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Boisson-Walsh A, Ravelomanana NLR, Tabala M, Malongo F, Kawende B, Babakazo P, Yotebieng M. Association of comprehensiveness of antiretroviral care and detectable HIV viral load suppression among pregnant and postpartum women in the Democratic Republic of the Congo: a cross-sectional study. Front Glob Womens Health 2024; 5:1308019. [PMID: 38903153 PMCID: PMC11188341 DOI: 10.3389/fgwh.2024.1308019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 05/21/2024] [Indexed: 06/22/2024] Open
Abstract
Introduction Worldwide, over two-thirds of people living with HIV are on antiretroviral therapy (ART). Despite increased ART access, high virological suppression prevalence remains out of reach. Few studies consider the quality of ART services and their impact on recipients' viral suppression. We assessed the association between ART service readiness and HIV viral load suppression among pregnant and breastfeeding women living with HIV (WLH) receiving ART in maternal and child health (MCH) clinics in Kinshasa, Democratic Republic of Congo. Methods We performed a cross-sectional analysis leveraging data from a continuous quality improvement intervention on WLH's long-term ART outcomes. From November 2016 to May 2020, we enrolled WLH from the three largest clinics in each of Kinshasa'Łs 35 health zones. We measured clinic's readiness using three WHO-identified ART care quality indicators: relevant guidelines in ART service area, stocks of essential ART medicines, and relevant staff training in ≥24 months, scoring clinics 0-3 based on observed indicators. We defined viral load suppression as ≤1,000 cp/ml. Multilevel mixed-effect logistic models were used to estimate prevalence odds ratios (ORs) measuring the strength of the association between ART service readiness and viral suppression. Results Of 2,295 WLH, only 1.9% received care from a clinic with a score of 3, 24.1% received care from a 0-scoring clinic, and overall, 66.5% achieved virologically suppression. Suppression increased from 65% among WLH receiving care in 0-scoring clinics to 66.9% in 1-scoring clinics, 65.8% in 2-scoring clinics, and 76.1% in 3-scoring clinics. We did not observe a statistically significant association between ART service readiness score and increased viral suppression prevalence, however we did find associations between other factors, such as the location of the health center and pharmacist availability with suppressed viral load. Discussion A lack of comprehensive ART care underscores the need for enhanced structural and organizational support to improve virological suppression and overall health outcomes for women living with HIV..
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Affiliation(s)
- Alix Boisson-Walsh
- Department of Health Policy and Management, University of Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | - Martine Tabala
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Fathy Malongo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Bienvenu Kawende
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pélagie Babakazo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Marcel Yotebieng
- Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
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Kushitor M, Wright K, Biney A, Kanmiki EW, Kyei P, Phillips JF, Awoonor-Williams JK, Bawah AA. "The trip actually opened our eyes to things that we were supposed to do and we were not doing": developing primary health care system leadership in a low-income country with peer exchanges. RESEARCH IN HEALTH SERVICES & REGIONS 2023; 2:15. [PMID: 39177712 PMCID: PMC11281752 DOI: 10.1007/s43999-023-00030-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 09/27/2023] [Indexed: 08/24/2024]
Abstract
BACKGROUND Health care systems in low and middle-income countries are decentralizing and devolving power to the periphery. Transferring power without systematic processes to develop and nurture leaders at the district compromises the effectiveness and sustainability of the decentralized health system. To address this problem, we developed an approach to leadership learning by observation and experience that improved the organization and performance of the health care system in a district in Ghana. METHODOLOGY Using two rounds of a longitudinal qualitative study, the study explores the determinants of implementing the Community-Based Health Planning and Services (CHPS) initiative in a district in Ghana. Insights were gained concerning the leadership regimes of two leaders who administered health services in a common geographic area at different points in time with remarkably contrasting outcomes. Insights of health workers who participated in both periods were elicited to clarify interview contexts. Ten focus group discussions (FGDs) and five expert interviews were conducted for each round of the study. The study was informed by a systems appraisal approach that utilized a thematic analytical framework. RESULTS Providing district leaders with a practical observational experience had a significant influence on health care delivery in all aspects of health care provision at the district level. Exposing participants to models of best practices facilitated the replication of processes that improved the conduct of service delivery and CHPS implementation. Upon reflection, district leaders attributed performance constraints to their lack of understanding of practical ways of responding to complex district health system development needs. Observation from community members, volunteers, and health workers who witnessed the system development period corroborated narratives that leaders had expressed. CONCLUSION Effective leadership is optimally developed with participatory learning that provides leaders with direct access to fully functioning systems. Learning by observation can be structured and used to quicken the spread of managerial excellence.
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Affiliation(s)
- Mawuli Kushitor
- The Department of Health Policy, Planning and Management (UHAS), School of Public Health (SPH), University of Health and Allied Sciences (UHAS), Ho, Ghana.
| | - Kalifa Wright
- The Center for Health Information and Analysis, Boston, MA, USA
| | - Adriana Biney
- Regional Institute for Population Studies (RIPS), University of Ghana, Legon, Ghana
| | - Edmund W Kanmiki
- Institute for Social Science Research, The University of Queensland, Indooroopilly, QLD, 4068, Australia
| | - Pearl Kyei
- Regional Institute for Population Studies (RIPS), University of Ghana, Legon, Ghana
| | - James F Phillips
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Ayaga A Bawah
- Regional Institute for Population Studies (RIPS), University of Ghana, Legon, Ghana
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Ayim A, Agyepong IA, Enyimayew N. Why district assemblies disburse resources to district health systems for service delivery at district level in the context of decentralization: a comparative study of two districts in the Volta Region of Ghana. Front Public Health 2023; 11:1136210. [PMID: 37645704 PMCID: PMC10461447 DOI: 10.3389/fpubh.2023.1136210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 05/24/2023] [Indexed: 08/31/2023] Open
Abstract
Objectives To explore why the District Assembly disburses financial and other resources to the District Health System. Design Multiple case study with a single unit of analysis (holistic) using quantitative and qualitative methods of data collection involving a desk review, analysis of routine health management information system data and key informant interviews. Setting Two districts in the Volta Region of Ghana. Participants Twelve key officials of each district assembly and the district health system (24 total) who had worked in the district at least a year or more. Interventions None. Results Both District Assemblies had moderate decision space which was influenced by their capacity, power and contextual factors like politics, economics, legal and situational factors. Disbursement of financial and other resources to the District Health Systems was influenced by financial capacity, use of power by stakeholders, context and the decision space of the District Assembly. Political actors appeared to have more power in resource disbursement decision making than community members and technocrats in a context of resource constraints and inadequate funding. The funding available was used predominantly for capital investments, mainly construction of Community Based Health Planning and Services (CHPS) compounds. Conclusion It is important to make policies that will regulate the relative power among the political appointees like the District Chief Executives (DCEs), public and civil servants in decentralized departments and agencies and Community members to make resource disbursement more sensitive to communities and decentralized departments.
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Affiliation(s)
- Andrews Ayim
- Policy, Planning, Monitoring and Evaluation Division, Ghana Health Service, Accra, Ghana
- Public Health Faculty Ministries, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Irene Akua Agyepong
- Dodowa Health Research Center, Research and Development Division, Ghana Health Service, Dodowa, Ghana
- Public Health Faculty Ministries, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Nana Enyimayew
- Public Health Faculty Ministries, Ghana College of Physicians and Surgeons, Accra, Ghana
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Satyarth S, Subramani SK, Ahmed H, Singh G, Selvakumar R, Bhandary S, Babu JS, Swarnalatha C, Nayyar AS. Perception of dental students regarding possible career challenges and associated factors towards working in rural areas: A questionnaire based survey. J Orthod Sci 2023; 12:31. [PMID: 37351413 PMCID: PMC10282548 DOI: 10.4103/jos.jos_46_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/03/2022] [Accepted: 12/17/2022] [Indexed: 06/24/2023] Open
Abstract
OBJECTIVE The shortage of health care professionals in rural areas contributes toward discriminatory health care delivery. The present study was planned with a similar intent and aimed to evaluate the perception of dental students regarding their future in rural areas. MATERIALS AND METHODS The present study was designed as a cross-sectional study comprising of a 30-item questionnaire survey instrument distributed among a total of 550 dental students while the results obtained were subjected to statistical analysis. Statistical analysis was done using SPSS version 12.0 (SPSS Inc., Chicago, IL, USA). Independent student's t-test and one-way analysis of variance (ANOVA) were used for comparison among the variables while the Chi-square test was used to determine the association between the variables. P < 0.05 was considered statistically significant. RESULTS No significant difference was observed in the attitude based on gender (P = 0.43), although, a statistically significant difference was observed in the attitude of students based on the year of their education with a positive attitude toward rural dental practice generally noted in the first year Bachelor of Dental Surgery (BDS) students which significantly declined with the increasing level of education (P = 0.01). CONCLUSIONS Dental students were more influenced by the negative aspects of rural dental practice though they had, in their mind, a positive approach for the same at the beginning of their education, but this significantly declined with the increasing level of their education.
