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Mbuthia F, Reid M, Fichardt A. Development and validation of a mobile health communication framework for postnatal care in rural Kenya. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Kinney RG, Zakumumpa H, Rujumba J, Gibbons K, Heard A, Galárraga O. Community-funded integrated care outreach clinics as a capacity building strategy to expand access to health care in remote areas of Uganda. Glob Health Action 2021; 14:1988280. [PMID: 34720066 PMCID: PMC8567937 DOI: 10.1080/16549716.2021.1988280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Most Ugandans live in rural, medically underserved communities where geography and poverty lead to reduced access to healthcare. We present a novel low-cost approach for supplemental primary care financing through 1) pooling community wealth to cover overhead costs for outreach clinic activities and 2) issuing microfinance loans to motorcycle taxi entrepreneurs to overcome gaps in access to transportation. The intervention described here, which leverages community participation as a means to extend the reach of government health service delivery, was developed and implemented by Health Access Connect (HAC), a non-governmental organization based in Uganda. HAC began its work in August 2015 in the Lake Victoria region and now serves over 40 sites in Uganda across 5 districts, helping government health-care workers to provide over 1,300 patient services per month (and over 35,000 since the program's inception) with an average administrative cost of $6.24 per patient service in 2020. In this article, we demonstrate how integrated and appropriately resourced monthly outreach clinics, based on a microfinance-linked model of wealth pooling and government cooperation, can expand the capacity of government-provided healthcare to reach more patients living in remote communities. This scalable, sustainable, and flexible model is responsive to shifting needs of patients and health systems and presents an alternative approach to healthcare financing in low-resource settings. More rigorous evaluation of health outcomes stemming from such community-based models of service delivery is warranted.
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Affiliation(s)
| | - Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda
| | - Joseph Rujumba
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Kampala, Uganda
| | | | - Anna Heard
- Independent Consultant, Washington, DC, USA
| | - Omar Galárraga
- School of Public Health, Brown University, Providence, RI, USA
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Tran NT, Greer A, Kini B, Abdi H, Rajeh K, Cortier H, Boboeva M. Integrating sexual and reproductive health into health system strengthening in humanitarian settings: a planning workshop toolkit to transition from minimum to comprehensive services in the Democratic Republic of Congo, Bangladesh, and Yemen. Confl Health 2020; 14:81. [PMID: 33250933 PMCID: PMC7686834 DOI: 10.1186/s13031-020-00326-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 11/10/2020] [Indexed: 12/03/2022] Open
Abstract
Background Planning to transition from the Minimum Initial Service Package for Sexual and Reproductive Health (SRH) toward comprehensive SRH services has been a challenge in humanitarian settings. To bridge this gap, a workshop toolkit for SRH coordinators was designed to support effective planning. This article aims to describe the toolkit design, piloting, and final product. Methods Anchored in the Health System Building Blocks Framework of the World Health Organization, the design entailed two complementary and participatory strategies. First, a collaborative design phase with iterative feedback loops involved global partners with extensive operational experience in the initial toolkit conception. The second phase engaged stakeholders from three major humanitarian crises to participate in pilot workshops to contextualize, evaluate, validate, and improve the toolkit using qualitative interviews and end-of-workshop evaluations. The aim of this two-phase design process was to finalize a planning toolkit that can be utilized in and adapted to diverse humanitarian contexts, and efficiently and effectively meet its objectives. Pilots occurred in the Democratic Republic of Congo for the Kasai region crisis, Bangladesh for the Rohingya humanitarian response in Cox’s Bazar, and Yemen for selected Governorates. Results Results suggest that the toolkit enabled facilitators to foster a systematic, participatory, interactive, and inclusive planning process among participants over a two-day workshop. The approach was reportedly effective and time-efficient in producing a joint work plan. The main planning priorities cutting across settings included improving comprehensive SRH services in general, healthcare workforce strengthening, such as midwifery capacity development, increasing community mobilization and engagement, focusing on adolescent SRH, and enhancing maternal and newborn health services in terms of quality, coverage, and referral pathways. Recommendations for improvement included a dedicated and adequately anticipated pre-workshop preparation to gather relevant data, encouraging participants to undertake preliminary study to equalize knowledge to partake fully in the workshop, and enlisting participants from marginalized and underserved populations. Conclusion Collaborative design and piloting efforts resulted in a workshop toolkit that could support a systematic and efficient identification of priority activities and services related to comprehensive SRH. Such priorities could help meet the SRH needs of communities emerging from acute humanitarian situations while strengthening the overall health system.
