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Salem MR, Hegazy N, Eldeeb S, Shaguy JA, Nassery RM, Khawari A, Tanoli J, Abouzeid A. The current situation of health equity in underserved areas of Afghanistan. Front Public Health 2024; 12:1370500. [PMID: 39381764 PMCID: PMC11458526 DOI: 10.3389/fpubh.2024.1370500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 08/15/2024] [Indexed: 10/10/2024] Open
Abstract
Background In Afghanistan, providing universal health coverage (UHC) in accordance with the principles of the UHC declaration is challenging on two fronts: the geographic topography of the country and the prevailing gender dynamics within the local culture. Methods We conducted a desk review of underserved areas in the context of health services by gathering and analyzing existing literature, reports, and data using a combination of keywords and phrases such as: "underserved areas," "healthcare disparities," "access to healthcare," and "health services." The primary data were derived from an analysis of underserved populations conducted by the World Health Organization (WHO) Afghanistan's Emergency Program, supplemented by information from in-country partners. In addition to other reports, this review focused on analyzing the geographical availability of primary healthcare (PHC) services by employing the guidelines set forth in the SPHERE framework. It also took into account the social dynamics within the Afghan population that may create barriers to equity in terms of demand and access to PHC services. Results Although there are a significant number of primary healthcare facilities in operation (4,242), they are unevenly distributed across different regions of Afghanistan, resulting in almost 25% of the population being underserved. The underserved population is nearly equally distributed between genders, with the majority residing in rural communities. Women of childbearing age represent 28% of the underserved population. Children under the age of five represent 16-18% of the underserved population in all regions, except in the western region, where they represent between 12 and 13%. Individuals over 60 years of age represent 1-3% of the underserved population across all regions. More than 50% of the population in the Central Highlands of Afghanistan is underserved, followed by the western and southern regions. Ghor province in the western region has the highest proportion of underserved populations, followed by Zabul province in the southern region. Conclusion Afghanistan is currently experiencing a protracted humanitarian crisis, with millions of people living in poverty and lacking access to healthcare. This situation exposes them to serious risks such as disease epidemics, starvation, and maternal and child mortality. It is crucial to implement alternative strategies to reach the most affected populations and to increase funding for the delivery of healthcare services in Afghanistan.
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Affiliation(s)
- Marwa Rashad Salem
- Public Health and Community Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nelly Hegazy
- Public Health and Community Medicine, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Sherif Eldeeb
- Community Medicine Research Department, National Research Centre, Giza, Egypt
| | - Jerome A. Shaguy
- Emergency Department of the WHO Organization, The World Health Organization, Kabul, Afghanistan
| | - Ramesh Mohammad Nassery
- Emergency Department of the WHO Organization, The World Health Organization, Kabul, Afghanistan
| | - Abdullah Khawari
- Emergency Department of the WHO Organization, The World Health Organization, Kabul, Afghanistan
| | - Jamshed Tanoli
- Emergency Department of the WHO Organization, The World Health Organization, Kabul, Afghanistan
| | - Alaa Abouzeid
- Public Health and Community Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
- Emergency Department of the WHO Organization, The World Health Organization, Kabul, Afghanistan
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Homer CS, Turkmani S, Wilson AN, Vogel JP, Shah MG, Fogstad H, Langlois EV. Enhancing quality midwifery care in humanitarian and fragile settings: a systematic review of interventions, support systems and enabling environments. BMJ Glob Health 2022; 7:e006872. [PMID: 35058304 PMCID: PMC8772423 DOI: 10.1136/bmjgh-2021-006872] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/19/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Women and children bear a substantial burden of the impact of conflict and instability. The number of people living in humanitarian and fragile settings (HFS) has increased significantly over the last decade. The provision of essential maternal and newborn healthcare by midwives is crucial everywhere, especially in HFS. There is limited knowledge about the interventions, support systems and enabling environments that enhance midwifery care in these settings. The aim of this paper is to identify the factors affecting an enabling environment for midwives in HFS and to explore the availability and effectiveness of support systems for midwives. METHODS A structured systematic review was undertaken to identify peer-reviewed primary research articles published between 1995 and 2020. RESULTS In total, 24 papers were included from Afghanistan, Bangladesh, Nigeria, Democratic Republic of Congo, South Sudan and Sudan, Ethiopia, Pakistan, Uganda and Liberia. There were two broad themes: (1) the facilitators of, and barriers to, an enabling environment, and (2) the importance of effective support systems for midwives. Facilitators were: community involvement and engagement and an adequate salary, incentives or benefits. Barriers included: security and safety concerns, culture and gender norms and a lack of infrastructure and supplies. Support systems were: education, professional development, supportive supervision, mentorship and workforce planning. CONCLUSION More efforts are needed to develop and implement quality midwifery services in HFS. There is an urgent need for more action and financing to ensure better outcomes and experiences for all women, girls and families living in these settings. PROSPERO REGISTRATION NUMBER CRD42021226323.
