Health sector reforms in sub-Saharan Africa: lessons of the last 10 years

Barriers to Equitable Public Participation in Health-System Priority Setting Within the Context of Decentralization: The Case of Vulnerable Women in a Ugandan District

BACKGROUND

Decentralization of healthcare decision-making in Uganda led to the promotion of public participation. To facilitate this, participatory structures have been developed at sub-national levels. However, the degree to which the participation structures have contributed to improving the participation of vulnerable populations, specifically vulnerable women, remains unclear. We aim to understand whether and how vulnerable women participate in health-system priority setting; identify any barriers to vulnerable women's participation; and to establish how the barriers to vulnerable women's participation can be addressed.

METHODS

We used a qualitative description study design involving interviews with district decision-makers (n=12), sub-county leaders (n=10), and vulnerable women (n=35) living in Tororo District, Uganda. Data was collected between May and June 2017. The analysis was conducting using an editing analysis style.

RESULTS

The vulnerable women expressed interest in participating in priority setting, believing they would make valuable contributions. However, both decision-makers and vulnerable women reported that vulnerable women did not consistently participate in decision-making, despite participatory structures that were instituted through decentralization. There are financial (transportation and lack of incentives), biomedical (illness/disability and menstruation), knowledge-based (lack of knowledge and/or information about participation), motivational (perceived disinterest, lack of feedback, and competing needs), socio-cultural (lack of decision-making power), and structural (hunger and poverty) barriers which hamper vulnerable women's participation.

CONCLUSION

The identified barriers hinder vulnerable women's participation in health-system priority setting. Some of the barriers could be addressed through the existing decentralization participatory structures. Respondents made both short-term, feasible recommendations and more systemic, ideational recommendations to improve vulnerable women's participation. Integrating the vulnerable women's creative and feasible ideas to enhance their participation in health-system decision-making should be prioritized.

Health Insurance Exemptions for Older Ghanaians: Stakeholder Perspectives on Challenges Confronting an Ambitious Policy

The health and wellbeing of older adults have taken center-stage in global policy agendas in recent times. In 2003, Ghana introduced an insurance exemption policy to eliminate financial barriers to healthcare for older adults and other vulnerable population groups. Embedded within the National Health Insurance Scheme (NHIS), this policy ostensibly guarantees free healthcare for older adults at publicly-funded facilities across the country. In this paper, we applied the implementation problem framework to identify gaps in the implementation of the exemptions policy and their impact on the healthcare experiences of older adults. Our data collection involved qualitative interviews with a purposive sample of community-residing older adults, health workers, community leaders, and policymakers. Our thematic data analysis identified resource, substantive, bureaucratic, political, and administrative constraints in the policy implementation process which, in turn, affected quality healthcare delivery. While most of these constraints are general challenges confronting the NHIS, they serve to undermine the intent of the scheme's exemptions policy. In particular, despite the exemptions, older adults continued to pay out-of-pocket for certain categories of treatments and medications, creating as yet financial barriers to healthcare. We present policy recommendations for addressing these implementation challenges, including suggestions to decentralize, depoliticize, and financially liberate the operations of the NHIS.

Factors associated with access to healthcare in Burkina Faso: evidence from a national household survey

BACKGROUND

Burkina Faso has undertaken major reforms, the cornerstone of which has been the decentralization of the health system to increase access to primary healthcare and to increase the effectiveness, efficiency, financial viability and equity of health services. This study aims to analyze the socio-demographic determinants of households' access to healthcare in Burkina Faso.

METHODS

We used data from a national household survey conducted in 2014 in Burkina Faso. We carried out binary logistic and linear regression analysis using data from a national household survey. The statistical analysis explored the associations between socio-demographic characteristics on the one side, and the use of health services, satisfaction with health services and expenditures on health services, on the other side.

RESULTS

The findings indicate an association between age, education, income and use of services (p < 0.0005). The results show that healthcare users' satisfaction is influenced by age, the association is stronger with the age group under 24 (p < 0.0005) than the age group of 25-39 (p < 0.005). An association was found between the age group under 15 (p < 0.005), the type of health facility used (p < 0.0005), the distance traveled to health facilities (p < 0.005) and households' individuals' health expenditure.

CONCLUSION

Specific policies are needed to enhance geographical access to healthcare, financial access to and satisfaction with healthcare in moving towards universal health coverage (UHC).

Exploring decision makers' knowledge, attitudes and practices about decentralisation and health resources transfer to local governments in Burkina Faso

In the health sector, decentralisation mainly consists of the devolution of administrative functions to local governments. Since 2009, Burkina Faso has engaged in a process to transfer health resources to local governments. This study examines the decision-makers' knowledge, attitudes and practices (KAP) about the decentralisation and health resources transfer to local governments in Burkina Faso. We used a qualitative research method. In-depth semi-structured interviews were conducted with key decision-makers. The data collected went through a directed qualitative content analysis. Findings suggest that all respondents are aware of the rationale of the decentralisation and resources transfer to local governments. The vast majority of respondents have a positive opinion towards decentralisation and the main elements that appear to be motivating their attitude, are the expected outcomes from decentralisation. The practical experience was limited to awareness raising, training, supervision, technical assistance and resources mobilisation. Poor collaboration between health districts and local governments, the control of certain resources by the state and the health districts constrain the implementation of health resources and skills transfer policy at grassroots level. Careful attention should be given to the country's political context and institutional design.

District Health Teams' Readiness to Institutionalize Integrated Community Case Management in the Uganda Local Health Systems: A Repeated Qualitative Study

District health teams failed to transition from partner-supported integrated community case management (iCCM) programs to locally-run and fully-institutionalized programs. Successful iCCM institutionalization requires local ownership with increased coordination among governmental and nongovernmental actors at the national and district levels.

Introduction:

Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition.

Methods:

We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas.

Findings:

In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level.

Conclusion:

Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.

Who is in and who is out? A qualitative analysis of stakeholder participation in priority setting for health in three districts in Uganda

Stakeholder participation is relevant in strengthening priority setting processes for health worldwide, since it allows for inclusion of alternative perspectives and values that can enhance the fairness, legitimacy and acceptability of decisions. Low-income countries operating within decentralized systems recognize the role played by sub-national administrative levels (such as districts) in healthcare priority setting. In Uganda, decentralization is a vehicle for facilitating stakeholder participation. Our objective was to examine district-level decision-makers' perspectives on the participation of different stakeholders, including challenges related to their participation. We further sought to understand the leverages that allow these stakeholders to influence priority setting processes. We used an interpretive description methodology involving qualitative interviews. A total of 27 district-level decision-makers from three districts in Uganda were interviewed. Respondents identified the following stakeholder groups: politicians, technical experts, donors, non-governmental organizations (NGO)/civil society organizations (CSO), cultural and traditional leaders, and the public. Politicians, technical experts and donors are the principal contributors to district-level priority setting and the public is largely excluded. The main leverages for politicians were control over the district budget and support of their electorate. Expertise was a cross-cutting leverage for technical experts, donors and NGO/CSOs, while financial and technical resources were leverages for donors and NGO/CSOs. Cultural and traditional leaders' leverages were cultural knowledge and influence over their followers. The public's leverage was indirect and exerted through electoral power. Respondents made no mention of participation for vulnerable groups. The public, particularly vulnerable groups, are left out of the priority setting process for health at the district. Conflicting priorities, interests and values are the main challenges facing stakeholders engaged in district-level priority setting. Our findings have important implications for understanding how different stakeholder groups shape the prioritization process and whether representation can be an effective mechanism for participation in health-system priority setting.

