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

Imagining maternity care as a complex adaptive system: understanding health system constraints to the promotion of respectful maternity care

Evidence of the health system challenges to promoting respectful maternity care (RMC) is limited in Ethiopia and globally. This study investigated the health system constraints to RMC in three Southern Ethiopian hospitals. We conducted a qualitative study (7 focus group discussions (FGDs) with providers of RMC and 12 in-depth interviews with focal persons and managers) before and after the implementation of an RMC intervention. We positioned childbirth services within the health system and applied complex adaptive system theory to analyse the opportunities and constraints to the promotion of RMC. Both system “hardware” and “software” factors influencing the promotion of RMC were identified, and their interaction was complex. The “hardware” factors included bed availability, infrastructure and supplies, financing, and health workforce. “Software” factors encompassed service providers’ mindset, staff motivation, and awareness of RMC. Interactions between these factors included privacy breaches for women when birth companions were admitted in labour rooms. Delayed reimbursement following the introduction of fee-exemption for maternity services resulted in depleted revenues, supply shortages, and ultimately disrespectful behaviour among providers. Other financial constraints, including the insufficient and delayed release of funds, also led to complex interactions with the motivation of staff and the availability of workforce and supplies, resulting in poor adherence to RMC guidance. Interventions aimed at improving only behavioural components fall short of mitigating the mistreatment of women. System-wide interventions are required to address the complex interactions that constraint RMC.

Protecting the poor? Impact of the national health equity fund on utilization of government health services in Cambodia, 2006-2013

INTRODUCTION

Cambodia's health equity fund (HEF) is the country's most significant social security scheme, covering the poorest one-fifth of the national population. During the last two decades, the HEF system was scaled up from an initial two health districts to national coverage of public health facilities. This is the first national study to examine the impact of the HEF on the utilisation of public health facilities.

METHODS

We first investigated the level of national HEF population coverage and health service use made by HEF eligible members using an administrative HEF operational dataset. Second, through multilevel interrupted time series analysis of routine monthly utilisation statistics during 2006-2013, we evaluated the impact of the HEF on hospital and health centre utilisation.

RESULTS

The proportion of HEF beneficiaries using hospital services in a given year (4.6%) appeared to exceed rates in the general population (3.3%). The introduction of the HEF was associated with: a significant level change in the monthly number of consultations at HCs followed by a gradual slope increase in time trend and a significant level change in the monthly number of deliveries. Overall, this was equivalent to a 15.6% net increase in number of consultations and 5.3% in deliveries in the first year. At RHs: a significant level change in the number of RH inpatient cases, followed by a sustained slope increase; a significant slope increase in the number of outpatient consultations and in the overall number of newborn deliveries. Overall, this was equivalent to a 47.9% net increase in inpatient cases, 24.1% in outpatient cases and 31.4% in deliveries in the first year.

CONCLUSION

The implementation of the HEF scheme was associated with increased utilisation of primary and secondary care services by the poor.

"We are called the et cetera": experiences of the poor with health financing reforms that target them in Kenya

BACKGROUND

Through a number of healthcare reforms, Kenya has demonstrated its intention to extend financial risk protection and service coverage for poor and vulnerable groups. These reforms include the provision of free maternity services, user-fee removal in public primary health facilities and a health insurance subsidy programme (HISP) for the poor. However, the available evidence points to inequity and the likelihood that the poor will still be left behind with regards to financial risk protection and service coverage. This study examined the experiences of the poor with health financing reforms that target them.

METHODS

We conducted a qualitative cross-sectional study in two purposively selected counties in Kenya. We collected data through focus group discussions (n = 8) and in-depth interviews (n = 30) with people in the lowest wealth quintile residing in the health and demographic surveillance systems, and HISP beneficiaries. We analyzed the data using a framework approach focusing on four healthcare access dimensions; geographical accessibility, affordability, availability, and acceptability.

RESULTS

Health financing reforms reduced financial barriers and improved access to health services for the poor in the study counties. However, various access barriers limited the extent to which they benefited from these reforms. Long distances, lack of public transport, poor condition of the roads and high transport costs especially in rural areas limited access to health facilities. Continued charging of user fees despite their abolition, delayed insurance reimbursements to health facilities that HISP beneficiaries were seeking care from, and informal fees exposed the poor to out of pocket payments. Stock-outs of medicine and other medical supplies, dysfunctional medical equipment, shortage of healthcare workers, and frequent strikes adversely affected the availability of health services. Acceptability of care was further limited by discrimination by healthcare workers and ineffective grievance redress mechanisms which led to a feeling of disempowerment among the poor.

