitation/challenges in prioritizing MNH, the respondents mostly NGOs and policymakers and a few CSOs stated that most of the challenges/limitations they face includes lack of motivation from their employees, having a few trained personnel present in most health facilities, having limited budget allocation to cater for MNH services, poor quality of care rendered to patient, not actively including HCW in decision making, absence of health facilities in some rural communities, health workers having difficulties in accessing and reaching the government with concerns on MNH services/practices, increase in population growth which places high demand on health facilities and manpower available and limited accommodation for health personnel in some hard to reach communities.                                                          I think the critical issue is also lack of accommodation in the rural areas, if you are posted there you have to stay in the village heads house, and some of our challenge is when the girls graduate, they go back to their communities but don't have senior ones to mentor so they become their own doctors and their own masters in their areas and so I think all this is affecting the quality of the services given.","To address the delays in transportation, over 300 Emergency Transport Scheme volunteers have been trained in collaboration with National Union of Road Transport Workers and Saving One Million Lives programme. To improve skilled birth attendance, the community-based Traditional Birth Attendants were trained in a new role of community-facility linkage focal persons. They sensitise pregnant women on the need to attend antenatal care services as well as facility-based delivery. To promote the utilisation of Reproductive, Maternal, Newborn and Child Health Services (RMNCH), especially among young married women, more than 2,000 young women benefited from the Safe Space Initiative Young Women Support Groups (YWSGs) where young adolescent women can meet to openly discuss their health. As an accountability mechanism, MNCH2 supported the establishment of 89 Facility Health Committees to improve community participation in management of health facilities. MNCH2 also supported a platform for advocacy and accountability in health i.e. the Yobe State Accountability Mechanismon MNCH(YOSAMM)\n\n\nLiterature:\n\nThe performance of health workers in providing services can be negatively impacted by a poor enabling environment and lack of motivation. The Kaduna State Government (2011) reports that poor conditions of service, including inadequate staff housing, make it difficult to recruit and retain staff, especially in rural areas. Murray and Frenk (2000) suggest that a knowledge gap and inappropriate use of available technology can also result in low-quality care. Several factors may contribute to a low standard of care, such as situations resulting from the woman or her relatives' actions, which may be beyond the clinician's control. It also includes shortages of resources for staffing facilities, administrative failures in maternity services, and backup facilities such as anesthetics services (Victorian Government, 2001).\n \nIn rural communities, people may face challenges accessing services due to social distance. Social distance refers to the differences in language, behavior, and expectations between healthcare providers and consumers. Even when providers are of the same ethnic group, social distance barriers may arise due to variations in education, experience, and socioeconomic status. This can be further compounded by ethnic and linguistic differences. (PNMN, 1997 cited in Ladipo, 2008). \n\nThe distribution of health infrastructure is biased towards urban areas, leaving rural areas with inadequate access to quality health care services. This is especially problematic for maternal health in rural areas where health care services are often inadequate. In emergency situations, the lack of skilled personnel, life-saving equipment, essential drugs, and ambulances can be fatal. These issues can negatively impact the acceptance and utilization of maternity services, which are necessary to reduce maternal mortality rates. Women's experiences with health care will also influence their future health-seeking behavior. These problems may hinder efforts to reduce maternal mortality rates in rural areas through health care services\n","1.\tService providers should engage in collaboration and provide evidence-based practices, patient-centred care, and addressing social determinants of health.\n2.\tWe recommend that employment policies should be very strict to reduce the hiring of unskilled staff, strengthened supervision for quality services and sustainability of intervention programs should be encouraged.\n3.\tWe recommend that government should expand their focus on employment and deployment of more manpower to rural communities, increase sensitization and intervention programs and sustainability of ongoing interventions.\n"]
["MNH priority or not"]
["stakeholder prioritization of MNH "]
["regional prioritization of MNH"]
["MNH prioritization compared to other region"]
["Limitation/challenges in prioritizing"]