The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation

Background

In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations.

Methods

A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES.

Results

Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme.

Conclusions

Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.

Public private partnership in the training of doctors after the 1990s' health sector reforms: the case of Tanzania

Similar to many other low- and middle-income countries, public private partnership (PPP) in the training of the health workforce has been emphasized since the launch of the 1990s' health sector reforms in Tanzania. PPP in training aims to contribute to addressing the critical shortage of health workforce in these countries. This study aimed to analyse the policy process and experienced outcomes of PPP for the training of doctors in Tanzania two decades after the 1990s' health sector reforms. We reviewed documents and interviewed key informants to collect data from training institutions and umbrella organizations that train and employ doctors in both the public and private sectors. We adopted a hybrid thematic approach to analyse the data while guided by the policy analysis framework by Gagnon and Labonté. PPP in training has contributed significantly to the increasing number of graduating doctors in Tanzania. In tandem, undermining of universities' autonomy and the massive enrolment of medical students unfavourably affect the quality of graduating doctors. Although PPP has proven successful in increasing the number of doctors graduating, unemployment of the graduates and lack of database to inform the training needs and capacity to absorb the graduates have left the country with a health workforce shortage and maldistribution at service delivery points, just as before the introduction of the PPP. This study recommends that Tanzania revisit its PPP approach to ensure the health workforce crisis is addressed in its totality. A comprehensive plan is needed to address issues of training within the framework of PPP by engaging all stakeholders in training and deployment starting from the planning of the number of medical students, and when and how they will be trained while taking into account the quality of the training.

System dynamics modeling of public health services provided by China CDC to control infectious and endemic diseases in China

BACKGROUND

Infectious and endemic diseases are a serious public health concern worldwide, and their prevention and treatment are globally controversial. This study aimed to establish an system dynamics (SD) model to analyze the factors influencing public health services provided by the Chinese Centers for Disease Control and Prevention (China CDC) to implement infectious and endemic disease control in China, by establishing more effective interventions to provide public health services and thus achieving the goal of controlling infectious and endemic diseases.

MATERIALS AND METHODS

An SD model was constructed using the Vensim DSS program. Intervention experiments were performed using the SD model, which reflected the influences on disease control by adjusting the governmental investment and compensation level for public health products.

RESULTS

The experimental results showed that increasing the governmental investment in China CDC and compensation level for public health products will significantly increase the public health product rate provided by China CDC.

DISCUSSION

Problems with infectious and endemic disease prevention and treatment are the result of the system's incomplete functioning and limited health resources. To address the current problems and improve the system, the government should increase its investment in the public health service system and improve the compensation system to ensure smooth implementation of infectious and endemic disease prevention and treatment and, ultimately, improve public health in China.

Understanding the implementation of Direct Health Facility Financing and its effect on health system performance in Tanzania: a non-controlled before and after mixed method study protocol

Background

Globally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania.

Methods

An evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients’ experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness.

Discussion

This evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0400-3) contains supplementary material, which is available to authorized users.

Influence of organisational culture on the implementation of health sector reforms in low- and middle-income countries: a qualitative interpretive review

BACKGROUND

Health systems, particularly in low- and middle-income countries, are commonly plagued by poor access, poor performance, inefficient use and inequitable distribution of resources. To improve health system efficiency, equity and effectiveness, the World Development Report of 1993 proposed a first wave of health sector reforms, which has been followed by further waves. Various authors, however, suggest that the early reforms did not lead to the anticipated improvements. They offer, as one plausible explanation for this gap, the limited consideration given to the influence over implementation of the software aspects of the health system, such as organisational culture - which has not previously been fully investigated.

OBJECTIVE

To identify, interpret and synthesise existing literature for evidence on organisational culture and how it influences implementation of health sector reforms in low- and middle-income countries.

METHODS

We conducted a systematic search of eight databases: PubMed; Africa-Wide Information, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Econlit, PsycINFO, SocINDEX with full text, Emerald and Scopus. Eight papers were identified. We analysed and synthesised these papers using thematic synthesis.

RESULTS

This review indicates the potential influence of dimensions of organisational culture such as power distance, uncertainty avoidance, and in-group and institutional collectivism over the implementation of health sector reforms. This influence is mediated through organisational practices such as communication and feedback, management styles, commitment and participation in decision-making.

CONCLUSION

This interpretive review highlights the dearth of empirical literature around organisational culture and therefore its findings can only be tentative. There is a need for health policymakers and health system researchers to conduct further analysis of organisational culture and change within the health system.

The role of leadership in people-centred health systems: a sub-national study in The Gambia

Recently, increasing attention has been given to behavioural and relational aspects of the people who both define and shape health systems, placing them at the core. A growing refrain includes the assertion that important decisions determining health system performance, including agenda setting, policy formulation and policy implementation, are made by people. Within this actor-oriented approach, good leadership has been identified as a key contributing factor in health systems strengthening. However, leadership remains ill-defined and under-researched, especially in resource-limited settings, and understanding the links between leadership and health outcomes remains a challenge. We explore the concept and practice of healthcare leadership at sub-national level in a low-income country setting, using a people-centric research methodology. In June and July 2013, 15 in-depth interviews were conducted with key informants in formal healthcare leadership roles across urban, peri-urban and rural settings of The Gambia, West Africa. Participants included the entire spectrum of Regional Health Team (RHT) Directors and Chief Executive Officers of all government hospitals, as well as one clinical officer-in-charge in a secondary-level major health centre. We found reference to several important aspects of, and approaches to, leadership, including (i) setting a clear vision; (ii) engendering shared leadership; and (iii) paying attention to human relations in management. Participants described attending to constituencies in government, international development agencies and civil society, as well as to the populations they serve. By illuminating the multi-polar networks within which these leaders are embedded, and through which they operate, we provide insight into the complex 'organizational ecology' of the Gambian health system. There is a need to further research and develop healthcare leadership across all levels, within various political, socio-economic and cultural contexts, in order to better work with a range of health actors and to engage them in identifying and acting upon opportunities for health systems strengthening.

Decision space for health workforce management in decentralized settings: a case study in Uganda

The aim of this paper is to improve understanding about how district health managers perceive and use their decision space for human resource management (HRM) and how this compares with national policies and regulatory frameworks governing HRM. The study builds upon work undertaken by PERFORM Research Consortium in Uganda using action-research to strengthen human resources management in the health sector. To assess the decision space that managers have in six areas of HRM (e.g. policy, planning, remuneration and incentives, performance management, education and information) the study compares the roles allocated by Uganda's policy and regulatory frameworks with the actual room for decision-making that district health managers perceive that they have. Results show that in some areas District Health Management Team (DHMT) members make decisions beyond their conferred authority while in others they do not use all the space allocated by policy. DHMT members operate close to the boundaries defined by public policy in planning, remuneration and incentives, policy and performance management. However, they make decisions beyond their conferred authority in the area of information and do not use all the space allocated by policy in the area of education. DHMTs' decision-making capacity to manage their workforce is influenced by their own perceived authority and sometimes it is constrained by decisions made at higher levels. We can conclude that decentralization, to improve workforce performance, needs to devolve power further down from district authorities onto district health managers. DHMTs need not only more power and authority to make decisions about their workforce but also more control over resources to be able to implement these decisions.