CONCLUSIONS

Pro-poor health financing reforms improved access to care for the poor to some extent. However, to enhance the effectiveness of pro-poor reforms and to ensure that the poor in Kenya benefit fully from them, there is a need to address barriers to healthcare seeking across all access dimensions.

Health workers' strikes in low-income countries: the available evidence

Objective

To analyse the characteristics, frequency, drivers, outcomes and stakeholders of health workers' strikes in low-income countries.

Methods

We reviewed the published and grey literature from online sources for the years 2009 to 2018. We used four search strategies: (i) exploration of main health and social sciences databases; (ii) use of specialized websites on human resources for health and development; (iii) customized Google search; and (iv) consultation with experts to validate findings. To analyse individual strike episodes, pre-existing conditions and influencing actors, we developed a conceptual framework from the literature.

Results

We identified 116 records reporting on 70 unique health workers' strikes in 23 low-income countries during the period, accounting for 875 days of strike. Year 2018 had the highest number of events (17), corresponding to 170 work days lost. Strikes involving more than one professional category was the frequent strike modality (32 events), followed by strikes by physicians only (22 events). The most commonly reported cause was complaints about remuneration (63 events), followed by protest against the sector's governance or policies (25 events) and safety of working conditions (10 events). Positive resolution was achieved more often when collective bargaining institutions and higher levels of government were involved in the negotiations.

Conclusion

In low-income countries, some common features appear to exist in health sector strikes' occurrence and actors involved in such events. Future research should focus on both individual events and regional patterns, to form an evidence base for mechanisms to prevent and resolve strikes.

Hardship financing of out-of-pocket payments in the context of free healthcare in Zambia

Despite the removal of user fees on public primary healthcare in Zambia, prior studies suggest that out-of-pocket payments are still significant. However, we have little understanding of the extent to which out-of-pocket payments lead patients to hardship methods of financing out-of-pocket costs. This study analyses the prevalence and determinants of hardship financing arising from out-of-pocket payments in healthcare, using data from a nationally-representative household health expenditure survey conducted in 2014. We employ a sequential logistic regression model to examine the factors associated with the risk of hardship financing conditional on reporting an illness and an out-of-pocket expenditure. The results show that up to 11% of households who reported an illness had borrowed money, or sold items or asked a friend for help, or displaced other household consumption in order to pay for health care. The risk of hardship financing was higher among the poorest households, female headed-households and households who reside further from health facilities. Improvements in physical access and quality of public health services have the potential to reduce the incidence of hardship financing especially among the poorest.

Commercialization of obstetric and neonatal care in the Democratic Republic of the Congo: A study of the variability in user fees in Lubumbashi, 2014

OBJECTIVE

In the Democratic Republic of the Congo, insufficient state financing of the health system produced weak progress toward targets of Millennium Development Goals 4 and 5. In Lubumbashi, almost all women pay out-of-pocket for obstetric and neonatal care. As no standard pricing system has been implemented, there is great variation in payments related to childbirth between health facilities and even within the same facility. This work investigates the determinants of this variation.

METHODS

We conducted a cross-sectional study including women from admission through discharge at 92 maternity wards in Lubumbashi in March 2014. The women's payments were collected and validated by triangulating interviews of new mothers and nurses with document review. We studied payments related to delivery from the perspective of women delivering. The total was the sum of the payments linked to seeking and accessing care and transport of the woman and companion. The determinants were assessed by multilevel regression.

RESULTS

Median payments for delivery varied by type: for an uncomplicated vaginal delivery, US$45 (range, US$17-260); for a complicated vaginal delivery US$60 (US$16-304); and for a Cesarean section, US$338 (US$163-782). Vaginal delivery was more expensive at health centers than in general referral hospitals or polyclinics. Cesarean sections done in corporate polyclinics and hospitals were more expensive than those done in the general referral hospitals. Referral of delivering women, use of more highly trained personnel, and a longer stay in the maternity unit contributed to higher expenses. A vaginal delivery in the private sector was more cost-effective than in the public sector.