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Affiliation(s)
- Saurabh Satyarth
- Department of Dentistry, Government Medical College, Bettiah, Bihar, India
| | | | - Hina Ahmed
- Department of Conservative Dental Sciences, Ibn Sina National College for Medical Studies, Jeddah, Kingdom of Saudi Arabia
| | - Gautam Singh
- Department of Conservative Dental Sciences, Ibn Sina National College for Medical Studies, Jeddah, Kingdom of Saudi Arabia
| | - Rajkumar Selvakumar
- Department of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, Annamalai University, Annamalai Nagar, Tamil Nadu, India
| | - Srikala Bhandary
- Department of Paediatric and Preventive Dentistry, A B Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India
| | - J Suresh Babu
- Department of Preventive Dental Sciences, Division of Periodontology, College of Dentistry, University of Ha’il, Ha’il, Kingdom of Saudi Arabia
| | - C Swarnalatha
- Department of Preventive Dental Sciences, Division of Periodontology, College of Dentistry, University of Ha’il, Ha’il, Kingdom of Saudi Arabia
| | - Abhishek S. Nayyar
- Department of Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-Graduate Research Institute, Parbhani, Maharashtra, India
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Bawontuo V, Adomah-Afari A, Atinga RA, Kuupiel D, Agyepong IA. Power sources among district health managers in Ghana: a qualitative study. BMC PRIMARY CARE 2022; 23:68. [PMID: 35379175 PMCID: PMC8981779 DOI: 10.1186/s12875-022-01678-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 03/30/2022] [Indexed: 05/31/2023]
Abstract
Background In Ghana district directors of health services and district hospital medical superintendents provide leadership and management within district health systems. A healthy relationship among these managers is dependent on the clarity of formal and informal rules governing their routine duties. These rules translate into the power structures within which district health managers operate. However, detailed nuanced studies of power sources among district health managers are scarce. This paper explores how, why and from where district health directors and medical superintendents derive power in their routine functions. Methods A multiple case study was conducted in three districts; Bongo, Kintampo North and Juaboso. In each case study site, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and 61 participants for interview and focus group discussion. A total of 11 interviews (3 in each district and 2 with deputy regional directors), and 9 focus group discussions (3 in each district) were conducted. Transcriptions of the voice-recordings were done verbatim, cleaned and imported into the Nvivo version 11 software for analysis using the inductive content analysis approach. Results The findings revealed that legitimacy provides formal power source for district health managers since they are formally appointed by the Director General of the Ghana Health Service after going through the appointment processes. These appointments serve as the primary power source for district health managers based on the existing legal and policy framework of the Ghana Health Service. Additionally, resource control especially finances and medical dominance are major informal sources of power that district health managers often employ for the management and administration of their functional areas in the health districts. Conclusions The study concludes that district health managers derive powers primarily from their positions within the hierarchical structure (legitimacy) of the district health system. Secondary sources of power stems from resource control (medical dominance and financial dominance), and these power sources inform the way district health managers relate to each other. This paper recommends that district health managers are oriented to understand the power dynamics in the district health system.
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Amoako Johnson F. Spatiotemporal clustering and correlates of childhood stunting in Ghana: Analysis of the fixed and nonlinear associative effects of socio-demographic and socio-ecological factors. PLoS One 2022; 17:e0263726. [PMID: 35134090 PMCID: PMC8824350 DOI: 10.1371/journal.pone.0263726] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 01/25/2022] [Indexed: 11/21/2022] Open
Abstract
Childhood stunting remains a major public health issue in many low- and middle-income countries. In Ghana, the progress made is insufficient to reach the targets set by the 2025 World Health Assembly and the 2030 United Nations Sustainable Development Goals. Although studies have examined the socio-demographic determinants of childhood stunting, there has not been any systematic study to examine the spatial associative effects of the socio-demographic and socio-ecological factors at the district level, where health programmes are implemented and monitored. Bayesian geo-additive semiparametric regression technique was used to analyse five conservative rounds of Demographic and Health Surveys in Ghana, with socio-ecological covariates derived from the Demographic and Health Survey Program Geospatial Covariate datasets to examine the temporal trends in childhood stunting, the extent of geospatial clustering at the district level and their associative relationships with socio-demographic and socio-ecological factors. The findings show that childhood stunting in Ghana is not spatially randomly distributed but clustered. Clustering of high childhood stunting was observed amongst districts in the Upper West, Upper East, Northern, North East, Savannah, and Western North regions, whilst clustering of low childhood stunting was observed in districts in the Greater Accra, Volta, Bono and the Eastern regions. Whist socio-demographic factors were predominantly associated with clustering of districts with high childhood stunting, the socio-ecological factors were mainly associated with clustering of districts with low childhood stunting. The socio-ecological factors identified to have a nonlinear associative effect with childhood stunting were Insecticide Treated Net (ITN) coverage, nightlight composite, travel time to a main settlement and population density. The findings suggest that targeted interventions at the district level are essential to reducing childhood stunting in Ghana.
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Affiliation(s)
- Fiifi Amoako Johnson
- Department of Population and Health, Faculty of Social Sciences, College of Humanities and Legal Studies, University of Cape Coast, Cape Coast, Ghana
- * E-mail:
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Mwinnyaa G, Hazel E, Maïga A, Amouzou A. Estimating population-based coverage of reproductive, maternal, newborn, and child health (RMNCH) interventions from health management information systems: a comprehensive review. BMC Health Serv Res 2021; 21:1083. [PMID: 34689787 PMCID: PMC8542459 DOI: 10.1186/s12913-021-06995-z] [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: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/15/2022] Open
Abstract
Background Routinely collected health facility data usually captured and stored in Health Management Information Systems (HMIS) are potential sources of data for frequent and local disaggregated estimation of the coverage of reproductive, maternal, newborn, and child health interventions (RMNCH), but have been under-utilized due to concerns over data quality. We reviewed methods for estimation of national or subnational coverage of RMNCH interventions using HMIS data exclusively or in conjunction with survey data from low- and middle-income countries (LMICs). Methods We conducted a comprehensive review of studies indexed in PubMed and Scopus to identify potential papers based on predefined search terms. Two reviewers screened the papers using defined inclusion and exclusion criteria. Following sequences of title, abstract and full paper reviews, we retained 18 relevant papers. Results 12 papers used only HMIS data and 6 used both HMIS and survey data. There is enormous lack of standards in the existing methods for estimating RMNCH intervention coverage; all appearing to be highly author dependent. The denominators for coverage measures were estimated using census, non-census and combined projection-based methods. No satisfactory methods were found for treatment-based coverage indicators for which the estimation of target population requires the population prevalence of underlying conditions. The estimates of numerators for the coverage measures were obtained from the count of users or visits and in some cases correction for completeness of reporting in the HMIS following an assessment of data quality. Conclusions Standard methods for correcting numerators from HMIS data for accurate estimation of coverage of RMNCH interventions are needed to expand the use of these data. More research and investments are required to improve denominators for health facility-derived statistics. Improvement in routine data quality and analytical methods would allow for timely estimation of RMNCH intervention coverage at the national and subnational levels.
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Affiliation(s)
- George Mwinnyaa
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, MD, 21205, Baltimore, USA
| | - Elizabeth Hazel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, MD, 21205, Baltimore, USA
| | - Abdoulaye Maïga
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, MD, 21205, Baltimore, USA
| | - Agbessi Amouzou
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, MD, 21205, Baltimore, USA.
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Wireko I, Béland D, Kpessa-Whyte M. Self-undermining policy feedback and the creation of National Health Insurance in Ghana. Health Policy Plan 2020; 35:1150-1158. [PMID: 32989440 DOI: 10.1093/heapol/czaa080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2020] [Indexed: 11/13/2022] Open
Abstract
Contributing to the ongoing debate about policy feedback in comparative public policy research, this article examines the evolution of healthcare financing policy in Ghana. More specifically, this article investigates the shift in healthcare financing from full cost recovery, known as 'cash-and-carry', to a nation-wide public health insurance policy called the National Health Insurance Scheme (NHIS). It argues that unintended, self-undermining feedback effects from the existing health policy constrained the menu of options available to reformers, while simultaneously opening a window of opportunity for transformative policy change. The study advances the current public policy scholarship by showing how the interaction between policy feedbacks and other factors-particularly ideas and electoral pressures-can bring about path-departing policy change. Given the dearth of scholarship on self-undermining policy feedback effects in the Global South, this contribution's originality lies in its application of the novel theory to the sub-Saharan African context.
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Affiliation(s)
- Ishmael Wireko
- Government of Saskatchewan, Ministry of Energy and Resources1000, 2103 11th Avenue Regina SK S4P 3Z8, Canada
| | - Daniel Béland
- Department of Political Science, McGill University, Room 414, Leacock Building, 855 Sherbrooke Street West, Montreal, Quebec H3A 2T7, Canada
| | - Michael Kpessa-Whyte
- History and Politics Section, Institute of African Studies, Anne Jiage Road, P.O. Box LG 73, University of Ghana, Legon, Accra, Ghana
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Heerdegen ACS, Gerold J, Amon S, Agyemang SA, Aikins M, Wyss K. How Does District Health Management Emerge Within a Complex Health System? Insights for Capacity Strengthening in Ghana. Front Public Health 2020; 8:270. [PMID: 32733833 PMCID: PMC7360672 DOI: 10.3389/fpubh.2020.00270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/26/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: District health managers (DHMs) play a pivotal role in the operation of district health systems in low-and middle income countries, including Ghana. Their capacity is determined by their competencies, but also by the organization and system in which they are embedded. The objective of this paper is to explore how district health management emerges from contextual, organizational, and individual factors in order to demonstrate that capacity strengthening efforts at district level need to transcend individual competencies to take on more systemic approaches. Methods: Semi-structured interviews (n = 21) were conducted to gain insight into aspects that affect district health management in the Eastern Region of Ghana. Interviews were conducted with DHMs (n = 15) from six different districts, as well as with their superiors at the regional level (n = 4) and peers from non-governmental organizations (n = 2). A thematic analysis was conducted by using an analytical approach based on systems theory. Results: Contextual aspects, such as priorities among elected officials, poor infrastructure and working conditions, centralized decision-making, delayed disbursement of funds and staff shortages, affect organizational processes and the way DHMs carry out their role. Enabling organizational aspects that provide DHMs with direction and a clear perception of their role, include positive team dynamics, good relations with supervisors, job descriptions, appraisals, information systems, policies and guidelines. Meanwhile, hierarchical organizational structures, agendas driven by vertical programs and limited opportunities for professional development provide DHMs with limited authority to make decisions and dampens their motivation. The DHMs ability to carry out their role effectively depends on their perception of their role and the effort they expend, in addition to their competencies. In regards to competencies, a need for more general management and leadership skills were called for by DHMs as well as by their superiors and peers. Conclusion: Systemic approaches are called for in order to strengthen district health management capacity. This study can provide national policy-makers, donors and researchers with a deeper understanding of factors that should be taken into consideration when developing, planning, implementing, and assessing capacity-building strategies targeted at strengthening district health management.