Devolution and its effects on health workforce and commodities management - early implementation experiences in Kilifi County, Kenya

BACKGROUND

Decentralisation is argued to promote community participation, accountability, technical efficiency, and equity in the management of resources, and has been a recurring theme in health system reforms for several decades. In 2010, Kenya passed a new constitution that introduced 47 semi-autonomous county governments, with substantial transfer of responsibility for health service delivery from the central government to these counties. Focusing on two key elements of the health system, Human Resources for Health (HRH) and Essential Medicines and Medical Supplies (EMMS) management, we analysed the early implementation experiences of this major governance reform at county level.

METHODS

We employed a qualitative case study design, focusing on Kilifi County, and adapted the decision space framework developed by Bossert et al., to guide our inquiry and analysis. Data were collected through document reviews, key informant interviews, and participant and non-participant observations between December 2012 and December 2014.

RESULTS

As with other county level functions, HRH and EMMS management functions were rapidly transferred to counties before appropriate county-level structures and adequate capacity to undertake these functions were in place. For HRH, this led to major disruptions in staff salary payments, political interference with HRH management functions and confusion over HRH management roles. There was also lack of clarity over specific roles and responsibilities at county and national government, and of key players at each level. Subsequently health worker strikes and mass resignations were witnessed. With EMMS, significant delays in procurement led to long stock-outs of essential drugs in health facilities. However, when the county finally managed to procure drugs, health facilities reported a better order fill-rate compared to the period prior to devolution.

CONCLUSION

The devolved government system in Kenya has significantly increased county level decision-space for HRH and EMMS management functions. However, harnessing the full potential benefits of this increased autonomy requires targeted interventions to clarify the roles and responsibilities of different actors at all levels of the new system, and to build capacity of the counties to undertake certain specific HRH and EMMS management tasks. Capacity considerations should always be central when designing health sector decentralisation policies.

Navigating institutional complexity in the health sector: lessons from tobacco control in Kenya

INTRODUCTION

 This research examines the institutional dynamics of tobacco control following the establishment of Kenya's 2007 landmark tobacco control legislation. Our analysis focuses specifically on coordination challenges within the health sector.

METHODS

 We conducted semi-structured interviews with key informants (n = 17) involved in tobacco regulation and control in Kenya. We recruited participants from different offices and sectors of government and non-governmental organizations.

RESULTS

 We find that the main challenges toward successful implementation of tobacco control are a lack of coordination and clarity of mandate of the principal institutions involved in tobacco control efforts. In a related development, the passage of a new constitution in 2010 created structural changes that have affected the successful implementation of the country's tobacco control legislation.

DISCUSSION

 We discuss how proponents of tobacco control navigated these two overarching institutional challenges. These findings point to the institutional factors that influence policy implementation extending beyond the traditional focus on the dynamic between government and the tobacco industry. These findings specifically point to the intragovernmental challenges that bear on policy implementation. The findings suggest that for effective implementation of tobacco control legislation and regulation, there is need for increased cooperation among institutions charged with tobacco control, particularly within or involving the Ministry of Health. Decisive leadership was also widely presented as a component of successful institutional reform.

CONCLUSION

 This study points to the importance of coordinating policy development and implementation across levels of government and the need for leadership and clear mandates to guide cooperation within the health sector. The Kenyan experience offers useful lessons in the pitfalls of institutional incoherence, but more importantly, the value of investing in and then promoting well-functioning institutions.

Household satisfaction with a community-based health insurance scheme in Ethiopia

BACKGROUND

Community-based health insurance (CBHI) schemes are an emerging tool for providing financial protection against health-related poverty. In Ethiopia, CBHI is being piloted in 13 districts, but community experience and satisfaction with the scheme have yet to be studied. Therefore, this study aimed to assess the experiences and satisfaction of households enrolled in a pilot CBHI scheme.

METHODS

A community-based cross-sectional study method was used in one pilot district in South Ethiopia. Data were collected in March and April 2014. 386 households enrolled in the CBHI scheme were sampled by simple random sampling. Data were collected by trained data collectors using a pre-tested structured questionnaire. Descriptive statistics and bivariate and multiple linear regression analyses were performed. P values less than 0.05 and 95 % confidence intervals were used to determine associations between independent and dependent variables.

RESULTS

The study revealed that overall household satisfaction with CBHI was 91.38 %. Moreover, there was a significant association between health service provision and CBHI members' satisfaction scores. For instance, household heads that strongly disagreed with laboratory services provision had an average 0.878 decrease in CBHI satisfaction score compared to household heads that strongly agreed. CBHI process- and management-related factors were also significantly associated with satisfaction.

CONCLUSIONS

Satisfaction with CBHI was high. Age, family size, laboratory services provision, health services provider friendliness, CBHI offices opening times, membership card collection process, and time interval to use of services were significant predictors of satisfaction with CBHI.

Financial accessibility and user fee reforms for maternal healthcare in five sub-Saharan countries: a quasi-experimental analysis

OBJECTIVES

Evidence on whether removing fees benefits the poorest is patchy and weak. The aim of this paper is to measure the impact of user fee reforms on the probability of giving birth in an institution or undergoing a caesarean section (CS) in Ghana, Burkina Faso, Zambia, Cameroon and Nigeria for the poorest strata of the population.

SETTING

Women's experience of user fees in 5 African countries.

PRIMARY AND SECONDARY OUTCOME MEASURES

Using quasi-experimental regression analysis we tested the impact of user fee reforms on facilities' births and CS differentiated by wealth, education and residence in Burkina Faso and Ghana. Mapping of the literature followed by key informant interviews are used to verify details of reform implementation and to confirm and support our countries' choice.

PARTICIPANTS

We analysed data from consecutive surveys in 5 countries: 2 case countries that experienced reforms (Ghana and Burkina Faso) by contrast with 3 that did not experience reforms (Zambia, Cameroon, Nigeria).

RESULTS

User fee reforms are associated with a significant percentage of the increase in access to facility births (27 percentage points) and to a much lesser extent to CS (0.7 percentage points). Poor (but not the poorest), and non-educated women, and those in rural areas benefitted the most from the reforms. User fees reforms have had a higher impact in Burkina Faso compared with Ghana.

CONCLUSIONS

Findings show a clear positive impact on access when user fees are removed, but limited evidence for improved availability of CS for those most in need. More women from rural areas and from lower socioeconomic backgrounds give birth in health facilities after fee reform. Speed and quality of implementation might be the key reason behind the differences between the 2 case countries. This calls for more research into the impact of reforms on quality of care.

The Astronomy of Africa's Health Systems Literature During the MDG Era: Where Are the Systems Clusters?