CONCLUSION

To guarantee universal coverage of high-quality care, we suggest that the government and funders in DRC support health insurance and risk pool initiatives, and introduce and institutionalize free mother and infant care.

The unintended consequences of combining equity measures with performance-based financing in Burkina Faso

BACKGROUND

User fees and poor quality of care contribute to low use of healthcare services in Burkina Faso. The government implemented an innovative intervention that combines equity measures with performance-based financing (PBF). These health equity measures included a community-based selection of indigents to receive user fee exemptions and paying healthcare centres higher purchase prices for services provided to indigents. Research suggests complex interventions can trigger changes not targeted by program planners. To date, however, there is a knowledge gap regarding the unintended consequences that can emerge from combining PBF with health equity measures. Our objective is to document unintended consequences of the equity measures in this complex intervention.

METHODS

We developed a conceptual framework using the diffusion of innovations theory. For the design, we conducted a multiple case study. The cases were four healthcare facilities in one district. We collected data through 93 semi-structured interviews, informal discussions, observation, as well as intervention documents. We conducted thematic analysis using a hybrid deductive-inductive approach. We also used secondary data to describe the monthly evolution of services provided to indigent and non-indigent patients before and after indigent cards were distributed. Time series graphs were used to validate some results.

RESULTS

Local actors, including members of indigent selection committees and healthcare workers, re-invented elements of the PBF equity measures over which they had control to increase their relative advantage or to adapt to implementation challenges and context. Some individuals who did not meet the local conceptualization of indigents were selected to the detriment of others who did. Healthcare providers believed that distributing free medications led to financial difficulties and drug shortages, especially given the low purchase prices and long payment delays. Healthcare workers adopted measures to limit free services delivered to indigents, which led to conflicts between indigents and providers. Ultimately, selected indigents received uncertain and unequal coverage.

CONCLUSIONS

The severity of unintended consequences undermined the effectiveness and equity of the intervention. If the intervention is prolonged and expanded, decision-makers and implementers will have to address these unintended consequences to reduce inequities in accessing care.

Accountability mechanisms for implementing a health financing option: the case of the basic health care provision fund (BHCPF) in Nigeria

Background

The Nigerian National Health Act proposes a radical shift in health financing in Nigeria through the establishment of a fund – Basic Healthcare Provision Fund, (BHCPF). This Fund is intended to improve the functioning of primary health care in Nigeria. Key stakeholders at national, sub-national and local levels have raised concerns over the management of the BHCPF with respect to the roles of various stakeholders in ensuring accountability for its use, and the readiness of the implementers to manage this fund and achieve its objectives. This study explores the governance and accountability readiness of the different layers of implementation of the Fund; and it contributes to the generation of policy implementation guidelines around governance and accountability for the Fund.

Methods

National, state and LGA level respondents were interviewed using a semi structured tool. Respondents were purposively selected to reflect the different layers of implementation of primary health care and the levels of accountability. Different accountability layers and key stakeholders expected to implement the BHCPF are the Federal government (Federal Ministry of Health, NPHCDA, NHIS, Federal Ministry of Finance); the State government (State Ministry of Health, SPHCB, State Ministry of Finance, Ministry of Local Government); the Local government (Local Government Health Authorities); Health facilities (Health workers, Health facility committees (HFC) and External actors (Development partners and donors, CSOs, Community members).

Results

In general, the strategies for accountability encompass planning mechanisms, strong and transparent monitoring and supervision systems, and systematic reporting at different levels of the healthcare system. Non-state actors, particularly communities, must be empowered and engaged as instruments for ensuring external accountability at lower levels of implementation. New accountability strategies such as result-based or performance-based financing could be very valuable.

Conclusion

The key challenges to accountability identified should be addressed and these included trust, transparency and corruption in the health system, political interference at higher levels of government, poor data management, lack of political commitment from the State in relation to release of funds for health activities, poor motivation, mentorship, monitoring and supervision, weak financial management and accountability systems and weak capacity to implement suggested accountability mechanisms due to political interference with accountability structures.

Prevalence of non-communicable diseases and access to care among non-camp Syrian refugees in northern Jordan

Background

Tackling the high non-communicable disease (NCD) burden among Syrian refugees poses a challenge to humanitarian actors and host countries. Current response priorities are the identification and integration of key interventions for NCD care into humanitarian programs as well as sustainable financing. To provide evidence for effective NCD intervention planning, we conducted a cross-sectional survey among non-camp Syrian refugees in northern Jordan to investigate the burden and determinants for high NCDs prevalence and NCD multi-morbidities and assess the access to NCD care.