["Effect of crises","Religious and cultural issues/beliefs","Issues around religious and culture that hinders prioritization of MNH services in Yobe state Nigeria","In terms of the effect of crises or insecurity and influence on prioritization of MNH services in policies and funding, the respondents revealed that; \n\ntheir area has suffered ongoing conflict, from the Boko Haram insurgency. The HCWs listed among others disruption of MNH services, massive destruction of their health care facilities and equipment. While some staff were displaced, abducted and some killed, pregnant women on the other hand could not access MNH services and some died due to continues bleeding, lack of access to health facilities, other pregnancy/delivery complications.\n\nInsecurity has led to significant protection concerns, displacement, disrupted livelihoods, and persistent food insecurities. The respondents we interviewed mentioned the presence of camps and women leaving in uncomfortable environment as residence, they reported violence, sexual abuse, teenage pregnancies, rape, and lack of family planning services happening within those camps.\n\nWomen also suffer psychological effects which may lead to premature labour due to sounds of bomb blasting. The Boko haram insurgency has reduced efficiency of HCW due to lack of full operational services.\n\nDisplacement due to crises has also affected their source of livelihood, investments and exposed them to unfamiliar environment.\n\nGovernment facilities and heavy investments such as theatre equipment, hospital generators, incinerators, water treatment plant, ambulances snatched, drugs were destroyed, and some taken away by boko haram insurgents.\n\nThe respondents mentioned important events that shaped how MNH services is being carried out, like presence of NGOs and donors support focusing on issues relating to MNH for instance, reduction in stigmatization especially among HIV positive mothers, presence of modern facilities/infrastructure, insurgents such as Boko Haram which results in closing down of health facilities and absenteeism of healthcare workers.\n\n\nThe respondent also mentioned that there are cultural issues of the husbands not wanting a male medical staff to treat their wives and the policymaker mentioned the belief that women need to seek permission from their husbands before accessing some kind of medical services like family planning. Also, that giving birth at home implies that God permits the act. These religious and cultural beliefs pose as obstacles in prioritizing MNH services in this region.\n","It affected the care we render here because when staff is posted, they refuse to come here due to fear of being kidnap. Sometimes when you come to the hospital, you will see the nurse in casual wear; they will be instructed not to put on their professional wear. For that reason, these pregnant women will be encouraged to visit the hospital against all odds, so with this, you can see that it affected the way things should be done, like the maternity care and ANC services",null," We recommend employment, training and retaining of more health workers to address the inadequate human resources for health. \n2.        It is also recommended that the government should strengthen the emergency relief services in the state to cater for MNH services.\n3.        There should be more collaboration with donor agencies to rebuild the destroyed health care facilities and replace the destroyed equipment.\n4.        We recommend that security measures be strengthened to protect the HCW in places with high insurgency. Sustainability of donor support programs, continuous awareness, and sensitization to encourage HIV patient (especially pregnant mothers) to seek quality healthcare services and reduce stigmatization.\n"]
["Religious and Cultural issues"]
["Location/environment"]
["Emergency Plans"]
["Recovery from Crises"]
["Important events"]
["Religious belief/sociocultural"]
["influence policymaker's attitude","Attitudes of influential decisionmakers","Decisionmakers attitudes and composition within the political spaces","In terms of factors that influences policymakers’ attitude, the respondents who are all policymakers mentioned that mostly their attitude towards MNH services can be influenced by increase in high maternal mortality and morbidity rate given that Yobe state is having one of the highest mortality rates in Nigeria. Their attitudes can also be influenced by political reasons, but this can be disadvantaged as a result of lack of continuity in governance and projects, economic growth in terms of maintaining the economy by having a healthy population, demands from community on the prioritization of health services and mandate of the politicians as one of the expected deliverables. \n\nThe respondents also speak to high maternal mortality rate being a driver for political agenda, there was no mention of infant mortality and morbidity rate as an issue of concern in Yobe state by the respondents. Policy makers rely on maternal mortality data from Yobe State to make decisions.\n\nFor decision makers composition, the respondents mentioned the involvement of women and women led organizations like the ministry of women affairs and the United Nations (UN) in general decision making, however this involvement is limited to just a few of the women in power by virtue of their position. The decision by the Ward Development Committee (WDC) to place a woman representative in all communities to enhance their participation in decision making has been positive. Also, the involvement of religious bodies like the Muslim Sisters Organization provides a platform for women. This implies that with more women in power, MNH prioritization is likely to be increased to a larger extent.\n\nThe respondents who are all policymakers mentioned that prioritization of MNH services depends on the consistency of governance and whether it is a priority for the government in power especially with the so many tiers of government in Nigeria, this makes things complicated.\nThe respondents also mentioned the governments both at the state and local levels which consists of the governor who has the highest authority to make influential decisions regarding MNH in Yobe state, house of assembly members, commissioners of health and executive secretaries are major decision makers. Some other decision makers include the hospital managements, religious leaders, and traditional rulers whose power to make influential decision on MNH is limited, but whose opinion is highly regarded by the people.