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Affiliation(s)
- Caroline Se Homer
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Sabera Turkmani
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Alyce N Wilson
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Joshua P Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Mehr Gul Shah
- Partnership for Maternal, Newborn & Child Health (PMNCH), World Health Organization (WHO), Geneva, Switzerland
| | - Helga Fogstad
- Partnership for Maternal, Newborn & Child Health (PMNCH), World Health Organization (WHO), Geneva, Switzerland
| | - Etienne V Langlois
- Partnership for Maternal, Newborn & Child Health (PMNCH), World Health Organization (WHO), Geneva, Switzerland
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Khalil M, Alameddine M. Recruitment and retention strategies, policies, and their barriers: A narrative review in the Eastern Mediterranean Region. Health Sci Rep 2020; 3:e192. [PMID: 33033753 PMCID: PMC7534515 DOI: 10.1002/hsr2.192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/13/2020] [Accepted: 09/02/2020] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Understanding factors affecting recruitment and retention of health workers in rural and remote communities is necessary for proper policy development and the equitable achievement of Universal Health Coverage. AIM Review and synthesize the literature on interventions used to retain health workforce in rural and remote areas by low- and middle-income countries (LMICs) in the Eastern Mediterranean Region (EMR). METHOD We carried out a narrative review of literature (peer-reviewed and gray) on the distribution and retention of health workers in rural and remote areas in the LMICs of the EMR. Out of the 130 retrieved articles, 21 met the inclusion criteria and were studied using WHO's Global Recommendations For Increasing Access To Health Workers In Remote And Rural Areas Through Improved Retention (education, regulation, financial, and personal/professional) as the analytical framework for extractions. RESULTS There is a dearth of literature on retention in rural areas in the EMR and a complete absence of evaluation studies for implemented intervention. Various LMICs in the EMR have implemented interventions across one or more of the WHO four categories, especially educational and regulatory interventions. Limitations in the number and quality of published studies, fragmented data, over-representation of certain cadres in research and policies, and poor governance were chief barriers to the design, implementation, and evaluation of health workforce retention policies in rural and remote areas. The main challenges for EMR countries are in policy implementation and evaluation. Strengthening data governance and health information systems would improve evidence-based policies and enhance retention in rural and remote areas. CONCLUSIONS There is a need for a focused research agenda supported by regional collaboration to guide policymakers on factors, challenges, and best practices that need to be considered for improving the distribution and retention of the health workforce by cadre, gender, and region.
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Affiliation(s)
- Merette Khalil
- Department of Universal Health Coverage and Health Systems DevelopmentEastern Mediterranean Regional Office, World Health OrganizationCairoEgypt
| | - Mohamad Alameddine
- College of MedicineMohammed Bin Rashid University of Medicine and Health SciencesDubaiUnited Arab Emirates
- Department of Health Management and Policy, Faculty of Health SciencesAmerican University of BeirutBeirutLebanon
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Dal Santo LC, Rastagar SH, Hemat S, Alami SO, Pradhan S, Tharaldson J, Dulli LS, Todd CS. Feasibility and acceptability of a video library tool to support community health worker counseling in rural Afghan districts: a cross-sectional assessment. Confl Health 2020; 14:56. [PMID: 32774450 PMCID: PMC7405377 DOI: 10.1186/s13031-020-00302-z] [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: 08/28/2019] [Accepted: 07/23/2020] [Indexed: 12/04/2022] Open
Abstract
Background Rural Afghan populations have low skilled birth attendance rates and high maternal and infant mortality. Insecurity and armed conflict, geographic barriers, and cultural norms often hinder women’s access to facility-based reproductive, maternal, newborn, and child health (RMNCH) services. Community health workers (CHWs) are critical agents for behavioral change in this and similarly fragile settings, where RMNCH information exposure is limited by low literacy and mass media access. We assessed the feasibility and acceptability of a computer tablet-based health video library (HVL) to enhance CHW counseling on RMNCH topics in three rural Afghan districts. Methods The HVL was introduced by trained CHWs in 10 pilot communities within one rural district in each of Balkh, Herat, and Kandahar provinces. We used a mixed-methods study design to assess exposure to and perception of the HVL 6 months post-introduction. We surveyed married women (n = 473) and men (n = 468) with at least one child under 5 years and conducted in-depth interviews with CHWs and community leaders (shuras and Family Health Action groups) within pilot communities (n = 80). Program improvement needs were summarized using quantitative and qualitative data. Results Higher proportions of women in Balkh (60.3%) and Herat (67.3%) reported viewing at least one HVL video compared to women in Kandahar (15%), while male HVL exposure was low (8–17%) across all districts. Most HVL-exposed clients (85–93% of women and 74–92% of men) reported post-video counseling by CHWs. Nearly all (94–96% of women and 85–92% of men) were very interested in watching videos on other health topics in the future. Participants recommended increasing the number of videos and range of topics, using tablets with larger screens, and translating videos into additional local languages to improve the HVL program. Conclusion The HVL was a highly acceptable tool for relaying health information, but coverage of female audiences in Kandahar and male audiences broadly was low. The HVL should better engage men and other key influencers to engineer local solutions that directly facilitate male HVL exposure, indirectly improve women’s HVL access, and support collaborative spousal health decision-making. A larger efficacy trial is warranted to measure the HVL’s effect on knowledge and health-related behavioral outcomes.
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Affiliation(s)
- Leila C Dal Santo
- Global Health, Population, & Nutrition Division, FHI 360, Durham, North Carolina USA.,Boston College School of Social Work, 140 Commonwealth Avenue, Chestnut Hill, Massachusetts 02467 USA
| | | | - Shafiqullah Hemat
- Health Promotions Department, Ministry of Public Health, Islamic Republic of Afghanistan, Kabul, Afghanistan
| | | | - Subarna Pradhan
- Global Health, Population, & Nutrition Division, FHI 360, Durham, North Carolina USA
| | - Jenae Tharaldson
- Global Health, Population, & Nutrition Division, FHI 360, Durham, North Carolina USA
| | - Lisa S Dulli
- Global Health, Population, & Nutrition Division, FHI 360, Durham, North Carolina USA
| | - Catherine S Todd
- Global Health, Population, & Nutrition Division, FHI 360, Durham, North Carolina USA
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Bou-Karroum L, El-Harakeh A, Kassamany I, Ismail H, El Arnaout N, Charide R, Madi F, Jamali S, Martineau T, El-Jardali F, Akl EA. Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence. PLoS One 2020; 15:e0233757. [PMID: 32470071 PMCID: PMC7259645 DOI: 10.1371/journal.pone.0233757] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/13/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict. OBJECTIVE The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale. METHODS We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme. RESULTS Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%). CONCLUSIONS This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.
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Affiliation(s)
- Lama Bou-Karroum
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Amena El-Harakeh
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Clinical Research Institute (CRI), American University of Beirut Medical Center, Beirut, Lebanon
| | - Inas Kassamany
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hussein Ismail
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Nour El Arnaout
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Rana Charide
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Farah Madi
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sarah Jamali
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Fadi El-Jardali
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Elie A. Akl
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Clinical Research Institute (CRI), American University of Beirut Medical Center, Beirut, Lebanon
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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Naziri M, Higgins-Steele A, Anwari Z, Yousufi K, Fossand K, Amin SS, Hipgrave DB, Varkey S. Scaling up newborn care in Afghanistan: opportunities and challenges for the health sector. Health Policy Plan 2018; 33:271-282. [PMID: 29190374 DOI: 10.1093/heapol/czx136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 11/13/2022] Open
Abstract
Newborn health in Afghanistan is receiving increased attention, but reduction in newborn deaths there has not kept pace with declines in maternal and child mortality. Using the continuum of care and health systems building block frameworks, this article identifies, organizes and provides a synthesis of the available evidence on and gaps in coverage of care and health systems, programmes, policies and practices related to newborn health in Afghanistan. Newborn mortality in Afghanistan is related to the nation's weak health system, itself associated with decades of conflict, low and uneven coverage of essential interventions, demand-side and cultural specificities, and compromised quality. A majority of deliveries still take place at home. Birth asphyxia, low birth weight, perinatal infections and poor post-natal care are responsible for many preventable newborn deaths. Though the situation has improved, there remain many opportunities to accelerate progress. Analyses conducted using the Lives Saved Tools suggest that an additional 10 405 newborn lives could be saved in Afghanistan in 5 years (2015-20), through reasonable increases in coverage of these high-impact interventions. A long-term vision and strong leadership are essential for the Ministry of Public Health to play an effective stewardship role in formulating related policy and strategy, setting standards and monitoring maternal and newborn services. Promotion of equitable access to health services, including health workforce planning, development and management, and the coordination of much-needed donor support are also imperative.