Methods

We used a two-stage cluster design with 329 randomly selected clusters and eight households identified through snowball sampling. Consenting households were interviewed about self-reported NCDs, NCD service utilization, and barriers to care.

We estimated the adult prevalence of hypertension, diabetes type I/II, cardiovascular- and chronic respiratory conditions, thyroid disease and cancer and analysed the pattern of NCD multi-morbidities. We used the Cox proportional hazard model to calculate the prevalence ratios (PR) to analyse determinants for NCD prevalence and logistic regression to determine risk factors for NCD multi-morbidities by calculating odds ratios (ORs).

Results

Among 8041 adults, 21.8%, (95% CI: 20.9–22.8) suffered from at least one NCD; hypertension (14.0, 95% CI: 13.2–14.8) and diabetes (9.2, 95% CI: 8.5–9.9) were the most prevalent NCDs. NCD multi-morbidities were reported by 44.7% (95% CI: 42.4–47.0) of patients. Higher age was associated with higher NCD prevalence and the risk for NCD-multi-morbidities; education was inversely associated.

Of those patients who needed NCD care, 23.0% (95% CI: 20.5–25.6) did not seek it; 61.5% (95% CI: 54.7–67.9) cited provider cost as the main barrier. An NCD medication interruption was reported by 23.1% (95% CI: 20–4-26.1) of patients with regular medication needs; predominant reason was unaffordability (63.4, 95% CI: 56.7–69.6).

Conclusion

The burden of NCDs and multi-morbidities is high among Syrian refugees in northern Jordan. Elderly and those with a lower education are key target groups for NCD prevention and care, which informs NCD service planning and developing patient-centred approaches.

Important unmet needs for NCD care exist; removing the main barriers to care could include cost-reduction for medications through humanitarian pricing models. Nevertheless, it is still essential that international donors agencies and countries fulfill their commitment to support the Syrian-crisis response.

Electronic supplementary material

The online version of this article (10.1186/s13031-018-0168-7) contains supplementary material, which is available to authorized users.

Examining the Implementation of the Free Maternity Services Policy in Kenya: A Mixed Methods Process Evaluation

Background: Kenya introduced a free maternity policy in 2013 to address the cost barrier associated with accessing maternal health services. We carried out a mixed methods process evaluation of the policy to examine the extent to which the policy had been implemented according to design, and positive experiences and challenges encountered during implementation.

Methods: We conducted a mixed methods study in 3 purposely selected counties in Kenya. Data were collected through in-depth interviews (IDIs) with policy-makers at the national level, health managers at the county level, and frontline staff at the health facility level (n=60), focus group discussions (FGDs) with community representatives (n=10), facility records, and document reviews. We analysed the data using a framework approach.

Results: Rapid implementation led to inadequate stakeholder engagement and confusion about the policy. While the policy was meant to cover antenatal visits, deliveries, and post-natal visits, in practice the policy only covered deliveries. While the policy led to a rapid increase in facility deliveries, this was not matched by an increase in health facility capacity and hence compromised quality of care. The policy led to an improvement in the level of revenues for facilities. However, in all three counties, reimbursements were not made on time. The policy did not have a system of verifying health facility reports on utilization of services.

Conclusion: The Kenyan Ministry of Health (MoH) should develop a formal policy on the free maternity services, and provide clear guidelines on its content and implementation arrangements, engage with and effectively communicate the policy to stakeholders, ensure timeliness of payment disbursement to healthcare facilities, and introduce a mechanism for verifying utilization reports prepared by healthcare providers. User fee removal policies such as free maternity programmes should be accompanied by supply side capacity strengthening.

"Well, not me, but other women do not register because..."- Barriers to seeking antenatal care in the context of prevention of mother-to-child transmission of HIV among Zimbabwean women: a mixed-methods study

Background

While barriers to uptake of antenatal care (ANC) among pregnant women have been explored, much less is known about how integrating prevention of mother-to-child transmission (PMTCT) programmes within ANC services affects uptake. We explored barriers to uptake of integrated ANC services in a poor Zimbabwean community.