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Affiliation(s)
| | - Jana Gerold
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Samuel Amon
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Samuel Agyei Agyemang
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Uy J, Macarayan EK, Ratcliffe HL, Miller K, Otupiri E, Awoonor-Williams JK, Hirschhorn LR, Lipsitz SR, Schwarz D, Bitton A. Preliminary validation of the PRImary care facility Management Evaluation tool (PRIME-Tool), a national facility management survey implemented in Ghana. BMC Health Serv Res 2019; 19:937. [PMID: 31805931 PMCID: PMC6896786 DOI: 10.1186/s12913-019-4768-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 11/22/2019] [Indexed: 11/30/2022] Open
Abstract
Background The management quality of healthcare facilities has consistently been linked to facility performance, but available tools to measure management are costly to implement, often hospital-specific, not designed for low- and middle-income countries (LMICs), nor widely deployed. We addressed this gap by developing the PRImary care facility Management Evaluation Tool (PRIME-Tool), a primary health care facility management survey for integration into routine national surveys in LMICs. We present an analysis of the tool’s psychometric properties and suggest directions for future improvements. Methods The PRIME-Tool assesses performance in five core management domains: Target setting, Operations, Human resources, Monitoring, and Community engagement. We evaluated two versions of the PRIME-Tool. We surveyed 142 primary health care (PHC) facilities in Ghana in 2016 using the first version (27 items) and 148 facilities in 2017 using the second version (34 items). We calculated floor and ceiling effects for each item and conducted exploratory factor analyses to examine the factor structure for each year and version of the tool. We developed a revised management framework and PRIME-tool as informed by these exploratory results, further review of management theory literature, and co-author consensus. Results The majority (17 items in 2016, 23 items in 2017) of PRIME-Tool items exhibited ceiling effects, but only three (2 items in 2016, 3 items in 2017) showed floor effects. Solutions suggested by factor analyses did not fully fit our initial hypothesized management domains. We found five groupings of items that consistently loaded together across each analysis and named these revised domains as Supportive supervision and target setting, Active monitoring and review, Community engagement, Client feedback for improvement, and Operations and financing. Conclusion The revised version of the PRIME-Tool captures a range of important and actionable information on the management of PHC facilities in LMIC contexts. We recommend its use by other investigators and practitioners to further validate its utility in PHC settings. We will continue to refine the PRIME-Tool to arrive at a parsimonious tool for tracking PHC facility management quality. Better understanding the functional components of PHC facility management can help policymakers and frontline managers drive evidence-based improvements in performance.
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Affiliation(s)
- Jhanna Uy
- Ariadne Labs, Brigham and Women's Hospital & Harvard T.H. Chan School of Public Health, 3rd Floor East, 401 Park Drive, Boston MA, Boston, MA, 02215, USA
| | - Erlyn K Macarayan
- Ariadne Labs, Brigham and Women's Hospital & Harvard T.H. Chan School of Public Health, 3rd Floor East, 401 Park Drive, Boston MA, Boston, MA, 02215, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Hannah L Ratcliffe
- Ariadne Labs, Brigham and Women's Hospital & Harvard T.H. Chan School of Public Health, 3rd Floor East, 401 Park Drive, Boston MA, Boston, MA, 02215, USA
| | - Kate Miller
- Ariadne Labs, Brigham and Women's Hospital & Harvard T.H. Chan School of Public Health, 3rd Floor East, 401 Park Drive, Boston MA, Boston, MA, 02215, USA
| | - Easmon Otupiri
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Lisa R Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stuart R Lipsitz
- Ariadne Labs, Brigham and Women's Hospital & Harvard T.H. Chan School of Public Health, 3rd Floor East, 401 Park Drive, Boston MA, Boston, MA, 02215, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dan Schwarz
- Ariadne Labs, Brigham and Women's Hospital & Harvard T.H. Chan School of Public Health, 3rd Floor East, 401 Park Drive, Boston MA, Boston, MA, 02215, USA.,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.,Center for Primary Care, Harvard Medical School, Boston, MA, USA
| | - Asaf Bitton
- Ariadne Labs, Brigham and Women's Hospital & Harvard T.H. Chan School of Public Health, 3rd Floor East, 401 Park Drive, Boston MA, Boston, MA, 02215, USA. .,Center for Primary Care, Harvard Medical School, Boston, MA, USA. .,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA. .,Division of General Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Tumusiime P, Kwamie A, Akogun OB, Elongo T, Nabyonga-Orem J. Towards universal health coverage: reforming the neglected district health system in Africa. BMJ Glob Health 2019; 4:e001498. [PMID: 31681483 PMCID: PMC6797439 DOI: 10.1136/bmjgh-2019-001498] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/07/2019] [Accepted: 04/27/2019] [Indexed: 11/27/2022] Open
Abstract
In most African countries, the district sphere of governance is a colonial creation for harnessing resources from the communities that are located far away from the centre with the assistance of minimally skilled personnel who are subordinate to the central authority with respect to decision-making and initiative. Unfortunately, postcolonial reforms of district governance have retained the hierarchical structure of the local government. Anchored to such a district arrangement, the (district) health system (DHS) is too weak and impoverished to function in spite of enormous knowledge and natural resources for a seamless implementation of universal health coverage (UHC). Sadly, the quick-fix projects of the 1990s with the laudable intention to reduce the burden of disease within a specified time-point dealt the fatal blow on the DHS administration by diminishing it to a stop-post and a warehouse for commodities (such as bednets and vaccines) destined for the communities. We reviewed the situation of the district in sub-Saharan African countries and identified five attributes that are critical for developing a UHC-friendly DHS. In this analytical paper, we discuss decision-making authority, coordination, resource control, development initiative and management skills as critical factors. We highlight the required strategic shifts and recommend a dialogue for charting an African regional course for a reformed DHS for UHC. Further examination of these factors and perhaps other ancillary criteria will be useful for developing a checklist for assessing the suitability of a DHS for the UHC that Africa deserves.
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Affiliation(s)
- Prosper Tumusiime
- Health Systems and Services Cluster, WHO Regional office for Africa, Brazzaville, Congo
| | - Aku Kwamie
- School of Public Health, University of Ghana, Legon, Ghana
| | - Oladele B Akogun
- Tropical Health and Diseases Research, Federal University of Technology Yola, Yola, Nigeria
- Common Heritage Foundation, Common Heritage Foundation, Abuja, Nigeria
| | - Tarcisse Elongo
- Health Systems and Services Cluster, WHO Regional office for Africa, Brazzaville, Congo
| | - Juliet Nabyonga-Orem
- Health systems and services cluster, World Health Organization, Inter-Country Support Team for Eastern & Southern Africa, Harare, Zimbabwe
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Kipo-Sunyehzi DD, Ayanore MA, Dzidzonu DK, AyalsumaYakubu Y. Ghana's Journey towards Universal Health Coverage: The Role of the National Health Insurance Scheme. Eur J Investig Health Psychol Educ 2019; 10:94-109. [PMID: 34542472 PMCID: PMC8314219 DOI: 10.3390/ejihpe10010009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/26/2022] Open
Abstract
Background: the main aim of the study is to find if the National Health Insurance Scheme (NHIS) in Ghana is achieving universal health coverage (UHC) or not. The study gives the trajectories of health policies in Ghana and their implications on long term health financing. NHIS in Ghana was implemented in 2004, with the aim of increasing subscribers’ access to health care services and reduce financial barriers to health care. On equity access to healthcare, it addresses two core concerns: (1) enrolling particular groups (persons exempted from annual premium payments) and (2) achieving UHC for all citizens and persons with legal residence. It utilizes a multifactor approach to the conceptualization of UHC. The research question: Is Ghana’s NHIS on course to deliver or achieve universal health coverage? Methods: we used qualitative methods. In doing so, the study engaged participants in in-depth interviews, focus group discussions and direct observations of participants in their natural settings, like hospitals, clinics, offices and homes, with purposive and snowball techniques. This data triangulation approach aims to increase the reliability and validity of findings. Results: the empirical evidence shows NHIS performed relatively well in enrolling more exempt groups (particular groups) than enrolling all persons in Ghana (UHC). The biggest challenge for the implementation of NHIS from the perspectives of health insurance officials is inadequate funding. The health insurance beneficiaries complained of delays during registrations and renewals. They also complained of poor attitude of some health insurance officials and health workers at facilities. Conclusions: both health insurance officials and beneficiaries emphasized the need for increased public education and for implementers to adopt a friendly attitude towards clients. To move towards achieving UHC, there is a need to redesign the policy, to move it from current voluntary contributions, to adopt a broad tax-based approach to cover all citizens and persons with legal residence in Ghana. Also, to adopt a flexible premium payment system (specifically ‘payments by installation’ or ‘part payments’) and widen the scope of exempt groups as a way of enrolling more into the NHIS.