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Affiliation(s)
- Malalai Naziri
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
| | | | - Zelaikha Anwari
- Ministry of Public Health, Reproductive, Maternal, Newborn, Child, and Adolescent Directorate, Kabul, Afghanistan and
| | - Khaksar Yousufi
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
| | | | | | - David B Hipgrave
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
| | - Sherin Varkey
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
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Guerra Arias M, Nove A, Michel-Schuldt M, de Bernis L. Current and future availability of and need for human resources for sexual, reproductive, maternal and newborn health in 41 countries in Sub-Saharan Africa. Int J Equity Health 2017; 16:69. [PMID: 28468654 PMCID: PMC5415807 DOI: 10.1186/s12939-017-0569-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 04/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The WHO African region, covering the majority of Sub-Saharan Africa, faces the highest rates of maternal and neonatal mortality in the world. This study uses data from the State of the World's Midwifery 2014 survey to cast a spotlight on the WHO African region, highlight the specific characteristics of its sexual, reproductive, maternal and newborn health (SRMNH) workforce and describe and compare countries' different trajectories in terms of meeting the population need for services. METHODS Using data from 41 African countries, this study used a mathematical model to estimate potential met need for SRMNH services, defined as "the percentage of a universal SRMNH package that could potentially be obtained by women and newborns given the composition, competencies and available working time of the SRMNH workforce." The model defined the 46 key interventions included in this universal SRMNH package and allocated them to the available health worker time and skill set in each country to estimate the potential met need. RESULTS Based on the current and projected potential met need in the future, the countries were grouped into three categories: (1) 'making or maintaining progress' (expected to meet more, or the same level, of the need in the future than currently): 14 countries including Ghana, Senegal and South Africa, (2) 'at risk' (currently performing relatively well but expected to deteriorate due to the health workforce not keeping pace with population growth): 6 countries including Gabon, Rwanda and Zambia, and (3) 'low performing' (not performing well and not expected to improve): 21 countries including Burkina Faso, Eritrea and Sierra Leone. CONCLUSION The three groups face different challenges, and policy solutions to increasing met need should be tailored to the specific context of the country. National health workforce accounts should be strengthened so that workforce planning can be evidence-informed.
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Affiliation(s)
| | - Andrea Nove
- Instituto de Cooperación Social Integrare, Barcelona, Spain
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Frost A, Wilkinson M, Boyle P, Patel P, Sullivan R. An assessment of the barriers to accessing the Basic Package of Health Services (BPHS) in Afghanistan: was the BPHS a success? Global Health 2016; 12:71. [PMID: 27846910 PMCID: PMC5111262 DOI: 10.1186/s12992-016-0212-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/23/2016] [Indexed: 11/10/2022] Open
Abstract
Afghanistan is one of the most fragile and conflict-affected countries in the world. It has experienced almost uninterrupted conflict for the last thirty years, with the present conflict now lasting over a decade. With no history of a functioning healthcare system, the creation of the Basic Package of Health Services (BPHS) in 2003 was a response to Afghanistan's dire health needs following decades of war. Its objective was to provide a bare minimum of essential health services, which could be scaled up rapidly through contracting mechanisms with Non-Governmental Organisations (NGOs). The central thesis of this article is that, despite the good intentions of the BPHS, not enough has been done to overcome the barriers to accessing its services. This analysis, enabled through a review of the existing literature, identifies and categorises these barriers into the three access dimensions of: acceptability, affordability and availability. As each of these is explored individually, analysis will show the extent to which these barriers to access are a critical issue, consider the underlying reasons for their existence and evaluate the efforts to overcome these barriers. Understanding these barriers and the policies that have been implemented to address them is critical to the future of health system strengthening in Afghanistan.