Growing international concern about the need for improved health systems in Africa has catalyzed an expansion of the health systems literature. This review applies a bibliometric procedure to analyze the acceleration of scientific writing on this theme. We focus on research published during the Millennium Development Goal (MDG) era between 1990 and 2014, reporting findings from a systematic review of a database comprised of 17,655 articles about health systems themes from sub-Saharan African countries or subregions. Using bibliometric tools for co-word textual analysis, we analyzed the incidence and associations of keywords and phrases to generate and visualize topical foci on health systems as clusters of themes, much in the manner that astronomers represent groupings of stars as galaxies of celestial entities. The association of keywords defines their relative position, with the size of images weighted by the relative frequency of terms. Sets of associated keywords are arrayed as stars that cluster as "galaxies" of concepts in the knowledge universe represented by health systems research from sub-Saharan Africa. Results show that health systems research is dominated by literature on diseases and categorical systems research topics, rather than on systems science that cuts across diseases or specific systemic themes. Systems research is highly developed in South Africa but relatively uncommon elsewhere in the region. "Black holes" are identified by searching for terms in our keyword library related to terms in widely cited reviews of health systems. Results identify several themes that are unexpectedly uncommon in the country-specific health systems literature. This includes research on the processes of achieving systems change, the health impact of systems strengthening, processes that explain the systems determinants of health outcomes, or systematic study of organizational dysfunction and ways to improve system performance. Research quantifying the relationship of governance indicators to health systems strengthening is nearly absent from the literature. Long-term experimental studies and statistically rigorous research on cross-cutting themes of health systems strengthening are rare. Studies of organizational malaise or corruption are virtually absent. Trend analysis shows the emergence of organizational research on specific priority diseases, such as on HIV/AIDS, malaria, and tuberculosis, but portrays a lack of focus on integrated systems research on the general burden of disease. If health systems in Africa are to be strengthened, then organizational change research must be a more concerted focus in the future than has been the case in the past.

Malaria care seeking behavior of individuals in Ghana under the NHIS: Are we back to the use of informal care?

BACKGROUND

Malaria is Ghana's most endemic disease; occurring across most parts of the country with a significant impact on individuals and the health system as whole. Treatment seeking for malaria care takes various forms. The National Health Insurance Scheme (NHIS) was introduced in 2004 to promote access to health services to mitigate the negative impact of the user fee regime. Ten years on, national coverage is less than 40% of the total population and patients continue to make direct payments for health services. This paper analyses the care-seeking behaviour of households for treatment of malaria in Ghana under the NHI policy.

METHOD

Using a cross-sectional survey of household data collected from three districts in Ghana covering the 3 ecological zones namely the coastal, forest and savannah, a multinomial logit model is estimated. The sample consists of 365 adults and children reporting being ill with malaria in the last four weeks prior to the study.

RESULTS

Out of the total, 58% were insured and 71% of them sought care from a formal health facility. Among the insured, 15% chose informal care compared to 48% among the uninsured. The results from the multinomial logit estimations show that health insurance and travel time to health facility are significant determinants of health care demand. The results show that the insured are 6 times more likely to choose regional/district hospitals: 5 times more likely to choose health centres/clinics and 7 times more likely to choose private hospitals/clinics over informal care when compared with the uninsured. Individual characteristics such as age, education and wealth status were significant determinants of health care provider choice for specific categories of health facilities.

CONCLUSION

Overall, for malaria care the uninsured are more likely to choose informal care compared to the insured for the treatment of malaria.

Application of systems thinking in health: opportunities for translating theory into practice Comment on "Constraints to applying systems thinking concepts in health systems: a regional perspective from surveying stakeholders in Eastern Mediterranean countries"

Systems thinking is not a new concept to health system strengthening; however, one question remains unanswered: How policy-makers, system designers and consultants with a system thinking philosophy should act (have acted) as potential change agents in actually gaining opportunities to introduce systems thinking? Development of Comprehensive Multi-Year Plans (cMYPs) for Immunization System is one such opportunity because almost all Low- and Middle-Income Countries (LMICs) develop and implement cMYPs every five years. Without building upon examples and showing practical application, the discussions and deliberations on systems thinking may fade away with passage of time. There are opportunities that exist around us in our existing health systems that we can benefit from starting with an incremental approach and generating evidence for longer lasting system-wide changes.

Assessing catastrophic and impoverishing effects of health care payments in Uganda

BACKGROUND

Direct out-of-pocket payments for health care are recognised as limiting access to health care services and also endangering the welfare of households. In Uganda, such payments comprise a large portion of total health financing. This study assesses the catastrophic and impoverishing impact of paying for health care out-of-pocket in Uganda.

METHODS

Using data from the Uganda National Household Surveys 2009/10, the catastrophic impact of out-of-pocket health care payments is defined using thresholds that vary with household income. The impoverishing effect of out-of-pocket health care payments is assessed using the Ugandan national poverty line and the World Bank poverty line ($1.25/day).

RESULTS

A high level and intensity of both financial catastrophe and impoverishment due to out-of-pocket payments are recorded. Using an initial threshold of 10% of household income, about 23% of Ugandan households face financial ruin. Based on both the $1.25/day and the Ugandan poverty lines, about 4% of the population are further impoverished by such payments. This represents a relative increase in poverty head count of 17.1% and 18.1% respectively.

CONCLUSION

The absence of financial protection in Uganda's health system calls for concerted action. Currently, out-of-pocket payments account for a large share of total health financing and there is no pooled prepayment system available. There is therefore a need to move towards mandatory prepayment. In this way, people could access the needed health services without any associated financial consequence.

Peace corps partnered health services implementation research in global health: opportunity for impact

BACKGROUND

There is abundant evidence of the affordable, life-saving interventions effective at the local primary health care level in low- and middle-income countries (LMICs). However, the understanding of how to deliver those interventions in diverse settings is limited. Primary healthcare services implementation research is needed to elucidate the contextual factors that can influence the outcomes of interventions, especially at the local level. US universities commonly collaborate with LMIC universities, communities, and health system partners for health services research but common barriers exist. Current challenges include the capacity to establish an ongoing presence in local settings in order to facilitate close collaboration and communication. The Peace Corps is an established development organization currently aligned with local health services in many LMICs and is well-positioned to facilitate research partnerships. This article explores the potential of a community-Peace Corps-academic partnership approach to conduct local primary healthcare services implementation research.

DISCUSSION

The Peace Corps is well positioned to offer insights into local contextual factors because volunteers work closely with local leaders, have extensive trust within local communities, and have an ongoing, constant, well-integrated presence. However, the Peace Corps does not routinely conduct primary healthcare services implementation research. Universities, within the United States and locally, could benefit from the established resources and trust of the Peace Corps to conduct health services implementation research to advance access to local health services and further the knowledge of real world application of local health services in a diversity of settings. The proposed partnership would consist of (1) a local community advisory board and local health system leaders, (2) Peace Corps volunteers, and (3) a US-LMIC academic institutional collaboration. Within the proposed partnership approach, the contributions of each partner are as follows: the local community and health system leadership guides the work in consideration of local priorities and context; the Peace Corps provides logistical support, community expertise, and local trust; and the academic institutions offer professional technical and public health educational and training resources and research support.