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Affiliation(s)
- Nguyen Toan Tran
- Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, PO Box 123, Sydney, NSW 2007 Australia.,Faculty of Medicine, University of Geneva, Rue Michel-Servet 1, 1206 Genève, Switzerland.,Training Partnership Initiative of the Inter-Agency Working Group on Reproductive Health in Crises, Women's Refugee Commission, 15 West 37th Street, New York, NY 10018 USA
| | - Alison Greer
- Training Partnership Initiative of the Inter-Agency Working Group on Reproductive Health in Crises, Women's Refugee Commission, 15 West 37th Street, New York, NY 10018 USA
| | - Brigitte Kini
- World Health Organization Country Office in the Democratic Republic of Congo, Avenue des Cliniques 42, BP 1899 Kinshasa I, Democratic Republic of Congo
| | - Hassan Abdi
- Consultant, PO Box 617, Garissa, 70100 Kenya
| | - Kariman Rajeh
- World Health Organization, PO Box 543, Sana'a, Yemen
| | | | - Mohira Boboeva
- World Health Organization, Global Health Cluster, Avenue Appia 20, 1211, 27 Geneva, Switzerland
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Ferrinho P, Fronteira I, Correia T, Neves C. The relevance of educational attainments of parents of medical students for health workforce planning: data from Guiné-Bissau. HUMAN RESOURCES FOR HEALTH 2020; 18:90. [PMID: 33239031 PMCID: PMC7687985 DOI: 10.1186/s12960-020-00528-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/16/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND In this article, we analyze data collected in the context of health workforce planning (HWFP) for Guiné-Bissau as part of the development of the third National Health Strategy, to study the relationship between educational achievement of parents and medical student characteristics and professional expectations. METHODS Cross-sectional analytical study of all first-year medical students in Guiné-Bissau during December 2016. RESULTS Our results confirm that the isolated effect of each parent is different as it is the combined education of both parents. Parental influence also seems to vary according to the sex of the offspring. The higher the education of the father, the stronger the urban background of the offspring. Level of education of parents is also important in relation to the decision to study medicine and the age of starting those studies. It is also an important influence as to expectation regarding place of future practice: the highest the educational level, particularly of the father, the highest the expectation for a future urban practice. CONCLUSIONS Our main interest in medical education is to study it as a health system intervention in order to contribute to health system's strengthening in fragile states. This is discussed in the context of two frameworks: the labor market framework and WHO's health system strengthening framework. Our data and that of others, recognize that household characteristics are important regarding future training and a future career in the health sector. This recognition should be integrated into HWFP frameworks.
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Affiliation(s)
- Paulo Ferrinho
- Global Health and Tropical Medicine Research Center, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira 100, 1349 008 Alcântara, Lisbon, Portugal.
| | - Inês Fronteira
- Global Health and Tropical Medicine Research Center, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira 100, 1349 008 Alcântara, Lisbon, Portugal
| | - Tiago Correia
- Global Health and Tropical Medicine Research Center, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junqueira 100, 1349 008 Alcântara, Lisbon, Portugal
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Vaz LME, Franco L, Guenther T, Simmons K, Herrera S, Wall SN. Operationalising health systems thinking: a pathway to high effective coverage. Health Res Policy Syst 2020; 18:132. [PMID: 33143734 PMCID: PMC7641804 DOI: 10.1186/s12961-020-00615-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 08/03/2020] [Indexed: 01/25/2023] Open
Abstract
Background The global health community has recognised the importance of defining and measuring the effective coverage of health interventions and their implementation strength to monitor progress towards global mortality and morbidity targets. Existing health system models and frameworks guide thinking around these measurement areas; however, they fall short of adequately capturing the dynamic and multi-level relationships between different components of the health system. These relationships must be articulated for measurement and managed to effectively deliver health interventions of sufficient quality to achieve health impacts. Save the Children’s Saving Newborn Lives programme and EnCompass LLC, its evaluation partner, developed and applied the Pathway to High Effective Coverage as a health systems thinking framework (hereafter referred to as the Pathway) in its strategic planning, monitoring and evaluation. Methods We used an iterative approach to develop, test and refine thinking around the Pathway. The initial framework was developed based on existing literature, then shared and vetted during consultations with global health thought leaders in maternal and newborn health. Results The Pathway is a robust health systems thinking framework that unpacks system, policy and point of intervention delivery factors, thus encouraging specific actions to address gaps in implementation and facilitate the achievement of high effective coverage. The Pathway includes six main components – (1) national readiness; (2) system structures; (3) management capacity; (4) implementation strength; (5) effective coverage; and (6) impact. Each component is comprised of specific elements reflecting the range of facility-, community- and home-based interventions. We describe applications of the Pathway and results for in-country strategic planning, monitoring of progress and implementation strength, and evaluation. Conclusions The Pathway provides a cohesive health systems thinking framework that facilitates assessment and coordinated action to achieve high coverage and impact. Experiences of its application show its utility in guiding strategic planning and in more comprehensive and effective monitoring and evaluation as well as its potential adaptability for use in other health areas and sectors.