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Affiliation(s)
- Daniel Dramani Kipo-Sunyehzi
- Legon Centre for International Affairs and Diplomacy, College of Humanities, University of Ghana, P.O. Box LG 25, Accra, Ghana
- Correspondence:
| | - Martin Amogre Ayanore
- Department of Health Policy, Planning and Management, School of Public Health, University of Health and Allied Sciences, PMB 31 Hohoe, Ghana; (M.A.A.); (D.K.D.)
| | - Daniel Kweku Dzidzonu
- Department of Health Policy, Planning and Management, School of Public Health, University of Health and Allied Sciences, PMB 31 Hohoe, Ghana; (M.A.A.); (D.K.D.)
| | - Yakubu AyalsumaYakubu
- Department of Epidemiology and Biostatistics, School of Public Health, University of Health and Allied Sciences, PMB 31 Hohoe, Ghana;
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Sulley I, Abizari AR, Ali Z, Peprah W, Yakubu HG, Forfoe WW, Saaka M. Growth monitoring and promotion practices among health workers may be suboptimal despite high knowledge scores. BMC Health Serv Res 2019; 19:267. [PMID: 31035985 PMCID: PMC6489312 DOI: 10.1186/s12913-019-4103-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 04/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The child health record booklet (CHRB) is a powerful tool for screening children under five and for education of caregivers by health workers. The objective of the present study was to assess the knowledge and utilization of CHRB by mothers and health workers in child growth monitoring and promotion (GMP) in the East Mamprusi Municipal, Northern region, Ghana. METHODS A descriptive cross-sectional study was conducted among mothers attending child welfare clinics (CWC) and health workers providing GMP at CWC. Observational checklists were used to assess 73 CHRB on the completeness and correctness of growth charts. Mothers and health workers' knowledge on essential components of CHRB were assessed with a questionnaire. RESULTS Weight measurements were correctly recorded in all booklets analyzed. Even though a greater proportion (70.7%) of health workers exhibited high knowledge scores on the interpretation of the essential components of the CHRB,most of the charts analyzed were not completely filled (72.6%) but rather correctly filled (74.0%). Mean knowedge score (3.4 ± 1.3) on growth charting was low among mothers who attend GMP. Work overload (26.1%), inadequate supply of CHRB (26.1%) and vaccine shortages (18.7%) were concerns raised by health workers on the effective usage of the CHRB. CONCLUSION Knowledge scores on the child health record booklets among health workers and mothers in this part of northern Ghana were high but charting of growth of children was sub-optimal among health workers.
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Affiliation(s)
- Issahaku Sulley
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, P O Box 1883, Tamale, Ghana
| | - Abdul-Razak Abizari
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, P O Box 1883, Tamale, Ghana.
| | - Zakari Ali
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, P O Box 1883, Tamale, Ghana
| | - Wisdom Peprah
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, P O Box 1883, Tamale, Ghana
| | - Hamshawu Gombilla Yakubu
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, P O Box 1883, Tamale, Ghana
| | - Wilfred W Forfoe
- Impact Malaria Project, 14 Ollenu Street, East Legon, PMB 18, Accra, Ghana
| | - Mahama Saaka
- Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, P O Box 1883, Tamale, Ghana
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Rakmawati T, Hinchcliff R, Pardosi JF. District-level impacts of health system decentralization in Indonesia: A systematic review. Int J Health Plann Manage 2019; 34:e1026-e1053. [PMID: 30901111 DOI: 10.1002/hpm.2768] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 11/06/2022] Open
Abstract
The local-level impacts of decentralizing national health systems are significant yet infrequently examined. This review aims to assess whether localized health services delivery in Indonesia, which commenced a health system decentralization process in 2001, achieved its objectives or could be enhanced. A systematic review was undertaken to collate published evidence regarding this topic and synthesize key findings holistically using the six building blocks framework of the World Health Organization (WHO) to categorize health system performance. Four research databases were searched in 2016 for relevant evidence published between 2001 and 2015. The inclusion criteria were relevance to the topic of decentralization impacts at the district level, original research, and published in English. Included articles were appraised for quality using a standardized tool, with key findings synthesized using the WHO building blocks. Twenty-nine articles met the inclusion criteria and categorized under the WHO building blocks categories. The findings highlight problematic impacts of decentralization related to three building blocks: service delivery, health financing, and workforce. In the 15 years of post-decentralization in Indonesia, the service delivery, health workforce, and health financing blocks should be prioritized for further research and policy evaluation to improve the overall health system performance at the district level.
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Affiliation(s)
- Trisya Rakmawati
- Global Health Supply Chain-Procurement and Supply Management, Chemonics International, Jakarta, Indonesia.,School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Reece Hinchcliff
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.,School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Faculty of Health, Centre for Health Services Management, University of Technology Sydney, Sydney, Australia.,Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Australia
| | - Jerico Franciscus Pardosi
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.,School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia.,National Institute of Health Research and Development, Ministry of Health, Indonesia
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Aberese-Ako M, Agyepong IA, van Dijk H. Leadership styles in two Ghanaian hospitals in a challenging environment. Health Policy Plan 2018; 33:ii16-ii26. [PMID: 30053032 PMCID: PMC6037062 DOI: 10.1093/heapol/czy038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2018] [Indexed: 11/24/2022] Open
Abstract
Hospital managers’ power to exercise effective leadership in daily management can affect quality of care directly as well as through effects on frontline workers’ motivation. This paper explores the influence of contextual factors on hospital managers’ leadership styles and the motivation of frontline workers providing maternal and new born care in two public district hospitals in Ghana. It draws on data from an ethnographic study that involved participant observation, conversations and in-depth interviews conducted over 20 months, with frontline health workers and managers. Qualitative analysis software Nvivo 11 was used to facilitate coding, and common patterns emerging from the codes were grouped into themes. Ethical clearance was obtained from the Ghana Health Service Ethical Review Committee. Contextual factors such as institutional rules and regulations and funding constrained managers’ power, and influenced leadership styles and responses to expressed and observed needs of frontline workers and clients. The contextual constraints on mangers’ responses were a source of demotivation to both managers and frontline workers, as it hampered quality health service provision. Knowing what to do, but sometimes constrained by context, managers described ‘feeling sick’ and frustrated. On the other hand in the instances where managers’ were able to get round the constraints and respond effectively to frontline health workers and clients’ needs, they felt encouraged and motivated to work harder. Effective district hospital management and leadership is influenced by contextual factors; and not just individual manager’s knowledge and skills. Interventions to strengthen management and leadership of public sector hospitals in low- and middle-income countries like Ghana need to consider context and not just individual managers’ skills and knowledge strengthening.
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Affiliation(s)
- Matilda Aberese-Ako
- Institute of Health Research, University of Health and Allied Sciences, Ho, Volta Region, Ghana
| | - Irene Akua Agyepong
- Research and Development Division, Ghana Health Service, Dodowa Health Research Centre, Dodowa, Shai Osudoku district, Greater Accra Region, Ghana
| | - Han van Dijk
- Rural Development Sociology Group, Wageningen University, 6700 EW Wageningen, The Netherlands
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16
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Agyepong IA. Universal health coverage: breakthrough or great white elephant? Lancet 2018; 392:2229-2236. [PMID: 30309621 DOI: 10.1016/s0140-6736(18)32402-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/03/2018] [Indexed: 10/28/2022]
Abstract
Will the Sustainable Development Goal 3 sub-goal "Achieve universal health coverage, including financial risk protection, access to quality essential health care services and…safe, effective, quality and affordable essential medicines and vaccines for all" be judged a breakthrough or a great white elephant in implementation, when we look back with the clear eyes of hindsight in 2030? What are the ways in which this agenda might play out in implementation and why might it do so? Drawing on a desk review, this Essay explores dominant ideas, ideology, institutions, and interests in relation to global versus Ghana national health priorities since the WHO constitution came into effect in 1948, to reflect on these questions.
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Affiliation(s)
- Irene A Agyepong
- Dodowa Health Research Centre, Research and Development Division, Ghana Health Service, Dodowa, Ghana; Public Health Faculty, Ghana College of Physicians and Surgeons, Accra, Ghana.
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Kotoh AM, Aryeetey GC, Van der Geest S. Factors That Influence Enrolment and Retention in Ghana' National Health Insurance Scheme. Int J Health Policy Manag 2018; 7:443-454. [PMID: 29764108 PMCID: PMC5953527 DOI: 10.15171/ijhpm.2017.117] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 09/23/2017] [Indexed: 11/21/2022] Open
Abstract
Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and methodological tool to examine why enrolment and retention in the NHIS remains low.
Methods: A household survey was conducted after 20 months educational and promotional activities aimed at improving enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth interviews and informal conversations were used to collect qualitative data. Forty key informants (community members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy communities in the Central Region (CR) were interviewed. Several community members, health providers and DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed using thematic content analysis.
Results: The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’ positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health providers’ behaviour and service delivery challenges.
Conclusion: Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS policy to move the scheme towards universal coverage.