CONCLUSION

The Peace Corps offers the opportunity to enhance a community-academic partnership in LMICs through community-level guidance, logistical assistance, and research support for community based participatory primary health-care services implementation research that addresses local primary healthcare priorities.

Do community health workers perceive mechanisms associated with the success of community case management of malaria? A qualitative study from Burkina Faso

The use of community health workers to administer prompt treatments is gaining popularity in most sub-Saharan African countries. Their performance is a key challenge because it varies considerably, depending on the context, while being closely associated with the effectiveness of case management strategies. What determines community health workers' performance is still under debate. Based on a realist perspective, a systematic review recently hypothesized that several mechanisms are associated with good performance and successful community interventions. In order to empirically investigate this hypothesis and confront it with the reality, we conducted a study in Burkina Faso, where in 2010 health authorities have implemented a national program introducing community case management of malaria. The objective was to assess the presence of the mechanisms in community health workers, and explore the influence of contextual factors. In 2012, we conducted semi-structured interviews with 35 community health workers from a study area established in two similar health districts (Kaya and Zorgho). Results suggest that they perceive most of the mechanisms, except the sense of being valued by the health system and accountability to village members. Analysis shows that drug stock-outs and past experiences of community health workers simultaneously influence the presence of several mechanisms. The lack of integration between governmental and non-governmental interventions and the overall socio-economic deprivation, were also identified as influencing the mechanisms' presence. By focusing on community health workers' agency, this study puts the influence of the context back at the core of the performance debate and raises the question of their ability to perform well in scaled-up anti-malaria programs.

Has decentralisation affected child immunisation status in Indonesia?

BACKGROUND

The past two decades have seen many countries, including a number in Southeast Asia, decentralising their health system with the expectation that this reform will improve their citizens' health. However, the consequences of this reform remain largely unknown.

OBJECTIVE

This study analyses the effects of fiscal decentralisation on child immunisation status in Indonesia.

DESIGN

We used multilevel logistic regression analysis to estimate these effects, and multilevel multiple imputation to manage missing data. The 2011 publication of Indonesia's national socio-economic survey (Susenas) is the source of household data, while the Podes village census survey from the same year provides village-level data. We supplement these with local government fiscal data from the Ministry of Finance.

RESULTS

The findings show that decentralising the fiscal allocation of responsibilities to local governments has a lack of association with child immunisation status and the results are robust. The results also suggest that increasing the number of village health centres (posyandu) per 1,000 population improves probability of children to receive full immunisation significantly, while increasing that of hospitals and health centres (puskesmas) has no significant effect.

CONCLUSION

These findings suggest that merely decentralising the health system does not guarantee improvement in a country's immunisation coverage. Any successful decentralisation demands good capacity and capability of local governments.

Rethinking eye health systems to achieve universal coverage: the role of research

Achieving universal coverage in eye care remains a tremendous challenge as 226 million people in the world remain visually impaired, the majority from avoidable causes. The impact of eye care interventions has been constrained by the limited capacities of health systems in low-income and middle-income countries to deliver effective eye care services. Services for eye health are still not adequately integrated into the health systems of low-income and middle-income countries. We contend that radical rethinking and deeper development of eye health systems are necessary to achieve VISION 2020 goals. Responding to the challenges of chronic eye diseases will require systems thinking, analysis and action, based on evidence from health systems research.

Assessing responsiveness of health care services within a health insurance scheme in Nigeria: users' perspectives

BACKGROUND

Responsiveness of health care services in low and middle income countries has been given little attention. Despite being introduced over a decade ago in many developing countries, national health insurance schemes have yet to be evaluated in terms of responsiveness of health care services. Although this responsiveness has been evaluated in many developed countries, it has rarely been done in developing countries. The concept of responsiveness is multi-dimensional and can be measured across various domains including prompt attention, dignity, communication, autonomy, choice of provider, quality of facilities, confidentiality and access to family support. This study examines the insured users' perspectives of their health care services' responsiveness.

METHODS

This retrospective, cross-sectional survey took place between October 2010 and March 2011. The study used a modified out-patient questionnaire from a responsiveness survey designed by the World Health Organization (WHO). Seven hundred and ninety six (796) enrolees, insured for more than one year in Kaduna State-Nigeria, were interviewed. Generalized ordered logistic regression was used to identify factors that influenced the users' perspectives on responsiveness to health services and quantify their effects.

RESULTS

Communication (55.4%), dignity (54.1%), and quality of facilities (52.0%) were rated as "extremely important" responsiveness domains. Users were particularly contented with quality of facilities (42.8%), dignity (42.3%), and choice of provider (40.7%). Enrolees indicated lower contentment on all other domains. Type of facility, gender, referral, duration of enrolment, educational status, income level, and type of marital status were most related with responsiveness domains.

CONCLUSIONS

Assessing the responsiveness of health care services within the NHIS is valuable in investigating the scheme's implementation. The domains of autonomy, communication and prompt attention were identified as priority areas for action to improve this responsiveness. For the Nigerian context, we suggest that health care providers in the NHIS should pay attention to these domains, and the associated characteristics of users, when delivering health care services to their clients. Policy makers, and the insurance regulatory agency, should consider the reform strategies of monitoring and quality assurance which focus on the domains of responsiveness to lessen the gap between users' expectations and their experiences with health services.

Why do health workers in rural Tanzania prefer public sector employment?

BACKGROUND

Severe shortages of qualified health workers and geographical imbalances in the workforce in many low-income countries require the national health sector management to closely monitor and address issues related to the distribution of health workers across various types of health facilities. This article discusses health workers' preferences for workplace and their perceptions and experiences of the differences in working conditions in the public health sector versus the church-run health facilities in Tanzania. The broader aim is to generate knowledge that can add to debates on health sector management in low-income contexts.

METHODS

The study has a qualitative study design to elicit in-depth information on health workers' preferences for workplace. The data comprise ten focus group discussions (FGDs) and 29 in-depth interviews (IDIs) with auxiliary staff, nursing staff, clinicians and administrators in the public health sector and in a large church-run hospital in a rural district in Tanzania. The study has an ethnographic backdrop based on earlier long-term fieldwork in Tanzania.

RESULTS

The study found a clear preference for public sector employment. This was associated with health worker rights and access to various benefits offered to health workers in government service, particularly the favourable pension schemes providing economic security in old age. Health workers acknowledged that church-run hospitals generally were better equipped and provided better quality patient care, but these concerns tended to be outweighed by the financial assets of public sector employment. In addition to the sector specific differences, family concerns emerged as important in decisions on workplace.

CONCLUSIONS

The preference for public sector employment among health workers shown in this study seems to be associated primarily with the favourable pension scheme. The overall shortage of health workers and the distribution between health facilities is a challenge in a resource constrained health system where church-run health facilities are vital in the provision of health care in rural areas and where patients tend to prefer these services. In order to ensure equity in distribution of qualified health workers in Tanzania, a national regulation and legislation of the pension schemes is required.