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Affiliation(s)
- Lara M E Vaz
- Population Reference Bureau, 1875 Connecticut Avenue, NW Suite 520, Washington, DC, 20009, United States of America.
| | - Lynne Franco
- EnCompass LLC, 1451 Rockville Pike Suite 600, Rockville, MD, 20852, USA
| | - Tanya Guenther
- Formerly with Save the Children US, 899 North Capitol St NE Suite 900, Washington DC, 20001, USA
| | - Kelsey Simmons
- Ford Foundation, 320 E 43rd St, New York, NY, 10017, USA
| | - Samantha Herrera
- Save the Children US, 899 North Capitol St NE Suite 900, Washington DC, 20001, USA
| | - Stephen N Wall
- Save the Children US, 899 North Capitol St NE Suite 900, Washington DC, 20001, USA
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Mbindyo R, Kioko J, Siyoi F, Cheruiyot S, Wangai M, Onsongo J, Omwoyo A, Kisia C, Miriti K. Legal and institutional foundations for universal health coverage, Kenya. Bull World Health Organ 2020; 98:706-718. [PMID: 33177760 PMCID: PMC7652562 DOI: 10.2471/blt.19.237297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/01/2020] [Accepted: 07/21/2020] [Indexed: 11/28/2022] Open
Abstract
Kenya’s Constitution of 2010 triggered a cascade of reforms across all sectors to align with new constitutional standards, including devolution and a comprehensive bill of rights. The constitution acts as a platform to advance health rights and to restructure policy, legal, institutional and regulatory frameworks towards reversing chronic gaps and improving health outcomes. These constitutionally mandated health reforms are complex. All parts of the health system are transforming concurrently, with several new laws enacted and public health bodies established. Implementing such complex change was hampered by inadequate tools and approaches. To gain a picture of the extent of the health reforms over the first 10 years of the constitution, we developed an adapted health-system framework, guided by World Health Organization concepts and definitions. We applied the framework to document the health laws and public bodies already enacted and currently in progress, and compared the extent of transformation before and after the 2010 Constitution. Our analysis revealed multiple structures (laws and implementing public bodies) formed across the health system, with many new stewardship structures aligned to devolution, but with fragmentation within the regulation sub-function. By deconstructing normative health-system functions, the framework enabled an all-inclusive mapping of various health-system attributes (functions, laws and implementing bodies). We believe our framework is a useful tool for countries who wish to develop and implement a conducive legal foundation for universal health coverage. Constitutional reform is a mobilizing force for large leaps in health institutional change, boosting two aspects of feasibility for change: stakeholder acceptance and authority to proceed.
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Affiliation(s)
- Regina Mbindyo
- World Health Organization Country Office, UN Complex Gigiri, Block U3, UN Gigiri Avenue, Nairobi, Kenya
| | - Jackson Kioko
- Kenya Health Professions Oversight Authority, Nairobi, Kenya
| | - Fred Siyoi
- Pharmacy and Poisons Board, Nairobi, Kenya
| | | | | | - Joyce Onsongo
- World Health Organization Country Office, UN Complex Gigiri, Block U3, UN Gigiri Avenue, Nairobi, Kenya
| | | | - Christine Kisia
- World Health Organization Country Office, UN Complex Gigiri, Block U3, UN Gigiri Avenue, Nairobi, Kenya
| | - Koome Miriti
- Kenya National Commission on Human Rights, Nairobi, Kenya
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Marshall J, Scott B, Delva J, Ade C, Hernandez S, Patel J, Moreno-Cheek M, Rojas D, Tanner JP, Kirby RS. An Evaluation of Florida's Zika Response Using the WHO Health Systems Framework: Can We Apply These Lessons to COVID-19? Matern Child Health J 2020; 24:1212-1223. [PMID: 32583172 PMCID: PMC7314660 DOI: 10.1007/s10995-020-02969-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES From 2016 to 2018 Florida documented 1471 cases of Zika virus, 299 of which were pregnant women (Florida Department of Health, https://www.floridahealth.gov/diseases-and-conditions/mosquito-bornediseases/surveillance.html , 2019a). Florida's response required unprecedented rapid and continuous cross-sector communication, adaptation, and coordination. Zika tested public health systems in new ways, particularly for maternal child health populations. The systems are now being challenged again, as the Coronavirus COVID-19 pandemic spreads throughout Florida. This qualitative journey mapping evaluation of Florida's response focused on care for pregnant women and families with infants exposed to Zika virus. METHODS Fifteen focus groups and interviews were conducted with 33 public health and healthcare workers who managed outbreak response, case investigations, and patient care in south Florida. Data were thematically analyzed, and the results were framed by the World Health Organization's (WHO) Healthcare Systems Framework of six building blocks: health service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership and governance (World Health Organization, https://www.who.int/healthsystems/strategy/everybodys_business.pdf , 2007, https://www.who.int/healthinfo/systems/monitoring/en/ , 2010). RESULTS Results highlighted coordination of resources, essential services and treatment, data collection, communication among public health and healthcare systems, and dissemination of information. Community education, testing accuracy and turnaround time, financing, and continuity of health services were areas of need, and there was room for improvement in all indicator areas. CONCLUSIONS The WHO Framework encapsulated important infrastructure and process factors relevant to the Florida Zika response as well as future epidemics. In this context, similarities, differences, and implications for the Coronavirus COVID-19 pandemic response are discussed.
