Table 8 Strength, Weaknesses, Opportunities, Threat (SWOT) Analysis

Strengths

Weaknesses

Improved Health Facility attendance: 93% enrollment within first 2 trimesters indicates that the CCT programme encouraged women to register and attend antenatal visit (ANC) and Skilled Attendance during childbirth. Early results from the CCT Programme pilot phase was highly positive in terms of before-and-after comparisons of facility attendance in the selected clusters, and feedback from facility staff and women accessing the programme [18].

Irregular and Inconsistent pay out events: The pay-outs were highly inconsistent and irregular following delayed release of funds from federal government. This resulted in large crowds during pay-out events and long waiting times for beneficiaries.

Supply-side intervention: The combination of the CCT programme with supply-side interventions where 69.9% of respondents reported not paying for PHC services motivated more women to seek health services and utilize other free medical services provided at SURE-P supported PHCs.

Non-Payment of Cash Incentives in two installments: Some respondents reported that they were not paid their full entitlement. Only 39.8% of eligible beneficiaries received the full N5,000. Many others who received their first installment were yet to receive the second installment.

Robust design of the CCT programme: The desk review showed that the CCT was designed with novel approaches drawn from similar schemes around the world. Adequately conceptualized strategic plan and implementation manual, clear co-responsibilities for eligibility, two installment payment plans to facilitate prompt payments, etc.

Referral to General Hospital: Beneficiaries with complications were unable to access the services of general hospitals at no cost, owing to programmatic challenges (Table 8). The referral loop was problematic and deprived beneficiaries from utilizing the service.

Beneficiary retention: The CCT Programme contributed immensely in sustaining beneficiary retention throughout the continuum of care as about 88.7% of respondents followed the programme from enrolment to pay-out and fulfilled their four co-responsibilities.

State Steering Committees (SSC): The desk review showed that the SSC meetings were irregular. However, as a result of unavailability of imprest account to fund such meetings, the SSC may not be sustainable.

Staffing and Capacity Building: The CCT Programme was adequately staffed at all levels from the PIU to field offices and all stakeholders were trained prior to the implementation. This facilitated the smooth roll-out of the programme and contributed to the 86% respondents who had no complaints about the CCT programme at enrolment and 88.7% who found the operational process to be easy – from enrolment to pay-out.

Security: The desk review indicated that security during CCT pay-out events was inadequate and this raised a lot of security concerns for the cash being disbursed at the venue by officers that make the payments.

Documentation and reporting tools: The timely provision of the CCT reporting tools such as; Beneficiary Registration Card, CCT Facility Registers, CCT Personal Consultation Forms and CCT Referral Forms CCT Tools, prior to registration and enrollment of pregnant women helped seamless documentation and easy information retrieval.

M & E Framework: There was no clear M and E framework for the CCT programme and particularly for the Pay-out events and this resulted in non-implementation of programmatic recommendations.

Opportunities

Threats

CCT awareness increased patronage for the PHCs: Respondents reported hearing about the CCT from family and friends, village health workers (VHWs), community health extension workers (CHEWs) and ward development committee (WDC) members. This led to a massive awareness of the CCT programme within the communities and huge patronage for the primary health facilities.

Lack of a sustainability plan: The CCT intervention was designed as a social safety net program without an apparent sustainability plan.

Availability of Skilled Health work force at the PHCs: The supply side component of the SURE-P MCH provided trained midwives and Community Health Extension Workers (CHEWs) at the PHCs who offered quality care to CCT enrollees and stimulated the smooth operation of the CCT operations.

Unsustainability of the SURE-P MCH Programme: Continuation of the CCT programme was largely dependent on the SURE-P MCH project which was politically motivated, therefore a regime change threatened its continuation.

Availability of other supply side incentives such as ‘Mama Kits’ which contained delivery items for mother and baby, free medicines etc. further attracted women to register for the CCT.

Unavailability of CCT funds at the PIU: Funds budgeted for CCT pay-outs were largely unavailable from the federal government on schedule. This hampered the funds disbursement plans.

Huge Potential: The design of the CCT Programme to support other supply side interventions helped entrench health seeking behaviours within communities.

Discontinuation: A sudden discontinuation of the programme resulted in thwarting the numerous gains made and reversed the positive trends achieved so far.

Access to health services: The use of the CCT to boost demand for MNCH services created more space for clients’ interaction with service providers at the health facilities.

Distrust for Government: Stoppage of the CCT programme led to strong distrust/lack of confidence for government programmes.