\n","there are so many NGOs that are giving support in Yobe, I want to believe is one of the target states because it is one of the state with high maternal mortality in this country, there are so many NGOs, so many Global Fund that are coming in this country and I’m sure Yobe is benefiting and I’m sure they are effectively utilizing that money and making the positive influence in order to reduce the maternal mortality in this country.","The ward development committee (WDC)  was designed and developed as a social strategy for encouraging community participation and access to primary health care services. WDCs help to ensure complete ownership by members of the community of all primary health issues such as health promotion and community mobilization, maternal and newborn child health services, nutrition, control of communicable and non-communicable diseases, and sexual and reproductive health. Furthermore, it also includes issues of water, sanitation, and hygiene (WASH) including waste disposal.","1.\tWe recommend that on the policy makers should be more familiar with their infant mortality data in terms of national ranking and utilize the national and state data to advocate politicians to keep neonatal and newborn healthcare in the fore front. We also recommend that there should be Yobe state data for maternal and infant mortality and morbidity rate and continuity in viable government projects that prioritize MNH services.\n2.\tWe recommend that more avenues should be provided for women to occupy participate in decision making.\n"]
[" Decision makers composition"]
["Political leadership"]
["Influencial decision makers"]
["Policymakers attitude on prioritization"]
["Intersectoral collaboration","Collaboration among service providers, intersectorial and among other organisations","Impact of collaboration among various sectors and between the facilities and other organisation or policy makers","In terms of intersectoral collaboration, the respondents majorly policymakers, CSOs, NGOs and HCW stated that there is collaboration between facilities and policymakers where the traditional institution played the role of health workers, NGO supporting hospitals, training and deployment of more skilled birth attendants to the rural areas of the state, building projects by the government, employment and reintegration of some retirees into service to mentor the younger ones. The respondents also revealed a level of competition and clash among the development partners leading to reduction of seriousness of NGOs and other stakeholders collaborating with the state government to coordinate activities. \n\nThe respondents mentioned coordination/collaboration among health systems during decision-making processes and the synergy between the various health sector (non-governmental) and the government especially on coordination and collaboration between stakeholders to create positive health impact especially at all levels of operation. solving problems of employment, logistics and collaborating with other partners to address issues from the grassroots.\n\n\nAlso, the respondents mostly HCWs, CSOs and policymakers mentioned some forms of collaboration between the facilities and policy makers which includes facility monitoring and supervision, traditional institutes supplementing roles being played by healthcare practitioners with the presence of Traditional birth attendants, meeting with the leadership of the primary healthcare and the local government to strengthen collaboration.\n\nFor facilities and other organisation collaboration and coordination; the healthcare workers and the policy makers that responded agreed that there is collaboration between health facilities and Organisations such as WHO, UNICEF, UNFPA, IRC, MCRP, Red Cross among others in terms of provision of structures, commodities, and manpower to meet MNH service needs. Few of the respondents stated that even though there are collaborations between the healthcare facilities and NGOs, there are no strong platforms for coordination, though irregular meetings have been organised by the United Nation Organisation for Coordination of Humanitarian Affairs (UNOCHA) supported by WHO.\n","You know the union rivalry, and political and professional rivalry is a big issue, in the hospital an incompetent doctor becomes a manager because he doesn’t want a competent nurse to be, even among the health workers they do they don’t usually go together, but the government usually listens to us but not to our satisfaction. I think there is also competition among the development partners ",null,"We recommend sustainable collaboration/collaboration between the government and stakeholders, especially in the health sector.\n\nWe recommend increased collaboration among various health sectors to prioritize MNH services, training and retraining of HCWs, mentoring and supervision for newly employed staff to further increase the opportunities of intersectoral collaboration.\n\nThe weak link in coordination of activities between the NGO and healthcare facilities should be strengthened through regular meetings.\nPolicy makers should include clear guidance in MNH policies on the level and modalities of collaboration and coordination  between healthcare facilities and NGOs which needs to be increased.\n"]
["Coordination/ collaboration among health systems"]
["Facilities/ policy makers collaboration"]
["Facilities/ other organisations collaboration"]
["Collaboration among service providers"]