Methods

A cross-sectional survey was conducted among post-natal women at Mbare Clinic, Harare, between September 2010 and February 2011. Collected data included participant characteristics and ANC uptake. Logistic regression was conducted to determine factors associated with ANC registration. In-depth interviews were held with the first 21 survey participants who either did not register or registered after twenty-four weeks gestation to explore barriers. Interviews were analysed thematically.

Results

Two hundred and ninety-nine participants (mean age 26.1 years) were surveyed. They came from ultra-poor households, with mean household income of US$181. Only 229 (76.6%) had registered for ANC, at a mean gestation of 29.5 weeks. In multivariable analysis, household income was positively associated with ANC registration, odds ratio (OR) for a $10-increase in household income 1.02 (95% confidence interval, CI, 1.0–1.04), as was education which interacted with having planned the pregnancy (OR for planned pregnancy with completed ordinary level education 3.27 (95%CI 1.55–6.70). Divorced women were less likely to register than married women, OR 0.20 (95%CI 0.07–0.58). In the qualitative study, barriers to either ANC or PMTCT services limited uptake of integrated services. Women understood the importance of integrated services for PMTCT purposes and theirs and the babies’ health and appeared unable to admit to barriers which they deemed “stupid/irresponsible”, namely fear of HIV testing and disrespectful treatment by nurses. They represented these commonly recurring barriers as challenges that “other women” faced. The major proffered personal barrier was unaffordability of user fees, which was sometimes compounded by unsupportive husbands who were the breadwinners.

Conclusion

Women who delayed/did not register were aware of the importance of ANC and PMTCT but were either unable to afford or afraid to register. Addressing the identified challenges will not only be important for integrated PMTCT/ANC services but will also provide a model for dealing with challenges as countries scale up ‘treat all’ approaches.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1898-7) contains supplementary material, which is available to authorized users.

Assessing the community-level impact of a decade of user fee policy shifts on health facility deliveries in Kenya, 2003-2014

Background

The long-term impact of user fee removal policies on health service utilization in low- and middle-income countries may vary depending on the context in which they are implemented, including whether there are policy actions to support implementation. We examined the community-level impact of a decade of user fee policy shifts on health facility delivery among poorest and rural women and compared the changes with those among the richest and urban women in Kenya using data from three rounds of nationally representative surveys.

Methods

Data are from births occurring in the 5 years preceding the survey to women aged 15-49 years who were interviewed in the 2003, 2008-2009 and 2014 Kenya Demographic and Health Surveys. A total of 5949, 6079 and 20,964 births were reported in respective surveys. We conducted interrupted time series analysis predicting changes in quarterly proportions of births occurring in public and private health facilities as well as at home before and after the 2004, 2007 and 2013 user fee policy shifts in Kenya.

Results

There were no statistically significant immediate changes in the proportion of births occurring in public facilities following the 2004, 2007 and 2013 user fee policy shifts among poor or rural women. There was, however, a statistically significant increase in home deliveries among all women and among those from the poorest households immediately following the 2004 policy. There was also a statistically significant increase in public facility deliveries among women from the two top quintiles, which was accompanied by a statistically decline in home deliveries immediately after the 2007 policy shift. Differences in trends in public facility deliveries between pre- and post-policy periods were not statistically significant for all sub-groups of women, indicating that even among the sub-group that experienced significant immediate increase after the 2007 policy shift, this pattern was not sustained over time.

Conclusion

The findings of this paper provide empirical evidence that poorly implemented user fee removal policies benefit more well-off than poor women and in cases where there are significant immediate effects on uptake of facility delivery, this trend is not sustained over time.

Electronic supplementary material

The online version of this article (10.1186/s12939-018-0774-4) contains supplementary material, which is available to authorized users.

User-fee-removal improves equity of children's health care utilization and reduces families' financial burden: evidence from Jamaica

Background

The impact of user–fee policies on the equity of health care utilization and households’ financial burdens has remained largely unexplored in Latin American and the Caribbean, as well as in upper–middle–income countries. This paper assesses the short– and long–term impacts of Jamaica’s user–fee–removal for children in 2007.

Methods

This study utilizes 14 rounds of data from the Jamaica Survey of Living Conditions (JSLC) for the periods 1996 to 2012. JSLC is a national household survey, which collects data on health care utilization and among other purposes for planning. Interrupted time series (ITS) analysis was used to examine the immediate impact of the user–fee–removal policy on children’s health care utilization and households’ financial burdens, as well as the impact in the medium– to long–term.