The role of social networks in the governance of health systems: the case of eye care systems in Ghana

Efforts have been increasingly invested to improve local health systems' capacities in developing countries. We describe the application of innovative methods based on a social network analysis approach. The findings presented refer to a study carried out between July 2008 and January 2010 in the Brong Ahafo region of Ghana. Social network analysis methods were applied in five different districts using the software package Ucinet to calculate the various properties of the social network of eye care providers. The study focused on the managerial decisions made by Ghanaian district hospital managers about the governance of the health system. The study showed that the health system in the Brong Ahafo region experienced significant changes specifically after a key shock, the departure of an international organization. Several other actors at different levels of the network disappeared, the positions of nurses and hospital managers changed, creating new relationships and power balances that resulted in a change in the general structure of the network. The system shifted from a centralized and dense hierarchical network towards an enclaved network composed of five sub-networks. The new structure was less able to respond to shocks, circulate information and knowledge across scales and implement multi-scale solutions than that which it replaced. Although the network became less resilient, it responded better to the management needs of the hospital managers who now had better access to information, even if this information was partial. The change of the network over time also showed the influence of the international organization on generating links and creating connections between actors from different levels. The findings of the study reveal the importance of creating international health connections between actors working in different spatial scales of the health system.

Removing user fees: learning from international experience to support the process

Removing user fees could improve service coverage and access, in particular among the poorest socio-economic groups, but quick action without prior preparation could lead to unintended effects, including quality deterioration and excessive demands on health workers. This paper illustrates the process needed to make a realistic forecast of the possible resource implications of a well-implemented user fee removal programme and proposes six steps for a successful policy change: (1) analysis of a country's initial position (including user fee level, effectiveness of exemption systems and impact of fee revenues at facility level); (2) estimation of the impact of user fee removal on service utilization; (3) estimation of the additional requirements for human resources, drugs and other inputs, and corresponding financial requirements; (4) mobilization of additional resources (both domestic and external) and development of locally-tailored strategies to compensate for the revenue gap and costs associated with increased utilization; (5) building political commitment for the policy reform; (6) communicating the policy change to all stakeholders. The authors conclude that countries that intend to remove user fees can maximize benefits and avoid potential pitfalls through the utilization of the approach and tools described.

Protocol: a realist review of user fee exemption policies for health services in Africa

Background Four years prior to the Millenium Development Goals (MDGs) deadline, low- and middle-income countries and international stakeholders are looking for evidence-based policies to improve access to healthcare for the most vulnerable populations. User fee exemption policies are one of the potential solutions. However, the evidence is disparate, and systematic reviews have failed to provide valuable lessons. The authors propose to produce an innovative synthesis of the available evidence on user fee exemption policies in Africa to feed the policy-making process. Methods The authors will carry out a realist review to answer the following research question: what are the outcomes of user fee exemption policies implemented in Africa? why do they produce such outcomes? and what contextual elements come into play? This type of review aims to understand how contextual elements influence the production of outcomes through the activation of specific mechanisms, in the form of context-mechanism-outcome configurations. The review will be conducted in five steps: (1) identifying with key stakeholders the mechanisms underlying user fee exemption policies to develop the analytical framework, (2) searching for and selecting primary data, (3) assessing the quality of evidence using the Mixed-Method Appraisal Tool, (4) extracting the data using the analytical framework and (5) synthesising the data in the form of context-mechanism-outcomes configurations. The output will be a middle-range theory specifying how user fee exemption policies work, for what populations and under what circumstances. Ethics and dissemination The two main target audiences are researchers who are looking for examples to implement a realist review, and policy-makers and international stakeholders looking for lessons learnt on user fee exemption. For the latter, a knowledge-sharing strategy involving local scientific and policy networks will be implemented. The study has been approved by the ethics committee of the CHUM Research Centre (CR-CHUM). It received funding from the Canadian Institutes of Health Research. The funders will not have any role in study design; collection, management, analysis, and interpretation of data; writing of the report and the decision to submit the report for publication, including who will have ultimate authority over each of these activities.

Strengthening fairness, transparency and accountability in health care priority setting at district level in Tanzania

Health care systems are faced with the challenge of resource scarcity and have insufficient resources to respond to all health problems and target groups simultaneously. Hence, priority setting is an inevitable aspect of every health system. However, priority setting is complex and difficult because the process is frequently influenced by political, institutional and managerial factors that are not considered by conventional priority-setting tools. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority setting in district health management were studied. This review is based on a PhD thesis that aimed to analyse health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness (A4R) approach to priority setting in Tanzania. A qualitative case study in Mbarali district formed the basis of exploring the sociopolitical and institutional contexts within which health care decision making takes place. The study also explores how the A4R intervention was shaped, enabled and constrained by the contexts. Key informant interviews were conducted. Relevant documents were also gathered and group priority-setting processes in the district were observed. The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. The study also found that while the A4R approach was perceived to be helpful in strengthening transparency, accountability and stakeholder engagement, integrating the innovation into the district health system was challenging. This study underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting decisions. A broader and more detailed analysis of health system elements, and socio-cultural context is imperative in fostering sustainability. Additionally, the study stresses the need to deal with power asymmetries among various actors in priority-setting contexts.

For money or service?: a cross-sectional survey of preference for financial versus non-financial rural practice characteristics among Ghanaian medical students

BACKGROUND

Health worker shortage and maldistribution are among the biggest threats to health systems in Africa. New medical graduates are prime targets for recruitment to deprived rural areas. However, little research has been done to determine the influence of workers' background and future plans on their preference for rural practice incentives and characteristics. The purpose of this study was to identify determinants of preference for rural job characteristics among fourth year medical students in Ghana.

METHODS

We asked fourth-year Ghanaian medical students to rank the importance of rural practice attributes including salary, infrastructure, management style, and contract length in considering future jobs. We used bivariate and multivariate ordinal logistic regression to estimate the association between attribute valuation and students' socio-demographic background, educational experience, and future career plans.

RESULTS

Of 310 eligible fourth year medical students, complete data was available for 302 students (97%). Students considering emigration ranked salary as more important than students not considering emigration, while students with rural living experience ranked salary as less important than those with no rural experience. Students willing to work in a rural area ranked infrastructure as more important than students who were unwilling, while female students ranked infrastructure as less important than male students. Students who were willing to work in a rural area ranked management style as a more important rural practice attribute than those who were unwilling to work in a rural area. Students studying in Kumasi ranked contract length as more important than those in Accra, while international students ranked contract length as less important than Ghanaian students.

CONCLUSIONS

Interventions to improve rural practice conditions are likely to be more persuasive than salary incentives to Ghanaian medical students who are willing to work in rural environments a priori. Policy experiments should test the impact of these interventions on actual uptake by students upon graduation.

Social solidarity and civil servants' willingness for financial cross-subsidization in South Africa: implications for health financing reform

In South Africa, anticipated health sector reforms aim to achieve universal health coverage for all citizens. Success will depend on social solidarity and willingness to pay for health care according to means, while benefitting on the basis of their need. In this study, we interviewed 1330 health and education sector civil servants in four South African provinces, about potential income cross-subsidies and financing mechanisms for a National Health Insurance. One third was willing to cross-subsidize others and half favored a progressive financing system, with senior managers, black Africans, or those with tertiary education more likely to choose these options than lower-skilled staff, white, Indian or Asian respondents, or those with primary or less education. Insurance- and health-status were not associated with willingness to pay or preferred type of financing system. Understanding social relationships, identities, and shared meanings is important for any reform striving toward universal coverage.