["Prioritization organisational role","Technical capacity/role","Level of organisational capacity, role and competencies","In terms of organizational role in prioritization of MNH services, the respondents revealed that organizational prioritization of MNH services exists in the state which includes policies for free medic care for pregnant women and under 5, basket fund that ensure all those critical services are being implemented, , provision of technical expertise in terms of drafting policy or quality antenatal care service centres by the organisations, quality assurance supervision of health workers by the state government to ensure quality MNH service delivery, and feedback from health workers on implementation process at the grassroot.\n\n\nOn organizational capacity to deliver and prioritize MNH services, the respondents who are majorly policymakers mentioned various capacities in which organizations can deliver MNH services which includes staffing, provision of manpower to sit at the decision table as well supervise field activities, availability of resources to carryout services relating to MNH, increased capacity building supported by various organizations such as W.H.O, UNICEF, and employment of support staff to increase efficiency at health centres.\n\nFor organizational policy role, the respondents’ policymakers and CSOs mentioned the role of their organizations in prioritizing MNH services through the creation of new laws and policies, which includes advocating for policies and guidelines that is related to MNH matters, involving religious leaders in the creation of policies to enable effective tackling of grassroot issues. The challenges faced however is that these policies are hindered due to poor interface between the government and the stakeholders in policy creation.\n","we are lacking the adequate human resources in the department, I think usually we are only three in the department and for the three persons to be part of the decision making to also be part of supervisory action in the field is a serious gap ",null,"We recommend that more organizations be involved in the prioritization of MNH services, more policies that encourages the provision of MNH services be created and sustained, increased provision, supervision, and feedback on quality of ANC services centres and implementation processes.\nWe recommend that the communication channels between the government and the stakeholders be strengthened for effective creation and dissemination of policies especially at the grassroot level\n"]
["Organizational technical capacity"]
["Organizational policy role"]
["Competencies"]
["Inclusion of female staff","Inclusiveness, Competencies/ perception/ Acceptance","Inclusion of women, PWD as well as leadership selection to  prioritize MNH services in Yobe state","In terms of inclusion of female staff in decision making at the facility level, the respondents who are HCW and majorly CSOs and NGOs mentioned that women are included in decision making, however some NGO respondents have a contrary opinion to that and reiterated how women are side-lined in leadership position, with most of the primary health centres being male dominated. Even though women are being involved in decision making at higher levels, there is very little inclusion at the facility level.\n\nRegarding inclusiveness of PWD in MNH decision making, the respondents a policymaker, HCW, NGO, and CSO mentioned that women, persons with disabilities and vulnerable persons are being involved in decision making in MNH which impacts how they benefit from these services. Also, they occupy key positions at the community level and PWD are provided with special assistance during ANC and other hospital visits.\n\nOn the selection of leaders/decision makers the respondents who are all healthcare workers mentioned that selection of leaders in health facilities depends on the settings; for some of these facilities who have very few staff, the most senior in terms of hierarchy becomes the leader while for some if they are the only qualified staff around, they automatically become leaders. Others are chosen based on their hard work and knowledge of the job, duration of stay on the job as well as their qualifications. The respondents pointed out the issues around people retaining leadership positions for lack of staff to replace them, unavailability of qualified staff to take over and absence of trained personnels.\n\nIn respect to the acceptance for MNH services, all but one of the respondents stated that there is acceptance of maternal and neonatal health (MNH) services irrespective of the patients’ belief, incentives, and external influence. However, a civil society officer had identified how religious belief influences people’s acceptance to seek medical services but rather to trust in God for their healing as they believe that sickness comes from God and only him can heal. There is a gap in social behaviours and religious practice among patients. \n\nWhen asked on the gender mix, most of the respondents (NGO, CSO, policymaker and HCW) agreed that there is a degree of gender mix in terms of the composition of both males and females as health providers across the health facilities. However, some of the respondents (HCW & policymaker) argue that only the female staff are involved in the issues related to MNH services, as male staff cannot be granted access to female/labour wards due to cultural practices in the northern part of the country (Yobe State). \n\nOn the current behaviour that affects the prioritization of MNH services, the respondents who are mostly NGOs, HCWs, and CSOs mentioned some of the behaviour and practices that health providers must undertake to provide quality and show priority for MNH services. These includes respect for persons, good clinical and ethical practices, motivation, visiting and follow-up of patients as required.