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Affiliation(s)
- Alexandra Frost
- Centre for Global Health, King’s Health Partners and King’s College London, London, UK
- Conflict and Health Research Group, King’s College London, London, UK
| | - Matthew Wilkinson
- Conflict and Health Research Group, King’s College London, London, UK
- Centre of Islamic Studies, SOAS, University of London, London, UK
| | - Peter Boyle
- International Prevention Research Institute, France and University of Strathclyde Institute of Global Public Health @iPRI, Lyon, France
| | - Preeti Patel
- Conflict and Health Research Group, King’s College London, London, UK
- Department of War Studies, King’s College London, London, UK
| | - Richard Sullivan
- Centre for Global Health, King’s Health Partners and King’s College London, London, UK
- Conflict and Health Research Group, King’s College London, London, UK
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Smith JM, de Graft-Johnson J, Zyaee P, Ricca J, Fullerton J. Scaling up high-impact interventions: how is it done? Int J Gynaecol Obstet 2016; 130 Suppl 2:S4-10. [PMID: 26115856 DOI: 10.1016/j.ijgo.2015.03.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Building upon the World Health Organization's ExpandNet framework, 12 key principles of scale-up have emerged from the implementation of maternal and newborn health interventions. These principles are illustrated by three case studies of scale up of high-impact interventions: the Helping Babies Breathe initiative; pre-service midwifery education in Afghanistan; and advanced distribution of misoprostol for self-administration at home births to prevent postpartum hemorrhage. Program planners who seek to scale a maternal and/or newborn health intervention must ensure that: the necessary evidence and mechanisms for local ownership for the intervention are well-established; the intervention is as simple and cost-effective as possible; and the implementers and beneficiaries of the intervention are working in tandem to build institutional capacity at all levels and in consideration of all perspectives.
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Affiliation(s)
| | | | - Pashtoon Zyaee
- International Confederation of Midwives, The Hague, Netherlands
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10
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Durham J, Pavignani E, Beesley M, Hill PS. Human resources for health in six healthcare arenas under stress: a qualitative study. HUMAN RESOURCES FOR HEALTH 2015; 13:14. [PMID: 25889864 PMCID: PMC4381404 DOI: 10.1186/s12960-015-0005-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 03/06/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Research on "human resources for health" (HRH) typically focuses on the public health subsector, despite the World Health Organization's inclusive definition to the contrary. This qualitative research examines the profile of HRH in six conflict-affected contexts where the public health subsector does not dominate healthcare service provision and HRH is a less coherent and cohesive entity: Afghanistan, the Central African Republic (CAR), the Democratic Republic of Congo (DR Congo), Haiti, the Occupied Palestinian Territories and Somalia. METHODS The study uses a multiple-country qualitative research design including documentary analysis and key informant interviews undertaken between 2010 and 2012. The documentary analysis included peer-reviewed articles, books, unpublished research and evaluations and donor and non-government organisation reviews. A common thematic guide, informed by this analysis, was used to undertake key informant interviews. Informants thought able to provide some insight into the research questions were identified from ministry of health organograms, and from listings of donors and non-government organisations. Local informants outside the familiar structures were also contacted. In CAR, 74 were interviewed; in Somalia 25; . in Haiti, 45; in Afghanistan, 41; in DR Congo, 32; and in the Occupied Palestinian Territories, 30. In addition, peer review was sought on the initial country reports. RESULTS The study discovered, in each healthcare arena investigated, a crowded HRH space with a wide range of public, private, formal and informal providers of varying levels of competence and a diverse richness of initiatives, shaped by the easy commodification of health and an unregulated market. The weak regulatory framework and capacity to regulate, combined with limited information regarding those not on the state payroll, allowed non-state providers to flourish, if not materially then at least numerically. CONCLUSION When examining HRH, a reliance on information provided by the state health sector can only provide a partial and inadequate representation of reality. For policy-makers and planners in disrupted contexts to begin to appreciate fully current and potential HRH, there is a need to study the workforce using conceptual tools that reflect the situation on the ground, rather than idealised patterns generated by incomplete inventories and unrealistic standards.
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Affiliation(s)
- Jo Durham
- School of Public Health, The University of Queensland, Brisbane, Qld, 4006, Australia.
| | - Enrico Pavignani
- School of Public Health, The University of Queensland, Brisbane, Qld, 4006, Australia.
| | - Mark Beesley
- School of Public Health, The University of Queensland, Brisbane, Qld, 4006, Australia.
| | - Peter S Hill
- School of Public Health, The University of Queensland, Brisbane, Qld, 4006, Australia.