Results

Immediately following the implementation of user–fee–removal, the odds of seeking for health care if the children fell ill in the past 4 weeks increased by 97% (odds ratio 2.0, 95% confidence interval (CI) 1.1 to 3.5, P = 0.018). In the short–term (2007–2008), health care utilization increased at a faster rate among children not in poverty than children in poverty; while this gap narrowed after 2008. There was minimal difference in health care utilization across wealth groups in the medium– to long–term. The household’s financial burden (health expenditure as a share of household’s non–food expenditures) reduced by 6 percentage points (95% CI: –11 to –1, P = 0.020) right after the policy was implemented and kept at a low level. The difference in financial burden between children in poverty and children not in poverty shrunk rapidly after 2007 and remained small in subsequent years.

Conclusions

User–fee–removal had a positive impact on promoting health care utilization among children and reducing their household health expenditures in Jamaica. The short–term and the medium– to long–term results have different indications: In the short–term, the policy deteriorated the equity of access to health care for children, while the equity status improved fast in the medium– to long–term.

How effective and fair is user fee removal? Evidence from Zambia using a pooled synthetic control

Despite its high political interest, the impact of removing user charges for health care in low-income settings remains a debatable issue. We try to clear up this contentious issue by estimating the short-term effects of a policy change that occurred in 2006 in Zambia, when 54 of 72 districts removed fees. We use a pooled synthetic control method in order to estimate the causal impact of the policy on health care use, the provider chosen, and out-of-pocket medical expenses. We find no evidence that user fee removal increased health care utilisation, even among the poorest group. However, we find that the policy is likely to have led to a substitution away from the private sector for those using care and that it virtually eliminated medical expenditures, thereby providing financial protection to service users. We estimate that the policy was equivalent to a transfer of US$3.2 per health visit for the 50% richest but of only US$1.1 for the 50% poorest.

Implementation of the free maternity services policy and its implications for health system governance in Kenya

Introduction

To move towards universal health coverage, the government of Kenya introduced free maternity services in all public health facilities in June 2013. User fees are, however, important sources of income for health facilities and their removal has implications for the way in which health facilities are governed.

Objective

To explore how implementation of Kenya’s financing policy has affected the way in which the rules governing health facilities are made, changed, monitored and enforced.

Methods

Qualitative research was carried out using semistructured interviews with 39 key stakeholders from six counties in Kenya: 10 national level policy makers, 10 county level policy makers and 19 implementers at health facilities. Participants were purposively selected using maximum variation sampling. Data analysis was informed by the institutional analysis framework, in which governance is defined by the rules that distribute roles among key players and shape their actions, decisions and interactions.

Results

Lack of clarity about the new policy (eg, it was unclear which services were free, leading to instances of service user exploitation), weak enforcement mechanisms (eg, delayed reimbursement to health facilities, which led to continued levying of service charges) and misaligned incentives (eg, the policy led to increased uptake of services thereby increasing the workload for health workers and health facilities losing control of their ability to generate and manage their own resources) led to weak policy implementation, further complicated by the concurrent devolution of the health system.

Conclusion

The findings show the consequences of discrepancies between formal institutions and informal arrangements. In introducing new policies, policy makers should ensure that corresponding institutional (re)arrangements, enforcement mechanisms and incentives are aligned with the objectives of the implementers.

Piloting a mHealth intervention to improve newborn care awareness among rural Cambodian mothers: a feasibility study

BACKGROUND

Globally, the World Health Organization reports that the chances of a child dying is highest in the first month of life, the neonatal period. The neonatal mortality rate in Cambodia is 18 per 1000 live births. In the province of Kampong Chhnang, that rate is the fifth highest among the 24 provinces of Cambodia at 27 per 1000 live births. We piloted a project to determine the feasibility of using a mHealth intervention (the use of mobile devices to improve health outcomes) to increase mothers' awareness about neonatal care and promote the government policy 'Safe Motherhood Protocols for Health Centres' which are in line with WHO recommendations for neonatal care.