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Affiliation(s)
| | | | - Sjaak Van der Geest
- Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands
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18
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Agyapong A, Afi JD, Kwateng KO. Examining the effect of perceived service quality of health care delivery in Ghana on behavioural intentions of patients: The mediating role of customer satisfaction. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2017. [DOI: 10.1080/20479700.2017.1326703] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ahmed Agyapong
- School of Business, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Joel Duah Afi
- School of Business, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Kwame Owusu Kwateng
- School of Business, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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19
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Gyedu A, Agbedinu K, Dalwai M, Osei-Ampofo M, Nakua EK, Oteng R, Stewart B. Triage capabilities of medical trainees in Ghana using the South African triage scale: an opportunity to improve emergency care. Pan Afr Med J 2016; 24:294. [PMID: 28154649 PMCID: PMC5267868 DOI: 10.11604/pamj.2016.24.294.8728] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Accepted: 06/02/2016] [Indexed: 12/04/2022] Open
Abstract
Introduction The incidence of emergency conditions is increasing worldwide, particularly in low- and middle-income countries (LMICs). However, triage and emergency care training has not been prioritized in LMICs. We aimed to assess the reliability and validity of the South African Triage Scale (SATS) when used by providers not specifically trained in SATS, as well as to compare triage capabilities between senior medical students and senior house officers to examine the effectiveness of our curriculum for house officer training with regards to triage. Methods Sixty each of senior medical students and senior house officers who had not undergone specific triage or SATS training were asked to triage 25 previously validated emergency vignettes using the SATS. Estimates of reliability and validity were calculated. Additionally, over- and under-triage, as well as triage performance between the medical students and house officers was assessed against a reference standard. Results Fifty-nine senior medical students (98% response rate) and 43 senior house officers (72% response rate) completed the survey (84% response rate overall). A total of 2,550 triage assignments were included in the analysis (59 medical student and 43 house officer triage assignments for 25 vignettes each; 1,475 and 1,075 triage assignments, respectively). Inter-rater reliability was moderate (quadratically weighted κ 0.59 and 0.60 for medical students and house officers, respectively). Triage using SATS performed by these groups had low sensitivity (medical students: 54%, 95% CI 49–59; house officers: 55%, 95% CI 48–60) and moderate specificity (medical students: 84%, 95% CI 82 - 89; house officers: 84%, 95% CI 82 - 97). Both groups under-triaged most ‘emergency’ level vignette patients (i.e. SATS Red; 80 and 82% for medical students and house officers, respectively). There was no difference between the groups for any metric. Conclusion Although the SATS has proven utility in a number of different settings in LMICs, its success relies on its use by trained providers. Given the large and growing burden of emergency conditions, training current and future emergency care providers in triage is imperative.
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Affiliation(s)
- Adam Gyedu
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Kwabena Agbedinu
- Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Mohammed Dalwai
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Maxwell Osei-Ampofo
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Emmanuel Kweku Nakua
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Rockefeller Oteng
- Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana; Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI, USA
| | - Barclay Stewart
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Surgery, University of Washington, Seattle, WA, USA; Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
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Nyonator F, Jones TC, Miller RA, Phillips JF, Awoonor-Williams JK. Guiding the Ghana Community-Based Health Planning and Services Approach to Scaling up with Qualitative Systems Appraisal. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2016. [DOI: 10.2190/ngm3-fydt-5827-ml1p] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
When a Navrongo Health Research Centre experiment demonstrated that community-based health services could reduce child mortality and fertility in impoverished communities, the Government of Ghana launched the Community-based Health Planning and Services (CHPS) Initiative to scale up results. This article reports on a “Qualitative Systems Appraisal” (QSA) of factors explaining why CHPS is implemented in some districts, but stalled in others. QSA consists of groups representing levels of the service hierarchy (community members, frontline service providers, supervisors, and district managers) to portray systemic reactions to CHPS. Community members are enthusiastic about CHPS and willing to mobilize labor and resources for constructing nurse accommodations. Participating staff are supportive, but staff not yet participating are apprehensive about the program. Nurses worry about their transfer to communities; supervisors and managers worry about constrained fuel, equipment, drugs, facilities, and manpower resources. Demonstrating CHPS at functioning sites clarifies ways to bridge resource gaps, address concerns, and build consensus for the implementation process.
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Affiliation(s)
- Frank Nyonator
- Ghana Health Services, Accra, Ghana and The Population Council, New York
| | - Tanya C. Jones
- Ghana Health Services, Accra, Ghana and The Population Council, New York
| | - Robert A. Miller
- Ghana Health Services, Accra, Ghana and The Population Council, New York
| | - James F. Phillips
- Ghana Health Services, Accra, Ghana and The Population Council, New York
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21
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Kwamie A, van Dijk H, Ansah EK, Agyepong IA. The path dependence of district manager decision-space in Ghana. Health Policy Plan 2016; 31:356-66. [PMID: 26318537 PMCID: PMC4779147 DOI: 10.1093/heapol/czv069] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2015] [Indexed: 11/27/2022] Open
Abstract
The district health system in Ghana today is characterized by high resource-uncertainty and narrow decision-space. This article builds a theory-driven historical case study to describe the influence of path-dependent administrative, fiscal and political decentralization processes on development of the district health system and district manager decision-space. Methods included a non-exhaustive literature review of democratic governance in Ghana, and key informant interviews with high-level health system officials integral to the development of the district health system. Through our analysis we identified four periods of district health system progression: (1) development of the district health system (1970-85); (2) Strengthening District Health Systems Initiative (1986-93); (3) health sector reform planning and creation of the Ghana Health Service (1994-96) and (4) health sector reform implementation (1997-2007). It was observed that district manager decision-space steadily widened during periods (1) and (2), due to increases in managerial profile, and concerted efforts at managerial capacity strengthening. Periods (3) and (4) saw initial augmentation of district health system financing, further widening managerial decision-space. However, the latter half of period 4 witnessed district manager decision-space contraction. Formalization of Ghana Health Service structures influenced by self-reinforcing tendencies towards centralized decision-making, national and donor shifts in health sector financing, and changes in key policy actors all worked to the detriment of the district health system, reversing early gains from bottom-up development of the district health system. Policy feedback mechanisms have been influenced by historical and contemporary sequencing of local government and health sector decentralization. An initial act of administrative decentralization, followed by incomplete political and fiscal decentralization has ensured that the balance of power has remained at national level, with strong vertical accountabilities and dependence of the district on national level. This study demonstrates that the rhetoric of decentralization does not always mirror actual implementation, nor always result in empowered local actors.
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Affiliation(s)
- Aku Kwamie
- Department of Health Policy, Planning and Management, University of Ghana, School of Public Health, PO Box LG 13 Accra, Ghana, Wageningen University, Sociology and Development of Change, Hollandseweg 1, PO Box 8130, 6700 EW, the Netherlands,
| | - Han van Dijk
- Wageningen University, Sociology and Development of Change, Hollandseweg 1, PO Box 8130, 6700 EW, the Netherlands
| | - Evelyn K Ansah
- Ghana Health Service, Research and Development Division, PO Box MB 190 Accra, Ghana and
| | - Irene Akua Agyepong
- Department of Health Policy, Planning and Management, University of Ghana, School of Public Health, PO Box LG 13 Accra, Ghana, Julius Global Health, University Medical Centre, HP STR.6.131, P.O. Box 85500, 3508 GA Utrecht, the Netherlands
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Waiswa P, O'Connell T, Bagenda D, Mullachery P, Mpanga F, Henriksson DK, Katahoire AR, Ssegujja E, Mbonye AK, Peterson SS. Community and District Empowerment for Scale-up (CODES): a complex district-level management intervention to improve child survival in Uganda: study protocol for a randomized controlled trial. Trials 2016; 17:135. [PMID: 26968957 PMCID: PMC4788939 DOI: 10.1186/s13063-016-1241-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 02/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Innovative and sustainable strategies to strengthen districts and other sub-national health systems and management are urgently required to reduce child mortality. Although highly effective evidence-based and affordable child survival interventions are well-known, at the district level, lack of data, motivation, analytic and planning capacity often impedes prioritization and management weaknesses impede implementation. The Community and District Empowerment for Scale-up (CODES) project is a complex management intervention designed to test whether districts when empowered with data and management tools can prioritize and implement evidence-based child survival interventions equitably. METHODS The CODES strategy combines management, diagnostic, and evaluation tools to identify and analyze the causes of bottlenecks to implementation, build capacity of district management teams to implement context-specific solutions, and to foster community monitoring and social accountability to increase demand for services. CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. Implementation and all data collection will be by the districts teams or local Community-based Organizations who will be supported by two local implementing partners. The study will be evaluated as a cluster randomized trial with eight intervention and eight comparison districts over a period of 3 years. Evaluation will focus on differences in uptake of child survival interventions and will follow an intention-to-treat analysis. We will also document and analyze experiences in implementation including changes in management practices. DISCUSSION By increasing the District Health Management Teams' capacity to prioritize and implement context-specific solutions, and empowering communities to become active partners in service delivery, coverage of child survival interventions will increase. Lessons learned on strengthening district-level managerial capacities and mechanisms for community monitoring may have implications, not only in Uganda but also in other similar settings, especially with regard to accelerating effective coverage of key child survival interventions using locally available resources. TRIAL REGISTRATION NUMBER ISRCTN15705788 , Date of registration; 24 July 2015.
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Affiliation(s)
- Peter Waiswa
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda. .,Karolinska Institutet, Solna, Sweden.
| | - Thomas O'Connell
- Economics and Finance, UNICEF NewYork, Three UN Plaza, New York, NY, 10017, USA
| | - Danstan Bagenda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,College of Public Health, University of Nebraska Medical Center, Omaha, NE, USA.,Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | | | - Flavia Mpanga
- Health Section, UNICEF Uganda Country Office, Box 7074, Kampala, Uganda
| | | | | | - Eric Ssegujja
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Anthony K Mbonye
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,Director Health Services, Ministry of Health, Box 7272, Kampala, Uganda
| | - Stefan Swartling Peterson
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,Uppsala University, Uppsala, Sweden
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Amoako Johnson F. A geospatial analysis of the impacts of maternity care fee payment policies on the uptake of skilled birth care in Ghana. BMC Pregnancy Childbirth 2016; 16:41. [PMID: 26925575 PMCID: PMC4772488 DOI: 10.1186/s12884-016-0833-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 02/24/2016] [Indexed: 11/19/2022] Open
Abstract
Background Many low and middle income countries have initiated maternity fee exemption and removal policies to promote use of skilled maternity care. After two and a half decades of these policies, uptake of skilled birth care remains low and inequalities continue to exist in many low and middle income countries. This study uses 2 decades of birth histories data to examine four maternity fee paying policies enacted in Ghana over the past 3 decades and their geospatial impacts on uptake of skilled delivery care. Methods Bayesian Geoadditive Semiparametric regression techniques were applied on four conservative rounds of Demographic and Health Surveys in Ghana to examine the extent of geospatial dependence in skilled birth care use at the district level and their associative relationships with maternity fee paying policies focusing on the temporal trends when the policies were functional. Results The results show that at the country-level, the policies had a positive influence on use of skilled delivery care; however their impacts on reducing between-district inequalities were trivial. Conclusions The findings suggest that targeted interventions at the district level are essential to strengthen maternal health programmes in Ghana.