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Nkwo PO, Lawani LO, Ubesie AC, Onodugo VA, Obu HA, Chinawa JM. Poor availability of skilled birth attendants in Nigeria: a case study of enugu state primary health care system. Ann Med Health Sci Res 2015; 5:20-5. [PMID: 25745571 PMCID: PMC4350057 DOI: 10.4103/2141-9248.149778] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The Government of Enugu State plans to offer free perinatal services at the primary health care (PHC) centers in order to improve perinatal outcomes in the state, but it was not clear whether there are skilled birth attendants (SBAs) at the PHC level to implement the program. Aims: To determine whether there are sufficient numbers of SBAs in the public PHC system in Enugu State of Nigeria. Subjects and Methods: This cross-sectional survey involved enumeration of health workers who worked at each public PHC facility in Enugu State and included verification of the qualifications and trainings of each health worker. Data analysis was performed with the help of Stata statistical package version 13 and results were presented in tables and as simple proportions. Results: There were 55 nurses and no midwife or doctor in the 152 PHC clinics studied. This number represents 0.36 nurses per health facility or about 9% (i.e., 55/608) of a minimum of 608 SBAs required for 24-h perinatal services at the 152 PHC clinics. There were 1233 junior community health extension worker/community health extension workers (JCHEW/CHEWs), averaging 8.1 JCHEW/CHEWs per PHC clinic. Conclusions: Enugu State has an acute shortage of SBAs. We recommend employment of qualified SBAs and in-service training of the JCHEW/CHEW and nurses to upgrade their midwifery skills. Incorporation of competency-based midwifery training into the pre-service training curricula of nurses and JCHEW/CHEW would provide a more sustainable supply of SBAs in Enugu state.
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Affiliation(s)
- Peter O Nkwo
- Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital Ituku-Ozalla, Nigeria
| | - Lucky O Lawani
- Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, Ebonyi, Nigeria
| | - Agozie C Ubesie
- Department of Pediatrics, University of Nigeria Teaching Hospital Ituku-Ozalla, Nigeria
| | - Vincent A Onodugo
- Department of Management, University of Nigeria, Enugu Campus, Enugu, Nigeria
| | - Herbert A Obu
- Department of Pediatrics, University of Nigeria Teaching Hospital Ituku-Ozalla, Nigeria
| | - Josephat M Chinawa
- Department of Pediatrics, University of Nigeria Teaching Hospital Ituku-Ozalla, Nigeria
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Fogarty L, Kim YM, Juon HS, Tappis H, Noh JW, Zainullah P, Rozario A. Job satisfaction and retention of health-care providers in Afghanistan and Malawi. HUMAN RESOURCES FOR HEALTH 2014; 12:11. [PMID: 24533615 PMCID: PMC3930828 DOI: 10.1186/1478-4491-12-11] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 01/20/2014] [Indexed: 05/03/2023]
Abstract
BACKGROUND This study describes job satisfaction and intention to stay on the job among primary health-care providers in countries with distinctly different human resources crises, Afghanistan and Malawi. METHODS Using a cross-sectional design, we enrolled 87 health-care providers in 32 primary health-care facilities in Afghanistan and 360 providers in 10 regional hospitals in Malawi. The study questionnaire was used to assess job satisfaction, intention to stay on the job and five features of the workplace environment: resources, performance recognition, financial compensation, training opportunities and safety. Descriptive analyses, exploratory factor analyses for scale development, bivariate correlation analyses and bivariate and multiple linear regression analyses were conducted. RESULTS The multivariate model for Afghanistan, with demographic, background and work environment variables, explained 23.9% of variance in job satisfaction (F(9,73) = 5.08; P < 0.01). However, none of the work environment variables were significantly related to job satisfaction. The multivariate model for intention to stay for Afghanistan explained 23.6% of variance (F(8,74) = 4.10; P < 0.01). Those with high scores for recognition were more likely to have higher intention to stay (β = 0.328, P < 0.05). However, being paid an appropriate salary was negatively related to intent to stay (β = -0.326, P < 0.01). For Malawi, the overall model explained only 9.8% of variance in job satisfaction (F(8,332) = 4.19; P < 0.01) and 9.1% of variance in intention to stay (F(10,330) = 3.57; P < 0.01). CONCLUSIONS The construction of concepts of health-care worker satisfaction and intention to stay on the job are highly dependent on the local context. Although health-care workers in both Afghanistan and Malawi reported satisfaction with their jobs, the predictors of satisfaction, and the extent to which those predictors explained variations in job satisfaction and intention to stay on the job, differed substantially. These findings demonstrate the need for more detailed comparative human resources for health-care research, particularly regarding the relative importance of different determinants of job satisfaction and intention to stay in different contexts and the effectiveness of interventions designed to improve health-care worker performance and retention.