Viewing the Kenyan health system through an equity lens: implications for universal coverage

Introduction

Equity and universal coverage currently dominate policy debates worldwide. Health financing approaches are central to universal coverage. The way funds are collected, pooled, and used to purchase or provide services should be carefully considered to ensure that population needs are addressed under a universal health system. The aim of this paper is to assess the extent to which the Kenyan health financing system meets the key requirements for universal coverage, including income and risk cross-subsidisation. Recommendations on how to address existing equity challenges and progress towards universal coverage are made.

Methods

An extensive review of published and gray literature was conducted to identify the sources of health care funds in Kenya. Documents were mainly sourced from the Ministry of Medical Services and the Ministry of Public Health and Sanitation. Country level documents were the main sources of data. In cases where data were not available at the country level, they were sought from the World Health Organisation website. Each financing mechanism was analysed in respect to key functions namely, revenue generation, pooling and purchasing.

Results

The Kenyan health sector relies heavily on out-of-pocket payments. Government funds are mainly allocated through historical incremental approach. The sector is largely underfunded and health care contributions are regressive (i.e. the poor contribute a larger proportion of their income to health care than the rich). Health financing in Kenya is fragmented and there is very limited risk and income cross-subsidisation. The country has made little progress towards achieving international benchmarks including the Abuja target of allocating 15% of government's budget to the health sector.

Conclusions

The Kenyan health system is highly inequitable and policies aimed at promoting equity and addressing the needs of the poor and vulnerable have not been successful. Some progress has been made towards addressing equity challenges, but universal coverage will not be achieved unless the country adopts a systemic approach to health financing reforms. Such an approach should be informed by the wider health system goals of equity and efficiency.

Understanding client satisfaction with a health insurance scheme in Nigeria: factors and enrollees experiences

BACKGROUND

Health insurance schemes have been widely introduced during this last decade in many African countries, which have strived for improvements in health service provision and the promotion of health care utilization. Client satisfaction with health service provision during the implementation of health insurance schemes has often been neglected since numerous activities take place concurrently. The satisfaction of enrollees and its influencing factors have been providing evidence which have assisted in policy and decision making. Our objective is to determine the enrollee's satisfaction with health service provision under a health insurance scheme and the factors which influence the satisfaction.

METHODS

This retrospective, cross-sectional survey took place between May and September 2008. Two hundred and eighty (280) enrollees insured for more than one year in Zaria-Nigeria were recruited using two stage sampling. Enrollee's satisfaction was categorized into more satisfied and less satisfied based on positive responses obtained. Satisfaction, general knowledge and awareness of contribution were each aggregated and assessed as composite measure. Logistic regression analysis was used to analyze factors that influenced the satisfaction of enrollees.

RESULTS

A high satisfaction rate with the health insurance scheme was observed (42.1%). Marital status (p < .05), general knowledge (p < .001) and awareness of contributions (p < .05) positively influenced clients' satisfaction. Length of employment, salary income, hospital visits and duration of enrolment slightly influenced satisfaction.

CONCLUSIONS

This study highlighted the potential effects of general health insurance knowledge and awareness of contributions by end-users (beneficiaries) of such new program on client satisfaction which have significant importance. The findings provided evidence which have assisted the amendment and re-prioritization of the medium term strategic plan of operations for the scheme. Future planning efforts could consider the client satisfaction and the factors which influenced it regularly.

The impact of user fees on access to health services in low- and middle-income countries

BACKGROUND

Following an international push for financing reforms, many low- and middle-income countries introduced user fees to raise additional revenue for health systems. User fees are charges levied at the point of use and are supposed to help reduce 'frivolous' consumption of health services, increase quality of services available and, as a result, increase utilisation of services.

OBJECTIVES

To assess the effectiveness of introducing, removing or changing user fees to improve access to care in low-and middle-income countries

SEARCH STRATEGY

We searched 25 international databases, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Trials Register, CENTRAL, MEDLINE and EMBASE. We also searched the websites and online resources of international agencies, organisations and universities to find relevant grey literature. We conducted the original searches between November 2005 and April 2006 and the updated search in CENTRAL (DVD-ROM 2011, Issue 1); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (January 25, 2011); MEDLINE, Ovid (1948 to January Week 2 2011); EMBASE, Ovid (1980 to 2011 Week 03) and EconLit, CSA Illumina (1969 - present) on the 26th of January 2011.

SELECTION CRITERIA

We included randomised controlled trials, interrupted time-series studies and controlled before-and-after studies that reported an objective measure of at least one of the following outcomes: healthcare utilisation, health expenditures, or health outcomes.

DATA COLLECTION AND ANALYSIS

We re-analysed studies with longitudinal data. We computed price elasticities of demand for health services in controlled before-and-after studies as a standardised measure. Due to the diversity of contexts and outcome measures, we did not perform meta-analysis. Instead, we undertook a narrative summary of evidence.

MAIN RESULTS

We included 16 studies out of the 243 identified. Most of the included studies showed methodological weaknesses that hamper the strength and reliability of their findings. When fees were introduced or increased, we found the use of health services decreased significantly in most studies. Two studies found increases in health service use when quality improvements were introduced at the same time as user fees. However, these studies have a high risk of bias. We found no evidence of effects on health outcomes or health expenditure.

AUTHORS' CONCLUSIONS

The review suggests that reducing or removing user fees increases the utilisation of certain healthcare services. However, emerging evidence suggests that such a change may have unintended consequences on utilisation of preventive services and service quality. The review also found that introducing or increasing fees can have a negative impact on health services utilisation, although some evidence suggests that when implemented with quality improvements these interventions could be beneficial. Most of the included studies suffered from important methodological weaknesses. More rigorous research is needed to inform debates on the desirability and effects of user fees.

Policy interventions that attract nurses to rural areas: a multicountry discrete choice experiment

OBJECTIVE

To evaluate the relative effectiveness of different policies in attracting nurses to rural areas in Kenya, South Africa and Thailand using data from a discrete choice experiment (DCE).

METHODS

A labelled DCE was designed to model the relative effectiveness of both financial and non-financial strategies designed to attract nurses to rural areas. Data were collected from over 300 graduating nursing students in each country. Mixed logit models were used for analysis and to predict the uptake of rural posts under different incentive combinations.

FINDINGS

Nurses' preferences for different human resource policy interventions varied significantly between the three countries. In Kenya and South Africa, better educational opportunities or rural allowances would be most effective in increasing the uptake of rural posts, while in Thailand better health insurance coverage would have the greatest impact.

CONCLUSION

DCEs can be designed to help policy-makers choose more effective interventions to address staff shortages in rural areas. Intervention packages tailored to local conditions are more likely to be effective than standardized global approaches.

Changes in utilization of health services among poor and rural residents in Uganda: are reforms benefitting the poor?

BACKGROUND

Uganda implemented health sector reforms to make services more accessible to the population. An assessment of the likely impact of these reforms is important for informing policy. This paper describes the changes in utilization of health services that occurred among the poor and those in rural areas between 2002/3 and 2005/6 and associated factors.