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Affiliation(s)
- Fiifi Amoako Johnson
- Department of Social Statistics and Demography & Centre for Global Health, Population, Poverty and Policy (GHP3), Faculty of Social, Human and Mathematical Sciences, University of Southampton, Southampton, UK.
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Bradley H, Lehmann U, Butler N. Emerging roles and competencies of district and sub-district pharmacists: a case study from Cape Town. HUMAN RESOURCES FOR HEALTH 2015; 13:88. [PMID: 26601807 PMCID: PMC4658810 DOI: 10.1186/s12960-015-0081-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 09/28/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND District and sub-district pharmacist positions were created during health sector reform in South Africa. High prevalence of HIV/AIDS, tuberculosis and increasing chronic non-communicable diseases have drawn attention to their pivotal roles in improving accessibility and appropriate use of medicines at the primary level. This research describes new roles and related competencies of district and sub-district pharmacists in Cape Town. METHODS Between 2008 and 2011, the author (HB) conducted participatory action research in Cape Town Metro District, an urban district in the Western Cape Province of South Africa, partnering with pharmacists and managers of the two government primary health care (PHC) providers. The two providers function independently delivering complementary PHC services across the entire geographic area, with one provider employing district pharmacists and the other sub-district pharmacists. After an initiation phase, the research evolved into a series of iterative cycles of action and reflection, each providing increasing understanding of district and sub-district pharmacists' roles and competencies. Data was generated through workshops, semi-structured interviews and focus groups with pharmacists and managers which were recorded and transcribed. Thematic analysis was carried out iteratively during the 4-year engagement and triangulated with document reviews and published literature. RESULTS Five main roles for district and sub-district pharmacists were identified: district/sub-district management; planning, co-ordination and monitoring of pharmaceuticals; information and advice; quality assurance and clinical governance; and research (district pharmacists)/dispensing at clinics (sub-district pharmacists). Although the roles looked similar, there were important differences, reflecting the differing governance and leadership models and services of each provider. Five competency clusters were identified: professional pharmacy practice; health system and public health; management; leadership; and personal, interpersonal and cognitive competencies. Whilst professional pharmacy competencies were important, generic management and leadership competencies were considered critical for pharmacists working in these positions. CONCLUSIONS Similar roles and competencies for district and sub-district pharmacists were identified in the two PHC providers in Cape Town, although contextual factors influenced precise specifications. These insights are important for pharmacists and managers from other districts and sub-districts in South Africa and inform health workforce planning and capacity development initiatives in countries with similar health systems.
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Affiliation(s)
- Hazel Bradley
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa.
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa.
| | - Nadine Butler
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, 7535, South Africa.
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Kwamie A, Agyepong IA, van Dijk H. What Governs District Manager Decision Making? A Case Study of Complex Leadership in Dangme West District, Ghana. Health Syst Reform 2015; 1:167-177. [DOI: 10.1080/23288604.2015.1032475] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Aku Kwamie
- School of Public Health; University of Ghana; Accra, Ghana
- Sociology of Development and Change; Wageningen University; Wageningen, The Netherlands
| | - Irene Akua Agyepong
- School of Public Health; University of Ghana; Accra, Ghana
- Julius Global Health; University Medical Center; Utrecht, The Netherlands
| | - Han van Dijk
- Sociology of Development and Change; Wageningen University; Wageningen, The Netherlands
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Non-small cell lung cancer treatment receipt and survival among African-Americans and whites in a rural area. J Community Health 2015; 39:696-705. [PMID: 24346819 DOI: 10.1007/s10900-013-9813-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Data on racial disparities among lung cancer patients in rural areas are scarce. We examined differences in treatment receipt and survival among African-American (AA) and Non-Hispanic White (NHW) non-small cell lung cancer (NSCLC) patients residing in Southwest Georgia (SWGA)-a primarily rural 33-county area; population 700,000. Medical records for 934 SWGA NSCLC patients diagnosed in 2001-2003 were used to extract information on age, race, marital status, insurance coverage, comorbidities, and treatment. Information pertaining to socioeconomic status, urban/rural residence, and survival was obtained from the cancer registry. Multivariable logistic regression analyses examined the relation of various patient and disease characteristics to receipt of tumor-directed therapy. Cox regression models were used to assess determinants of survival. Treatment receipt was associated with age, marital status, comorbidities, and disease stage in most analyses. No associations were observed between race and either surgery [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.49-1.39] or radiation (OR 0.72; 95% CI 0.52-1.00). NHW patients were more likely to receive no treatment at all (OR 1.50, 95% CI 1.01-2.23). There was no racial difference in survival (hazard ratio = 1.07, 95% CI 0.90-1.26). Effects of insurance and treatment on survival were most pronounced within 6 months post-diagnosis, but were attenuated over time. We found no evidence of racial disparities in survival and, in some analyses, a decreased likelihood of treatment receipt among NHW NSCLC patients compared to AA. The results from SWGA stand in contrast to studies that applied different methodologies and were conducted elsewhere.
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Choo S, Papandria D, Goldstein SD, Perry H, Hesse AAJ, Abatanga F, Abdullah F. Quality Improvement Activities for Surgical Services at District Hospitals in Developing Countries and Perceived Barriers to Quality Improvement: Findings From Ghana and the Scientific Literature. World J Surg 2013; 37:2512-9. [DOI: 10.1007/s00268-013-2169-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Aboagye E, Agyemang OS. Maternal health-seeking behavior: the role of financing and organization of health services in Ghana. Glob J Health Sci 2013; 5:67-79. [PMID: 23985108 PMCID: PMC4776872 DOI: 10.5539/gjhs.v5n5p67] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 05/15/2013] [Indexed: 11/03/2022] Open
Abstract
This paper examines how organization and financing of maternal health services influence health-seeking behavior in Bosomtwe district, Ghana. It contributes in furthering the discussions on maternal health-seeking behavior and health outcomes from a health system perspective in sub-Saharan Africa. From a health system standpoint, the paper first presents the resources, organization and financing of maternal health service in Ghana, and later uses case study examples to explain how Ghana's health system has shaped maternal health-seeking behavior of women in the district. The paper employs a qualitative case study technique to build a complex and holistic picture, and report detailed views of the women in their natural setting. A purposeful sampling technique is applied to select 16 women in the district for this study. Through face-to-face interviews and group discussions with the selected women, comprehensive and in-depth information on health- seeking behavior and health outcomes are elicited for the analysis. The study highlights that characteristics embedded in decentralization and provision of free maternal health care influence health-seeking behavior. Particularly, the use of antenatal care has increased after the delivery exemption policy in Ghana. Interestingly, the study also reveals certain social structures, which influence women's attitude towards their decisions and choices of health facilities.
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Rockers PC, Bärnighausen T. Interventions for hiring, retaining and training district health systems managers in low- and middle-income countries. Cochrane Database Syst Rev 2013; 2013:CD009035. [PMID: 23633365 PMCID: PMC7386782 DOI: 10.1002/14651858.cd009035.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND District managers are playing an increasingly important role in determining the performance of health systems in low- and middle-income countries as a result of decentralization. OBJECTIVES To assess the effectiveness of interventions to hire, retain and train district health systems managers in low- and middle-income countries. SEARCH METHODS We searched a wide range of international databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. We also searched online resources of international agencies, including the World Bank, to find relevant grey literature. Searches were conducted in December 2011. SELECTION CRITERIA District health systems managers are those persons who are responsible for overseeing the operations of the health system within a defined, subnational geographical area that is designated as a district. Hiring and retention interventions include those that aim to increase the attractiveness of district management positions, as well as those related to hiring and retention processes, such as private contracting. Training interventions include education programs to develop future managers and on-the-job training programs for current managers. To be included, studies needed to use one of the following study designs: randomized controlled trial, nonrandomized controlled trial, controlled before-and-after study, and interrupted time series analysis. DATA COLLECTION AND ANALYSIS We report measures of effect in the same way that the primary study authors have reported them. Due to the varied nature of interventions included in this review we could not pool data across studies. MAIN RESULTS Two studies met our inclusion criteria. The findings of one study conducted in Cambodia provide low quality evidence that private contracts with international nongovernmental organizations (NGOs) for district health systems management ('contracting-in') may improve health care access and utilization. Contracting-in increased use of antenatal care by 28% and use of public facilities by 14%. However, contracting-in was not found to have an effect on population health outcomes. The findings of the other study provide low quality evidence that intermittent training courses over 18 months may improve district health system managers' performance. In three countries in Latin America, managers who did not receive the intermittent training courses had between 2.4 and 8.3 times more management deficiencies than managers who received the training courses. No studies that aimed to investigate interventions for retaining district health systems managers met our study selection criteria for inclusion in this review. AUTHORS' CONCLUSIONS There is low quality evidence that contracting-in may improve health care accessibility and utilization and that intermittent training courses may improve district health systems managers' performance. More evidence is required before firm conclusions can be drawn regarding the effectiveness of these interventions in diverse settings. Other interventions that might be promising candidates for hiring and retaining (e.g., government regulations, professional support programs) as well as training district health systems managers (e.g., in-service workshops with on-site support) have not been adequately investigated.
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Affiliation(s)
- Peter C Rockers
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Boston, Massachusetts, USA.