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Affiliation(s)
- Jennifer Marshall
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA.
| | - Blake Scott
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Jennifer Delva
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Cedrick Ade
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Santiago Hernandez
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Jaladhikumar Patel
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Mantero Moreno-Cheek
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Dogeli Rojas
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Jean-Paul Tanner
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
| | - Russell S Kirby
- University of South Florida College of Public Health, 13201 Bruce B Downs Blvd, Tampa, FL, 33612, USA
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Sacks E, Schleiff M, Were M, Chowdhury AM, Perry HB. Communities, universal health coverage and primary health care. Bull World Health Organ 2020; 98:773-780. [PMID: 33177774 PMCID: PMC7607457 DOI: 10.2471/blt.20.252445] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/27/2022] Open
Abstract
Universal health coverage (UHC) depends on a strong primary health-care system. To be successful, primary health care must be expanded at community and household levels as much of the world's population still lacks access to health facilities for basic services. Abundant evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care. Policies and actions to improve primary health care must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Advancing the science of primary health care requires improved conceptual and analytical frameworks and research questions. Metrics used for evaluating primary health care and UHC largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand primary health care. Much of primary health care has taken place, and will continue to take place, outside health facilities. Involving community members in decisions about health priorities and in community-based service delivery is key to improving systems that promote access to care. Neither UHC nor the Health for All movement will be achieved without the substantial contribution of communities.
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Affiliation(s)
- Emma Sacks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
| | - Meike Schleiff
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
| | | | | | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E8011, Baltimore, Maryland, 21205, United States of America
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Yoshizaki M, Ramke J, Furtado JM, Burn H, Gichuhi S, Gordon I, Aghaji A, Marques AP, Dean WH, Congdon N, Buchan J, Burton MJ. Interventions to improve the quality of cataract services: protocol for a global scoping review. BMJ Open 2020; 10:e036413. [PMID: 32788187 PMCID: PMC7422650 DOI: 10.1136/bmjopen-2019-036413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/15/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Cataract is the leading cause of blindness globally and a major cause of vision impairment. Cataract surgery is an efficacious intervention that usually restores vision. Although it is one of the most commonly conducted surgical interventions worldwide, good quality services (from being detected with operable cataract to undergoing surgery and receiving postoperative care) are not universally accessible. Poor quality understandably reduces the willingness of people with operable cataract to undergo surgery. Therefore, it is critical to improve the quality of care to subsequently reduce vision loss from cataract. This scoping review aims to summarise the nature and extent of the published literature on interventions to improve the quality of services for primary age-related cataract globally. METHODS AND ANALYSIS We will search MEDLINE, Embase and Global Health for peer-reviewed manuscripts published since 1990, with no language, geographic or study design restrictions. To define quality, we have used the elements adopted by the WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we have added the element of planetary health. We will exclude studies focused on the technical aspects of the surgical procedure and studies that only involve children (<18 years). Two reviewers will screen all titles/abstracts independently, followed by a full-text review of potentially relevant articles. For included articles, data regarding publication characteristics, study details and quality-related outcomes will be extracted by two reviewers independently. Results will be synthesised narratively and presented visually using a spider chart. ETHICS AND DISSEMINATION Ethical approval was not sought, as our review will only include published and publicly accessible information. We will publish our findings in an open-access peer-reviewed journal and develop an accessible summary of the results for website posting. A summary of the results will be included in the ongoing Lancet Global Health Commission on Global Eye Health. REGISTRATION DETAILS Open Science Framework (https://osf.io/8gktz).