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Affiliation(s)
- Linda Fogarty
- Jhpiego/USA, an affiliate of Johns Hopkins University, 1615 Thames St., Baltimore, MD, USA
| | - Young Mi Kim
- Jhpiego/USA, an affiliate of Johns Hopkins University, 1615 Thames St., Baltimore, MD, USA
| | - Hee-Soon Juon
- Department of Health, Behavior and Society, Bloomberg School of Public Health, The Johns Hopkins University, 624 N. Broadway, Baltimore, MD, USA
| | - Hannah Tappis
- Department of International Health, Bloomberg School of Public Health, The Johns Hopkins University, 615 N. Wolfe St, Baltimore, MD, USA
| | - Jin Won Noh
- Department of Healthcare Management, Eulji University, 212 Yangji-dong, Sujeong-gu, Seongnam, Korea
| | - Partamin Zainullah
- Jhpiego/Afghanistan, an affiliate of Johns Hopkins University, Share-Naw Street 3, House 265, Kabul, Afghanistan
| | - Aleisha Rozario
- Jhpiego/USA, an affiliate of Johns Hopkins University, 1615 Thames St., Baltimore, MD, USA
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13
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Zainullah P, Ansari N, Yari K, Azimi M, Turkmani S, Azfar P, LeFevre A, Mungia J, Gubin R, Kim YM, Bartlett L. Establishing midwifery in low-resource settings: guidance from a mixed-methods evaluation of the Afghanistan midwifery education program. Midwifery 2013; 30:1056-62. [PMID: 24290947 DOI: 10.1016/j.midw.2013.10.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 10/16/2013] [Accepted: 10/31/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The shortage of skilled birth attendants has been a key factor in the high maternal and newborn mortality in Afghanistan. Efforts to strengthen pre-service midwifery education in Afghanistan have increased the number of midwives from 467 in 2002 to 2954 in 2010. OBJECTIVE We analyzed the costs and graduate performance outcomes of the two types of pre-service midwifery education programs in Afghanistan that were either established or strengthened between 2002 and 2010 to guide future program implementation and share lessons learned. DESIGN We performed a mixed-methods evaluation of selected midwifery schools between June 2008 and November 2010. This paper focuses on the evaluation's quantitative methods, which included (a) an assessment of a sample of midwifery school graduates (n=138) to measure their competencies in six clinical skills; (b) prospective documentation of the actual clinical practices of a subsample of these graduates (n=26); and (c) a costing analysis to estimate the resources required to educate students enrolled in these programs. SETTING For the clinical competency assessment and clinical practices components, two Institutes for Health Sciences (IHS) schools and six Community Midwifery Education (CME) schools; for the costing analysis, a different set of nine schools (two IHS, seven CME), all of which were funded by the US Agency for International Development. PARTICIPANTS Midwives who had graduated from either IHS or CME schools. FINDINGS CME graduates (n=101) achieved an overall mean competency score of 63.2% (59.9-66.6%) on the clinical competency assessment compared to 57.3% (49.9-64.7%) for IHS graduates (n=37). Reproductive health activities accounted for 76% of midwives' time over an average of three months. Approximately 1% of childbirths required referral or resulted in maternal death. On the basis of known costs for the programs, the estimated cost of graduating a class with 25 students averaged US$298,939, or US$10,784 per graduate. KEY CONCLUSIONS The pre-service midwifery education experience of Afghanistan can serve as a model to rapidly increase the number of skilled birth attendants. In such settings, it is important to ensure the provision of continued practice opportunities and refresher trainings after graduation to aid skill retention, a co-operative and supportive work environment that will use midwives for the reproductive health skills for which they were trained, and selection mechanisms that can identify the most promising students and post-graduation deployment options to maximise the return on the substantial educational investment.
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Affiliation(s)
- Partamin Zainullah
- Jhpiego, House #107, Street 3, Ansari Watt, Shar-e-Naw, District 4, Kabul, Afghanistan.
| | - Nasratullah Ansari
- Jhpiego, House #107, Street 3, Ansari Watt, Shar-e-Naw, District 4, Kabul, Afghanistan.
| | - Khalid Yari
- UNICEF, Jalalabad Road, Paktiakot, UN Compound, Kabul, Afghanistan.
| | - Mahmood Azimi
- MSH, House @ 24, Ayubkhan Mena, Darulaman Road, Kabul, Afghanistan.
| | - Sabera Turkmani
- Jhpiego, House #107, Street 3, Ansari Watt, Shar-e-Naw, District 4, Kabul, Afghanistan.
| | - Pashtoon Azfar
- International Confederation of Midwives, GK2 E Block 62, New Delhi, India.
| | - Amnesty LeFevre
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
| | - Jaime Mungia
- Jhpiego, 1615 Thames Street, Baltimore, MD 21231, USA.
| | - Rehana Gubin
- Jhpiego, 1615 Thames Street, Baltimore, MD 21231, USA.
| | - Young-Mi Kim
- Jhpiego, 1615 Thames Street, Baltimore, MD 21231, USA.
| | - Linda Bartlett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe Street, Baltimore, MD 21205, USA.