\n","that is a big gap and it has actually interfered with provision of services in some places where the husbands will not want a male midwife or nurse to care for their wives, and even sometimes the women themselves will prefer women and they are not there so there is imbalance in some places, ","The gender disparity in health care leadership is pronounced. Globally, it is estimated that women represent 70% of health workers, yet only 26% of representative positions are held by women1. Studies have shown that women appear more often in sub-directorates than in directorates and are more often section chiefs than service chiefs. This fact is especially striking considering that women represent more than half of the medical personnel hired. Arrizabalaga et al. noted that compared with two-thirds of male doctors, only one-third of female doctors reached the highest positions in their careers2\n\nHistorically, nursing has been considered a female-dominated profession. The idea of being a “good nurse” requires being “a good woman,” introduced by Florence Nightingale in the 19th century is based on the idea that nursing is perceived as women's work assuming that a woman's function is to care for and protect others3\n\nAlthough the proportion of male nurses has increased, it is still only 5–10% of the total of the nursing workforce in the western world, nursing continues to be seen as a female profession and thus its leaders are more often women; however, the percentage does not reach the same level as the percentage of female workers4, 5.\nSeveral studies from different parts of the world have reported that cultural factors such as ethnicity and religious beliefs influence the use of maternal health services and need to be taken into consideration for any effective intervention (1-7). This approach has been well-covered in some parts of South America (5). Furthermore, WHO considers the inclusion of approaches that address ethno-religious barriers as good practices that will facilitate the optimal utilization of ANC, natal, and post-natal maternal health services (7,8). Religion and ethnicity are part of the fabric of the culture of a defined population and have been reported as a pointer to a low utilization rate of maternal health services and poor pregnancy outcomes even in developed (9,10,11) and developing countries (12-14). In general, poor pregnancy outcome has been reported to be common among pregnant women with low use of ANC and delivery services (15,16). In Nigeria, the low rate of ANC and delivery was partly due to cultural factors such as ethnicity and religious beliefs 17,18) and the low level of female autonomy which is driven by religion and ethnic beliefs (19, 20). \n","We recommended that, further research be conducted on women inclusion and increased awareness among stakeholders for women inclusion especially at the community level be enforced. Also, more women should be employed and deployed to facilities that are male dominated.\n2.        More women and PWD should be placed in key decision-making position, as well as increased access to MNH services for PWD should be made readily available.\n3.        Training for all healthcare workers on leadership skills and qualified medical personnel should be employed and deployed to the rural facilities to take-up leadership positions.\n4.        Continuous advocacy be done on acceptance of MNH services, religious leaders should approach the use of religious texts, education and sermons, collaborate with healthcare providers, train community health workers, support health campaigns, address cultural and social norms, establish support networks and engage youth and women's groups with cultural sensitivity, respect for diverse beliefs, and an understanding of local contexts by leveraging their influence and platforms, contribute to raising awareness and acceptance of maternal and neonatal health services among their followers.\n5.        Further research be conducted to explore the women’s perspectives on gender preferences for service providers and impact of gender preference on health worker availability.\n6.        Increase awareness of good clinical practices, increase the proliferation of policies, and improve capacity building, mentoring, support, and supervision for early HCWs on how to prioritize MNH services\n"]
["Inclusiveness"]
["Selection of leaders/decision makers"]
["Acceptance (Beliefs, incentives, external influence)"]
[]
["Current behaviour and perception"]
["Funding for MNH","Funding/support for MNH","Availabity of funding for delivery of MNH services","In terms of funding for MNH, most of the respondents stated that there are available funds through government allocation and counterpart funding from development partners such as WHO, UNICEF, UNFPA, FCDO . The state has multiple avenues for prioritizing maternal funding through programs like Yobe State Contributory Healthcare Management Agency (YOSCHMA), Yobe drugs and consumable agency (YODMA) and Yobe State Emergency Medical Ambulance Service (YEMABUS) which cater for patients at every level including medication. There are gaps in budget allocation which includes; how continuity in governance/political interest affects funding for MNH services, unavailability of sufficient funds from the government  to cater/cover all facilities and timeliness of fund release by the government to implement services.",". If that government leaves and another government comes and the government is interested in infrastructure that is the end.",null,"We recommend increased prioritization and funding for MNH services during budgeting and fund allocation , continuous advocacy from the policymakers for sustained implementation of MNH policies, increase funding and timely release of funds."]