METHODS

Secondary data analysis was done using the socio-economic component of the Uganda National Household Surveys 2002/03 and 2005/06. The poor were identified from wealth quintiles constructed using an asset based index derived from Principal Components Analysis (PCA). The probability of choice of health care provider was assessed using multinomial logistic regression and multi-level statistical models.

RESULTS

The odds of not seeking care in 2005/6 were 1.79 times higher than in 2002/3 (OR = 1.79; 95% CI 1.65 - 1.94). The rural population experienced a 43% reduction in the risk of not seeking care because of poor geographical access (OR = 0.57; 95% CI 0.48 - 0.67). The risk of not seeking care due to high costs did not change significantly. Private for profit providers (PFP) were the major providers of services in 2002/3 and 2005/6. Using PFP as base category, respondents were more likely to have used private not for profit (PNFP) in 2005/6 than in 2002/3 (OR = 2.15; 95% CI 1.58 - 2.92), and also more likely to use public facilities in 2005/6 than 2002/3 (OR = 1.31; 95% CI 1.15 - 1.48). The most poor, females, rural residents, and those from elderly headed households were more likely to use public facilities relative to PFP.

CONCLUSION

Although overall utilization of public and PNFP services by rural and poor populations had increased, PFP remained the major source of care. The odds of not seeking care due to distance decreased in rural areas but cost continued to be an important barrier to seeking health services for residents from poor, rural, and elderly headed households. Policy makers should consider targeting subsidies to the poor and rural populations. Public private partnerships should be broadened to increase access to health services among the vulnerable.

Accountable priority setting for trust in health systems--the need for research into a new approach for strengthening sustainable health action in developing countries

Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed.

Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i) relevance to the local setting, decided by agreed criteria; ii) publicizing priority-setting decisions and the reasons behind them; iii) the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv) the provision of leadership to ensure that the first three conditions are met.

REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being applied in an action research framework to examine the potential of AFR to support sustainable improvements to health systems performance.

This paper reports on the project design and progress and argues that there is a high need for research into legitimate and fair priority setting to improve the knowledge base for achieving sustainable improvements in health outcomes.

Reducing user fees for primary health care in Kenya: Policy on paper or policy in practice?

BACKGROUND

Removing user fees in primary health care services is one of the most critical policy issues being considered in Africa. User fees were introduced in many African countries during the 1980s and their impacts are well documented. Concerns regarding the negative impacts of user fees have led to a recent shift in health financing debates in Africa. Kenya is one of the countries that have implemented a user fees reduction policy. Like in many other settings, the new policy was evaluated less that one year after implementation, the period when expected positive impacts are likely to be highest. This early evaluation showed that the policy was widely implemented, that levels of utilization increased and that it was popular among patients. Whether or not the positive impacts of user fees removal policies are sustained has hardly been explored. We conducted this study to document the extent to which primary health care facilities in Kenya continue to adhere to a 'new' charging policy 3 years after its implementation.

METHODS

Data were collected in two districts (Kwale and Makueni). Multiple methods of data collection were applied including a cross-sectional survey (n = 184 households Kwale; 141 Makueni), Focus Group Discussions (n = 12) and patient exit interviews (n = 175 Kwale; 184 Makueni).

RESULTS

Approximately one third of the survey respondents could not correctly state the recommended charges for dispensaries, while half did not know what the official charges for health centres were. Adherence to the policy was poor in both districts, but facilities in Makueni were more likely to adhere than those in Kwale. Only 4 facilities in Kwale adhered to the policy compared to 10 in Makueni. Drug shortage, declining revenue, poor policy design and implementation processes were the main reasons given for poor adherence to the policy.

CONCLUSION

We conclude that reducing user fees in primary health care in Kenya is a policy on paper that is yet to be implemented fully. We recommend that caution be taken when deciding on how to reduce or abolish user fees and that all potential consequences are carefully considered.

The decentralisation-centralisation dilemma: recruitment and distribution of health workers in remote districts of Tanzania

BACKGROUND

The implementation of decentralisation reforms in the health sector of Tanzania started in the 1980s. These reforms were intended to relinquish substantial powers and resources to districts to improve the development of the health sector. Little is known about the impact of decentralisation on recruitment and distribution of health workers at the district level. Reported difficulties in recruiting health workers to remote districts led the Government of Tanzania to partly re-instate central recruitment of health workers in 2006. The effects of this policy change are not yet documented. This study highlights the experiences and challenges associated with decentralisation and the partial re-centralisation in relation to the recruitment and distribution of health workers.

METHODS

An exploratory qualitative study was conducted among informants recruited from five underserved, remote districts of mainland Tanzania. Additional informants were recruited from the central government, the NGO sector, international organisations and academia. A comparison of decentralised and the reinstated centralised systems was carried out in order to draw lessons necessary for improving recruitment, distribution and retention of health workers.

RESULTS

The study has shown that recruitment of health workers under a decentralised arrangement has not only been characterised by complex bureaucratic procedures, but by severe delays and sometimes failure to get the required health workers. The study also revealed that recruitment of highly skilled health workers under decentralised arrangements may be both very difficult and expensive. Decentralised recruitment was perceived to be more effective in improving retention of the lower cadre health workers within the districts. In contrast, the centralised arrangement was perceived to be more effective both in recruiting qualified staff and balancing their distribution across districts, but poor in ensuring the retention of employees.

CONCLUSION

A combination of centralised and decentralised recruitment represents a promising hybrid form of health sector organisation in managing human resources by bringing the benefits of two worlds together. In order to ensure that the potential benefits of the two approaches are effectively integrated, careful balancing defining the local-central relationships in the management of human resources needs to be worked out.

Conducting unlinked anonymous HIV surveillance in developing countries: ethical, epidemiological, and public health concerns

Stuart Rennie and colleagues argue that while unlinked anonymous HIV testing is valuable and ethical, such surveillance can be conducted in ethically questionable ways in certain circumstances.

Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania

The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.

Poverty, user fees and ability to pay for health care for children with suspected dengue in rural Cambodia

User fees were introduced in public health facilities in Cambodia in 1997 in order to inject funds into the health system to enhance the quality of services. Because of inadequate health insurance, a social safety net scheme was introduced to ensure that all people were able to attend the health facilities. However, continuing high rates of hospitalization and mortality from dengue fever among infants and children reflect the difficulties that women continue to face in finding sufficient cash in cases of medical emergency, resulting in delays in diagnosis and treatment. In this article, drawing on in-depth interviews conducted with mothers of children infected with dengue in eastern Cambodia, we illustrate the profound economic consequences for households when a child is ill. The direct costs for health care and medical services, and added indirect costs, deterred poor women from presenting with sick children. Those who eventually sought care often had to finance health spending through out-of-pocket payments and loans, or sold property, goods or labour to meet the costs. Costs were often catastrophic, exacerbating the extreme poverty of those least able to afford it.

What’s Politics Got to Do with It? Health, the G8, and the Global Economy

This chapter examines the pledges made by developed countries, particularly the rich club of G8 nations, to make globalization work better for the world's poor. It shows that contrary to the ringing rhetoric, they find that levels of foreign aid remain pitifully inadequate.