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Atunah-Jay SJ, Pettingell S, Ohene SA, Michael Oakes J, Borowsky IW. The relationship between antenatal provider type and maternal care in rural Ghana: a cross-sectional study. Trop Med Int Health 2013; 18:678-86. [PMID: 23557101 DOI: 10.1111/tmi.12098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate the influence of antenatal provider type on maternity care in rural Ghana. METHODS An analysis of maternal care by antenatal provider type using the 2008 Ghana Demographic and Health Survey. Study population included rural Ghanaian women aged 15-49 years with report of a live birth between 2003 and 2008. Bivariate chi-square analysis was performed to examine differences in maternal report of WHO Maternal Health Interventions. Multivariate linear and logistic regression were performed to assess differences in antenatal care (ANC) scales and maternal care packages. RESULTS Thousand and three hundred and sixty-seven rural women reported a live birth. Provider distribution was: doctor, 15.6%; midwife, 70%; community health officer (CHO), 9.1%; no provider, 5.3%. Women from lower socio-demographic categories were more likely to report midwife or CHO. Report of CHO vs. no provider was positively associated with maternal services (P < 0.01). Report of doctor or midwife vs. CHO was significantly associated with maternal services (P < 0.01). CONCLUSION There is a positive association between antenatal provider length of training and maternal specialization and report of maternal services. Community-based providers are associated with markedly increased report of maternal services compared with no provider. Structural factors appear to underlie some differences in service provision.
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Affiliation(s)
- S J Atunah-Jay
- Division of Academic General Pediatrics, University of Minnesota, Minneapolis, MN, USA.
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Abstract
Understanding Health systems have now become the priority focus of researchers and policy makers, who have progressively moved away from a project-centred perspectives. The new tendency is to facilitate a convergence between health system developers and disease-specific programme managers in terms of both thinking and action, and to reconcile both approaches: one focusing on integrated health systems and improving the health status of the population and the other aiming at improving access to health care. Eye care interventions particularly in developing countries have generally been vertically implemented (e.g. trachoma, cataract surgeries) often with parallel organizational structures or specialised disease specific services. With the emergence of health system strengthening in health strategies and in the service delivery of interventions there is a need to clarify and examine inputs in terms governance, financing and management. This present paper aims to clarify key concepts in health system strengthening and describe the various components of the framework as applied in eye care interventions.
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Affiliation(s)
- Karl Blanchet
- International Centre for Eye Health, Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Loh LC, Ugarte-Gil C, Darko K. Private sector contributions and their effect on physician emigration in the developing world. Bull World Health Organ 2013; 91:227-33. [PMID: 23476095 DOI: 10.2471/blt.12.110791] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 12/11/2012] [Accepted: 12/13/2012] [Indexed: 11/27/2022] Open
Abstract
The contribution made by the private sector to health care in a low- or middle-income country may affect levels of physician emigration from that country. The increasing importance of the private sector in health care in the developing world has resulted in newfound academic interest in that sector's influences on many aspects of national health systems. The growth in physician emigration from the developing world has led to several attempts to identify both the factors that cause physicians to emigrate and the effects of physician emigration on primary care and population health in the countries that the physicians leave. When the relevant data on the emerging economies of Ghana, India and Peru were investigated, it appeared that the proportion of physicians participating in private health-care delivery, the percentage of health-care costs financed publicly and the amount of private health-care financing per capita were each inversely related to the level of physician expatriation. It therefore appears that private health-care delivery and financing may decrease physician emigration. There is clearly a need for similar research in other low- and middle-income countries, and for studies to see if, at the country level, temporal trends in the contribution made to health care by the private sector can be related to the corresponding trends in physician emigration. The ways in which private health care may be associated with access problems for the poor and therefore reduced equity also merit further investigation. The results should be of interest to policy-makers who aim to improve health systems worldwide.
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Affiliation(s)
- Lawrence C Loh
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Sixth Floor, Toronto, ON, M4S 1A7, Canada.
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Atinga RA, Mensah SA, Asenso-Boadi F, Adjei FXA. Migrating from user fees to social health insurance: exploring the prospects and challenges for hospital management. BMC Health Serv Res 2012; 12:174. [PMID: 22726666 PMCID: PMC3407489 DOI: 10.1186/1472-6963-12-174] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 06/22/2012] [Indexed: 11/29/2022] Open
Abstract
Background In 2003 Ghana introduced a social health insurance scheme which resulted in the separation of purchasing of health services by the health insurance authority on the one hand and the provision of health services by hospitals at the other side of the spectrum. This separation has a lot of implications for managing accredited hospitals. This paper examines whether decoupling purchasing and service provision translate into opportunities or challenges in the management of accredited hospitals. Methods A qualitative exploratory study of 15 accredited district hospitals were selected from five of Ghana’s ten administrative regions for the study. A semi-structured interview guide was designed to solicit information from key informants, Health Service Administrators, Pharmacists, Accountants and Scheme Managers of the hospitals studied. Data was analysed thematically. Results The results showed that under the health insurance scheme, hospitals are better-off in terms of cash flow and adequate stock levels of drugs. Adequate stock of non-drugs under the scheme was reportedly intermittent. The major challenges confronting the hospitals were identified as weak purchasing power due to low tariffs, non computerisation of claims processing, unpredictable payment pattern, poor gate-keeping systems, lack of logistics and other new and emerging challenges relating to moral hazards and the use of false identity cards under pretence for medical care. Conclusion Study’s findings have a lot of policy implications for proper management of hospitals. The findings suggest rationalisation of the current tariff structure, the application of contract based payment system to inject efficiency into hospitals management and piloting facility based vetting systems to offset vetting loads of the insurance authority. Proper gate-keeping mechanisms are also needed to curtail the phenomenon of moral hazard and false documentation.
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Affiliation(s)
- Roger A Atinga
- Department of Public Administration and Health Services Management, University of Ghana Business School, Legon, Accra, Ghana.
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Nnaji GA, Oguoma C, Nnaji LI, Nwobodo E. The challenges of budgeting in a newly introduced district health system: a case study. Glob Public Health 2010; 5:87-101. [PMID: 19946811 DOI: 10.1080/17441690903371762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Nigeria operates a three-tier political system consisting of a national government: 36 states, Federal Capital Territory and 768 local governments. There are three levels of health care: primary, secondary and tertiary levels corresponding to and funded by local, state and national governments, respectively. A budget prepared at the district level was not possible until 2006 when the 2007 annual budget was prepared. AIM The goal of this study was to identify the key challenges of budgeting in a newly introduced District Health System and to share our experience with other scholars. METHODOLOGY This study is a descriptive case study using interviews and focus group discussions of district and local health officers and the District Health Management Team as well as field notes made from participant observers and reviews of relevant documents. FINDINGS AND DISCUSSION The study showed that a bottom-up approach was used at the district level, while the concept of business planning was introduced to underscore the seriousness of health planning and efficient resource allocation. The two systems of expenditure classifications, i.e., functional and economic classification, were used in a complementary manner. The capacity for planning and budgeting was found to be lacking among the district health officers. The crosscutting contextual issues constraining budgeting included the inadequate Health Management Information System (HMIS), a non-functional Financial Management System (FMS) and an unreliable Human Resources Management System (HRMS). RECOMMENDATIONS There is a need for further study to be carried out to determine the factors that constrain the collection, analysis and dissemination of HMIS. In addition, there is a need to study the constraints to proper implementation of the FMS, HRMS and the linkage between the quality of the essential data-set with the efficiency of resource allocation in budgeting.
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Affiliation(s)
- G A Nnaji
- Department of Primary Health Care, Faculty of Medicine, Nnamdi Azikiwe University, P.M.B 5001, Nnewi, Nigeria.
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Mbindyo P, Gilson L, Blaauw D, English M. Contextual influences on health worker motivation in district hospitals in Kenya. Implement Sci 2009; 4:43. [PMID: 19627590 PMCID: PMC2727485 DOI: 10.1186/1748-5908-4-43] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 07/23/2009] [Indexed: 11/25/2022] Open
Abstract
Background Organizational factors are considered to be an important influence on health workers' uptake of interventions that improve their practices. These are additionally influenced by factors operating at individual and broader health system levels. We sought to explore contextual influences on worker motivation, a factor that may modify the effect of an intervention aimed at changing clinical practices in Kenyan hospitals. Methods Franco LM, et al's (Health sector reform and public sector health worker motivation: a conceptual framework. Soc Sci Med. 2002, 54: 1255–66) model of motivational influences was used to frame the study Qualitative methods including individual in-depth interviews, small-group interviews and focus group discussions were used to gather data from 185 health workers during one-week visits to each of eight district hospitals. Data were collected prior to a planned intervention aiming to implement new practice guidelines and improve quality of care. Additionally, on-site observations of routine health worker behaviour in the study sites were used to inform analyses. Results Study settings are likely to have important influences on worker motivation. Effective management at hospital level may create an enabling working environment modifying the impact of resource shortfalls. Supportive leadership may foster good working relationships between cadres, improve motivation through provision of local incentives and appropriately handle workers' expectations in terms of promotions, performance appraisal processes, and good communication. Such organisational attributes may counteract de-motivating factors at a national level, such as poor schemes of service, and enhance personally motivating factors such as the desire to maintain professional standards. Conclusion Motivation is likely to influence powerfully any attempts to change or improve health worker and hospital practices. Some factors influencing motivation may themselves be influenced by the processes chosen to implement change.
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Affiliation(s)
- Patrick Mbindyo
- Kenya Medical Research Institute Centre for Geographic Medical Research Coast-Wellcome Trust Collaborative Programme, P.O. Box 43640-00100 GPO, Nairobi, Kenya.