["Support or resistance for CBMNC"]
["Drivers of stakeholders behaviour and decision","Stakeholders behaviour/ decision/challenges","What are the drivers of stakeholders decision and behaviour, what are the challenges faced in policy implementation","In terms of challenges faced in implementing policies, most of these challenges on policy implementation which includes lack of proper dissemination of information/policies, feedback from service users, are seen at the grassroot level while at the state level the policy makers are not aware of some of these challenges   identified like low provider-patient ratio, long waiting time for G-ANC models resulting in patient loss, poor dissemination of new policies as well as shortage of manpower.","For instance, like the humanitarian content because we are in an insurgency area whereby many communities and people living there are being displaced from the area and some are in the IDPs while others are part of the community and find themselves where they can be able to accommodate themselves. In that case, you find out that these people are somehow not having the desired maternal and child health services. ","Group-ANC (G-ANC)  is an alternative way to provide healthcare to pregnant women with similar needs which require ongoing care as a small stable group. It is a proven health systems innovation that improves Antenatal Care (ANC) use and quality among underserved populations in diverse countries. It uses a Human-centered approach to improve time management, teaching and learning, client-client relationship, care provider-client relationship, client satisfaction, and uptake of services leading to better health outcome3.\n\nGroup-ANC in Nigeria, women of similar gestational ages attend ANC together throughout their pregnancies, actively engaging in their own care. G-ANC aimed to increased utilization of care (e.g., attendance at ANC), increased uptake in health practices (e.g., breastfeeding), higher patient satisfaction, and improved health outcomes (e.g., reduced rates of preterm birth)3.   \n"," We recommend that mid-level supervisors be held accountable for dissemination of policies for all healthcare workers, as well as strengthening communication channel between the government and service users and feedback mechanism to address the challenges faced at the grassroot level. The policymakers on the other hand need to be held accountable and be more involved, be aware and put forward majors to curb these challenges mentioned. "]
["Challenges faced in implementing policies"]
["Gender mix ","Feedback/Accountability processes",null,"In terms of feedback mechanisms on MNH services, the respondents mentioned that both the policymakers, NGOs and HCW agreed that feedback on service deliveries exists between the policy makers and the service users. Suggestion boxes, hotlines, and Gender Based Violence (GBV) referral pathways and organisations such as Ward Development Committee (WDC) are used as channels to receive feedback. We recommend that more research should be done on client’s awareness of the feedback channels, its accessibility and effectiveness given that the respondent think funding is the issue.",null,"Feedback mechanism improve MNH service delivery when used to guide program implementation, responsive feedback results in improved program outcomes, increased ownership, and sustainability of solutions. As observed in a study conducted in Kano State. Before the used of responsive feedback mechanism to improve the quality of antenatal care services in health facilities, few pregnant women knew of and used the MNH services9."]
["Feedback Mechanism"]
["The mechanism for feedback on satisfaction"]
["Feedback mechanisms for PLWD"]
["Accountability "]
["Accountability service provider"]
["Provider behaviour/practices"]
["Administration issues at facility level","Planning/Decision making process/Administrative issues"]
["Planning (Policy makers)"]
["Planning at facility level"]
["Planning (Policy makers)"]
["Planning/decision-making process"]
["Bureaucracy"]
["Federal and state level governance"]
["Donor driven policies"]
["Dissemination of policies"]

{"sheet":"Notes","index":4,"n_rows":1,"n_cols":1,"rows_kept":1}
["Explore discourse analysis around different stakeholders prioritization of MNH"]