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Affiliation(s)
- Miho Yoshizaki
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jacqueline Ramke
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- School of Optometry and Vision Science, The University of Auckland, Auckland, New Zealand
| | - João M Furtado
- Division of Ophthalmology, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirao Preto, São Paulo, Brazil
| | - Helen Burn
- Department of Ophthalmology, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, UK
| | - Stephen Gichuhi
- Department of Ophthalmology, University of Nairobi, Nairobi, Kenya
| | - Iris Gordon
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ada Aghaji
- Department of Ophthalmology, University of Nigeria, Nsukka, Enugu, Nigeria
| | - Ana P Marques
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - William H Dean
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Department of Ophthalmology, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - Nathan Congdon
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - John Buchan
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew J Burton
- International Centre for Eye Health, London School of Hygiene and Tropical Medicine, London, UK
- Moorfields Eye Hospital, London, UK
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Zakumumpa H, Rujumba J, Kwiringira J, Katureebe C, Spicer N. Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda. BMC Health Serv Res 2020; 20:222. [PMID: 32183796 PMCID: PMC7077133 DOI: 10.1186/s12913-020-5069-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/04/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Although Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)'s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients' and HIV service managers' perspectives on barriers to implementation of Differentiated ART service delivery in Uganda. METHODS We employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context. RESULTS Our data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. CONTEXT Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups. CONCLUSION This is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).
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Affiliation(s)
- Henry Zakumumpa
- Makerere University, School of Public Health, Kampala, Uganda.
| | - Joseph Rujumba
- Makerere University, School of Medicine, Kampala, Uganda
| | | | | | - Neil Spicer
- London School of Hygiene and Tropical Medicine, London, UK
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Heine M, Lupton-Smith A, Pakosh M, Grace SL, Derman W, Hanekom SD. Exercise-based rehabilitation for major non-communicable diseases in low-resource settings: a scoping review. BMJ Glob Health 2019; 4:e001833. [PMID: 31798993 PMCID: PMC6861093 DOI: 10.1136/bmjgh-2019-001833] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/10/2019] [Accepted: 10/12/2019] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION While there is substantial evidence for the benefits of exercise-based rehabilitation in the prevention and management of non-communicable disease (NCD) in high-resource settings, it is not evident that these programmes can be effectively implemented in a low-resource setting (LRS). Correspondingly, it is unclear if similar benefits can be obtained. The objective of this scoping review was to summarise existing studies evaluating exercise-based rehabilitation, rehabilitation intervention characteristics and outcomes conducted in an LRS for patients with one (or more) of the major NCDs. METHODS The following databases were searched from inception until October 2018: PubMed/Medline, Embase, CINAHL, Cochrane Library, PsycINFO and trial registries. Studies on exercise-based rehabilitation for patients with cardiovascular disease, diabetes, cancer or chronic respiratory disease conducted in an LRS were included. Data were extracted with respect to study design (eg, type, patient sample, context), rehabilitation characteristics (eg, delivery model, programme adaptations) and included outcome measures. RESULTS The search yielded 5930 unique citations of which 60 unique studies were included. Study populations included patients with cardiovascular disease (48.3%), diabetes (28.3%), respiratory disease (21.7%) and cancer (1.7%). Adaptations included transition to predominant patient-driven home-based rehabilitation, training of non-conventional health workers, integration of rehabilitation in community health centres, or triage based on contextual or patient factors. Uptake of adapted rehabilitation models was 54%, retention 78% and adherence 89%. The majority of the outcome measures included were related to body function (65.7%). CONCLUSIONS The scope of evidence suggests that adapted exercise-based rehabilitation programmes can be implemented in LRS. However, this scope of evidence originated largely from lower middle-income, urban settings and has mostly been conducted in an academic context which may hamper extrapolation of evidence to other LRS. Cost-benefits, impact on activity limitations and participation restrictions, and subsequent mortality and morbidity are grossly understudied.
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Affiliation(s)
- Martin Heine
- Institute of Sport and Exercise Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- Division of Physiotherapy, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Alison Lupton-Smith
- Division of Physiotherapy, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
| | - Maureen Pakosh
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Sherry L Grace
- School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada
- KITE & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Wayne Derman
- Institute of Sport and Exercise Medicine, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
- IOC Research Center, South Africa
| | - Susan D Hanekom
- Division of Physiotherapy, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa
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