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Sakyi EK. A retrospective content analysis of studies on factors constraining the implementation of health sector reform in Ghana. Int J Health Plann Manage 2008; 23:259-85. [PMID: 18536006 DOI: 10.1002/hpm.947] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Ghana has undertaken many public service management reforms in the past two decades. But the implementation of the reforms has been constrained by many factors. This paper undertakes a retrospective study of research works on the challenges to the implementation of reforms in the public health sector. It points out that most of the studies identified: (1) centralised, weak and fragmented management system; (2) poor implementation strategy; (3) lack of motivation; (4) weak institutional framework; (5) lack of financial and human resources and (6) staff attitude and behaviour as the major causes of ineffective reform implementation. The analysis further revealed that quite a number of crucial factors obstructing reform implementation which are particularly internal to the health system have either not been thoroughly studied or overlooked. The analysis identified lack of leadership; weak communication and consultation; lack of stakeholder participation, corruption and unethical professional behaviour as some of the missing variables in the literature. The study, therefore, indicated that there are gaps in the literature that needed to be filled through rigorous reform evaluation based on empirical research particularly at district, sub-district and community levels. It further suggested that future research should be concerned with the effects of both systems and structures and behavioural factors on reform implementation.
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Affiliation(s)
- E Kojo Sakyi
- Department of Public Administration, University of Ghana Business School, Legon, Accra, Ghana.
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Boateng J, Flanagan C. Women's access to health care in Ghana: effects of education, residence, lineage and self-determination. BIODEMOGRAPHY AND SOCIAL BIOLOGY 2008; 54:56-73. [PMID: 19350761 DOI: 10.1080/19485565.2008.9989132] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Women's physical and psychological access to health care was analyzed using the 2003 Ghana Demographic and Health Survey (GDHS), a nationally representative study for monitoring population and health in Ghana. Female respondents from the 2133 cases in the couple's data set were used in this study. Women's level of education was positively related to physical but not to psychological access to health care. Residing in an urban area was positively related to both types of access. Matriliny consistently showed positive effects on physical access. In addition to these demographic factors, both physical and psychological access were positively related to women's self-determination, i.e., women's right and ability to make real choices about their lives including their health, fertility, sexuality, childcare and all areas where women are denied autonomy and dignity in their identities as women. Self-determination factors both mediated the effects of background factors on access and added explanatory power to the models.
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Affiliation(s)
- John Boateng
- Department of Agricultural and Extension Education, The Pennsylvania State University, University Park Campus, State College, PA 16802-2601, USA
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Suh S, Moreira P, Ly M. Improving quality of reproductive health care in Senegal through formative supervision: results from four districts. HUMAN RESOURCES FOR HEALTH 2007; 5:26. [PMID: 18047678 PMCID: PMC2217524 DOI: 10.1186/1478-4491-5-26] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 11/29/2007] [Indexed: 05/25/2023]
Abstract
BACKGROUND In Senegal, traditional supervision often focuses more on collection of service statistics than on evaluation of service quality. This approach yields limited information on quality of care and does little to improve providers' competence. In response to this challenge, Management Sciences for Health (MSH) has implemented a program of formative supervision. This multifaceted, problem-solving approach collects data on quality of care, improves technical competence, and engages the community in improving reproductive health care. METHODS This study evaluated changes in service quality and community involvement after two rounds of supervision in 45 health facilities in four districts of Senegal. We used checklists to assess quality in four areas of service delivery: infrastructure, staff and services management, record-keeping, and technical competence. We also measured community involvement in improving service quality using the completion rates of action plans. RESULTS The most notable improvement across regions was in infection prevention.Management of staff, services, and logistics also consistently improved across the four districts. Record-keeping skills showed variable but lower improvement by region. The completion rates of action plans suggest that communities are engaged in improving service quality in all four districts. CONCLUSION Formative supervision can improve the quality of reproductive health services, especially in areas where there is on-site skill building and refresher training. This approach can also mobilize communities to participate in improving service quality.
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Affiliation(s)
- Siri Suh
- University of Michigan Population Fellow, Management Sciences for Health Cambridge, MA 02139, USA
| | | | - Moussa Ly
- Management Sciences for Health, Cambridge, MA 02139, USA
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Israr SM, Islam A. Good governance and sustainability: a case study from Pakistan. Int J Health Plann Manage 2007; 21:313-25. [PMID: 17175733 DOI: 10.1002/hpm.852] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE On the basis of a case study in Pakistan, the paper argues that good governance, characterized by transparency, accountability and meaningful community participation, plays a critical role in the sustainability of donor-funded health systems projects in the public health sector. METHODS The Family Health Project (FHP) (1992-1999), funded by the World Bank, has been used as a case study. Critical analysis of secondary data mainly obtained from the Department of Health (DoH) in the province of Sindh in Pakistan is the major tool used for the study. Data from other sources including the World Bank have also been used. RESULTS The analysis reveals that the existing health care system could not fully absorb and sustain major "sociopolitical" thrusts of the project, meaningful community participation and "democratic" decision-making processes being the most important ones. The hierarchical structure and management process made it difficult to produce a sense of ownership of the project among all managers and the rank and file staff. The Provincial Health Development Center (PHDC) and District Health Development Centers (DHDCs) established by the FHP did not receive adequate financial and political support from DoH and the Ministry of Health to have much control of the project at the local level. Consequently, these Centers largely failed to institutionalize a continuing training program for district level health officials/professionals. Due to lack of political support, the District Health Management Teams (DHMTs) could not be institutionalized. Community participation in the DHMTs was symbolic rather than forceful. Improved coordination among all stakeholders, more stable and competent leadership, more meaningful community participation, greater devolution of project management to the district level, and better management of resources would have resulted in more effective and efficient implementation of the project. Based on these findings, the paper introduces a Sustainable Management Approach (SMA) as a tool that can be used to ensure the sustainability of health systems projects, particularly those funded by international organizations in developing countries. CONCLUSIONS Good governance and a conducive organizational culture are important prerequisites for incorporating any new project within an existing system. This includes prior consensus building among all stakeholders, a meaningful and inclusive participatory planning, implementation and evaluation process involving communities, political commitment, and the identification and use of appropriate leadership for project management.
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Affiliation(s)
- Syed Muhammad Israr
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
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Asante AD, Zwi AB, Ho MT. Getting by on credit: how district health managers in Ghana cope with the untimely release of funds. BMC Health Serv Res 2006; 6:105. [PMID: 16916445 PMCID: PMC1563463 DOI: 10.1186/1472-6963-6-105] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Accepted: 08/17/2006] [Indexed: 11/25/2022] Open
Abstract
Background District health systems in Africa depend largely on public funding. In many countries, not only are these funds insufficient, but they are also released in an untimely fashion, thereby creating serious cash flow problems for district health managers. This paper examines how the untimely release of public sector health funds in Ghana affects district health activities and the way district managers cope with the situation. Methods A qualitative approach using semi-structured interviews was adopted. Two regions (Northern and Ashanti) covering the northern and southern sectors of Ghana were strategically selected. Sixteen managers (eight directors of health services and eight district health accountants) were interviewed between 2003/2004. Data generated were analysed for themes and patterns. Results The results showed that untimely release of funds disrupts the implementation of health activities and demoralises district health staff. However, based on their prior knowledge of when funds are likely to be released, district health managers adopt a range of informal mechanisms to cope with the situation. These include obtaining supplies on credit, borrowing cash internally, pre-purchasing materials, and conserving part of the fourth quarter donor-pooled funds for the first quarter of the next year. While these informal mechanisms have kept the district health system in Ghana running in the face of persistent delays in funding, some of them are open to abuse and could be a potential source of corruption in the health system. Conclusion Official recognition of some of these informal managerial strategies will contribute to eliminating potential risks of corruption in the Ghanaian health system and also serve as an acknowledgement of the efforts being made by local managers to keep the district health system functioning in the face of budgetary constraints and funding delays. It may boost the confidence of the managers and even enhance service delivery.
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Affiliation(s)
- Augustine D Asante
- National Centre in HIV Social Research, The University of New South Wales, Sydney, Australia
| | - Anthony B Zwi
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia
| | - Maria T Ho
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia
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Noor AM, Gikandi PW, Hay SI, Muga RO, Snow RW. Creating spatially defined databases for equitable health service planning in low-income countries: the example of Kenya. Acta Trop 2004; 91:239-51. [PMID: 15246930 PMCID: PMC2673552 DOI: 10.1016/j.actatropica.2004.05.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Equity is an important criterion in evaluating health system performance. Developing a framework for equitable and effective resource allocation for health depends upon knowledge of service providers and their location in relation to the population they should serve. The last available map of health service providers in Kenya was developed in 1959. We have built a health service provider database from a variety of traditional government and opportunistic non-government sources and positioned spatially these facilities using global positioning systems, hand-drawn maps, topographical maps and other sources. Of 6674 identified service providers, 3355 (50%) were private sector, employer-provided or specialist facilities and only 39% were registered in the Kenyan Ministry of Health database during 2001. Of 3319 public service facilities supported by the Ministry of Health, missions, not-for-profit organizations and local authorities, 84% were registered on a Ministry of Health database and we were able to acquire co-ordinates for 92% of these. The ratio of public health services to population changed from 1:26,000 in 1959 to 1:9300 in 1999-2002. There were 82% of the population within 5 km of a public health facility and resident in 20% of the country. Our efforts to recreate a comprehensive, spatially defined list of health service providers has identified a number of weaknesses in existing national health management information systems, which with an increased commitment and minimal costs can be redressed. This will enable geographic information systems to exploit more fully facility-based morbidity data, population distribution and health access models to target resources and monitor the ability of health sector reforms to achieve equity in service provision.
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Affiliation(s)
- A M Noor
- KEMRI/Wellcome Trust Collaborative Programme, P.O. Box 43640, 00100 Nairobi GPO, Kenya.
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