Causal Linkages in the Mitigation of the Risk Factors That Determine the Mediators and The Moderators of the Basic Health Care Provision Fund (BHCPF) Implementation of Basic Emergency Obstetric and new Born Care (BEmONC) Services in Kogi State

Abstract

Preventable maternal and neonatal mortality remain major public health and epidemiologic challenges in Nigeria despite ongoing Primary Health Care (PHC) reforms and implementation of the Basic Health Care Provision Fund (BHCPF) under the National Health Act 2014. In Kogi State, disparities in emergency obstetric readiness, skilled birth attendance, referral continuity, immunization coverage, and neonatal survival persist across demographic heterogeneous and environmentally vulnerable communities. Increasing implementation science evidence suggests that financing reforms improve outcomes primarily through operational and contextual pathways rather than financing inputs alone. Furthermore, the growing integration of Artificial Intelligence (AI), predictive analytics, digital health surveillance systems, and multilevel statistical software has expanded the capacity for longitudinal epidemiologic evaluation, forecasting, and policy-responsive PHC systems strengthening. This study therefore examined the causal linkages involved in mitigating the risk factors that determine the mediators and moderators of BHCPF implementation of Basic Emergency Obstetric and Newborn Care (BEmONC) services in Kogi State.
The study adopted a mixed-methods quasi-experimental longitudinal design integrating Difference-in-Differences (DiD), Interrupted Time Series (ITS), multilevel mixed-effects modeling, Bayesian sensitivity estimation, geospatial risk analysis, and multilevel causal mediation analysis within a facility-month panel framework covering 2019–2025 with projections toward 2028. The study population comprised N=239 BHCPF ward focal PHC facilities across the 21 LGAs of Kogi State. Quantitative data were obtained from DHIS2, eLMIS, BHCPF financial ledgers, Human Resources for Health databases, KPIT systems, Routine Immunization Supportive Supervision reports, geospatial environmental datasets, and ODK-based facility assessments, while qualitative data were generated through key informant interviews, facility observations, and focus group discussions.