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14
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Midwifery retention and coverage and impact on service utilisation in Afghanistan. Midwifery 2013; 29:1088-94. [DOI: 10.1016/j.midw.2013.07.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 07/04/2013] [Accepted: 07/20/2013] [Indexed: 11/20/2022]
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Michael M, Pavignani E, Hill PS. Too good to be true? An assessment of health system progress in Afghanistan, 2002-2012. Med Confl Surviv 2013; 29:322-45. [PMID: 24494581 DOI: 10.1080/13623699.2013.840819] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The bold decision was taken in Afghanistan in 2002 to provide donor-funded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field.
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Affiliation(s)
- Markus Michael
- lndependent Consultant for Public Health and Humanitarian Aid, Sao Paulo, Brazil.
| | - Enrico Pavignani
- School of Population Health, The University of Queensland, Maputo, Mozambique
| | - Peter S Hill
- School of Population Health, The University of Queensland, Brisbane, Australia
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Factors influencing the retention of midwives in the public sector in Afghanistan: A qualitative assessment of midwives in eight provinces. Midwifery 2013; 29:1137-44. [DOI: 10.1016/j.midw.2013.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 07/01/2013] [Accepted: 07/01/2013] [Indexed: 11/16/2022]
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Turkmani S, Currie S, Mungia J, Assefi N, Javed Rahmanzai A, Azfar P, Bartlett L. 'Midwives are the backbone of our health system': lessons from Afghanistan to guide expansion of midwifery in challenging settings. Midwifery 2013; 29:1166-72. [PMID: 23916402 DOI: 10.1016/j.midw.2013.06.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 05/20/2013] [Accepted: 06/21/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND over the last decade Afghanistan has made large investments in scaling up the number of midwives to address access to skilled care and the high burden of maternal and newborn mortality. OBJECTIVE at the request of the Ministry of Public Health (MOPH) an evaluation was undertaken to improve the pre-service midwifery education programme through identification of its strengths and weaknesses. The qualitative component of the evaluation specifically examined: (1) programme strengths; (2) programme weaknesses; (3) perceptions of the programme's community impact; (4) barriers to provision of care and challenges to impact; (5) perceptions of the recently graduated midwife's field experience, and (6) recommendations for programme improvement. DESIGN the evaluation used a mixed methods approach that included qualitative and quantitative components. This paper focuses on the qualitative components which included in-depth interviews with 138 graduated midwives and 20 key informants as well as 24 focus group discussions with women. SETTING eight provinces in Afghanistan with functioning and accredited midwifery schools between June 2008 and November 2010. PARTICIPANTS midwives graduated from one of the two national midwifery programmes: Institute of Health Sciences and Community Midwifery Education. Key informants comprised of stakeholders and female residents of the midwives catchment areas. FINDINGS midwives described overall satisfaction with the quality of their education. Midwives and stakeholders perceived that women were more likely to use maternal and child health services in communities where midwives had been deployed. Strengths included evidence-based content, standardised materials, clinical training, and supportive learning environment. Self-reported aspects of the quality education in respect to midwives empowerment included feeling competent and confident as demonstrated by respect shown by co-workers. Weaknesses of the programme included perceived low educational requirement to enter the programme and readiness of programmes to commence education. Insecurity and geographical remoteness are perceived as challenges with clients' access to care and the ability of midwives to make home visits. KEY CONCLUSIONS the depth of midwives' contribution in Afghanistan - from increased maternal health care service utilisation to changing community's perceptions of women's education and professional independence - is overwhelmingly positive. Lessons learned can serve as a model to other low resource, post-conflict settings that are striving to increase the workforce of skilled providers.
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Affiliation(s)
- Sabera Turkmani
- Jhpiego/Afghanistan, an affiliate of Johns Hopkins University, Shar-I-Nau, Kabul, Afghanistan
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