METHODS

Between September and December 2013, we piloted an Interactive Voice Response system that sent pre-recorded messages to mothers of newborns using the theme 'It takes a village to raise a baby'. Four hundred fifty-five mothers were registered onto this program and the intervention involved delivering seven periodic 60 to 90 s voice messages directly to the mobile phones of these mothers from day three of their neonate's life to day 28. An evaluation of the pilot was conducted in December 2013. One hundred twenty-nine mothers were randomly selected from the 455 registered mothers and interviewed using a quantitative questionnaire. We also held two focus group discussions with three mothers and seven health workers.

RESULTS

Quantitative and qualitative results of 126 respondents were included for analysis. They indicate that the intervention was well accepted. Seventy-one percent of respondents reported that they would recommend the intervention to other mothers, and 83% reported that they would be willing to pay for the service.

CONCLUSIONS

This type of mHealth intervention is an acceptable and feasible way of promoting the awareness of newborn care to rural Cambodian mothers.

Focused maternity care in Ghana: results of a cluster analysis

BACKGROUND

Ghana missed out in attaining Millennium Development Goal 5 in 2015. The provision of adequate prenatal and postnatal care remains problematic, with poor evidence on women's views on met and unmet maternity care needs across all regions in Ghana. This paper examines maternal care utilization in Ghana by applying WHO indicators for focused maternal care utilization.

METHODS

Two-step cluster analysis segregated women into groups based on the components of the maternity care used. Using cluster membership variables as dependent variables, we applied multinomial and binary regression to examine associations of care use with individual, household and regional characteristics.

RESULTS

We identified three patterns of care use: adequate, less and least adquate care. The presence of a female and skilled provider is an indicator of adequate care. Women in Volta, Upper West, Northern and Western regions received less adequate care compared with other regions. Supply-related factors (drugs availability, distance/transport, health insurance ownership, rural residence) were associated with adequacy of care. The lack of female autonomy, widowed/divorced women, age and parity were associated with less adequate care. Care patterns were distinctively associated with the quality of health care support (skilled and female attendant) instead of with the number of visits made to the facility. Across regions and within rural settings, disparities exist, often compounded by supply-related factors.

CONCLUSIONS

Efforts to address skilled workforce shortages, greater accountability for quality and equity, improving women motivation for care seeking and active participation are important for maternity care in Ghana.

Implementing a "free" tuberculosis (TB) care policy under the integrated model in Jiangsu, China: practices and costs in the real world

Background

In the 1990s, China introduced a “free” tuberculosis (TB) care policy under the national TB control program. Recently, as a part of a new TB diagnosis and treatment model, it has been recommended that the integrated model scale up. This paper examines whether or not TB designated hospitals in the selected project sites have provided TB care according to the national and local guidelines, and analyzes the actual practices and expenditures involved in completing TB treatment. It also explores the reasons why “free” TB care in China cannot be effectively implemented under the integrated model.

Methods

This study was conducted in three counties of Zhenjiang city, Jiangsu province. Mixed methods were used, which comprised reviewing the national and local TB control guidelines, conducting TB patient surveys, collecting TB inpatient and outpatient hospital records, and conducting qualitative interviews with stakeholders. Descriptive statistics were used for quantitative data analysis across counties and in order to compare patients who received only outpatient care and those who received both outpatient and inpatient care. The chi-square test and analysis of variance were performed where necessary. Qualitative data were analyzed using the framework approach.

Results

Although the national TB care guidelines recommend outpatient care as a basis for TB treatment in China, we found high hospital admission rates for TB patients ranging from 39 % in Yangzhong county to 83 % in Dantu county. Almost all outpatient TB patients paid for lab tests and over 80 % paid for liver protection drugs and around 70 % paid for image examinations. These three components accounted for three-quarters of the total outpatient expenditure. For patients who received only outpatient care, the total expenditure upon completion of TB treatment was on average 1,135 Chinese yuan. For patients who received outpatient and inpatient care, the total expenditure upon completion of TB treatment was 11,117 Chinese yuan.

Conclusion

The “free” TB care policy under the integrated model has not been effectively implemented in China. There has been substantial spending on non-recommended services, examinations, and drugs for TB treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0099-8) contains supplementary material, which is available to authorized users.

Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue

With user fees now seen as a major hindrance to universal health coverage, many countries have introduced fee reduction or elimination policies, but there is growing evidence that adherence to reduced fees is often highly imperfect. In 2004, Kenya adopted a reduced and uniform user fee policy providing fee exemptions to many groups. We present data on user fee implementation, revenue and expenditure from a nationally representative survey of Kenyan primary health facilities. Data were collected from 248 randomly selected public health centres and dispensaries in 2010, comprising an interview with the health worker in charge, exit interviews with curative outpatients, and a financial record review. Adherence to user fee policy was assessed for eight tracer conditions based on health worker reports, and patients were asked about actual amounts paid. No facilities adhered fully to the user fee policy across all eight tracers, with adherence ranging from 62.2% for an adult with tuberculosis to 4.2% for an adult with malaria. Three quarters of exit interviewees had paid some fees, with a median payment of US dollars (USD) 0.39, and a quarter of interviewees were required to purchase additional medical supplies at a later stage from a private drug retailer. No consistent pattern of association was identified between facility characteristics and policy adherence. User fee revenues accounted for almost all facility cash income, with average revenue of USD 683 per facility per year. Fee revenue was mainly used to cover support staff, non-drug supplies and travel allowances. Adherence to user fee policy was very low, leading to concerns about the impact on access and the financial burden on households. However, the potential to ensure adherence was constrained by the facilities' need for revenue to cover basic operating costs, highlighting the need for alternative funding strategies for peripheral health facilities.

Tracking implementation and (un)intended consequences: a process evaluation of an innovative peripheral health facility financing mechanism in Kenya

In many African countries, user fees have failed to achieve intended access and quality of care improvements. Subsequent user fee reduction or elimination policies have often been poorly planned, without alternative sources of income for facilities. We describe early implementation of an innovative national health financing intervention in Kenya; the health sector services fund (HSSF). In HSSF, central funds are credited directly into a facility's bank account quarterly, and facility funds are managed by health facility management committees (HFMCs) including community representatives. HSSF is therefore a finance mechanism with potential to increase access to funds for peripheral facilities, support user fee reduction and improve equity in access. We conducted a process evaluation of HSSF implementation based on a theory of change underpinning the intervention. Methods included interviews at national, district and facility levels, facility record reviews, a structured exit survey and a document review. We found impressive achievements: HSSF funds were reaching facilities; funds were being overseen and used in a way that strengthened transparency and community involvement; and health workers' motivation and patient satisfaction improved. Challenges or unintended outcomes included: complex and centralized accounting requirements undermining efficiency; interactions between HSSF and user fees leading to difficulties in accessing crucial user fee funds; and some relationship problems between key players. Although user fees charged had not increased, national reduction policies were still not being adhered to. Finance mechanisms can have a strong positive impact on peripheral facilities, and HFMCs can play a valuable role in managing facilities. Although fiduciary oversight is essential, mechanisms should allow for local decision-making and ensure that unmanageable paperwork is avoided. There are also limits to what can be achieved with relatively small funds in contexts of enormous need. Process evaluations tracking (un)intended consequences of interventions can contribute to regional financing and decentralization debates.

Exploring health facilities' experiences in implementing the free health-care policy (FHCP) in Nepal: how did organizational factors influence the implementation of the user-fee abolition policy?

BACKGROUND

This article presents an Asian experience of abolishing health-care user fees: Nepal's universal free health-care policy, implemented in 2008. Based on doctoral fieldwork between August 2008 and April 2009, the paper analyses primary-care facilities' and central and district health systems' experiences with the policy. It makes a unique contribution to existing evidence because it explicitly applies organizational theory within a carefully designed, rigorous, multiple case-study analysis to deepen our understanding of the organizational and 'people' factors in the successful removal of user fees.

METHODS

The cases were two pairs of primary-care facilities in one district, paired for comparison of the facilities' experiences with the policy in relation to its effects on health care utilization. Data collection methods included document reviews; key informant interviews at district and central levels; in-depth, semi-structured interviews and group interviews at case facilities. (Data on indicators of utilization and quality changes over time were also collected and will be published separately). Using key elements of Nadler and Tushman's 'Organizational Congruence' model, a degree-of-fit analysis tested the study's initial propositions and yielded generalizations for contexts in and outside Nepal.

RESULTS

The study found that Nepal's key implementation challenges were similar to Africa's: insufficient or delayed inputs of drugs and compensation; insufficient workforce and the resulting reduced quality of services that hampered facilities' relationships with their clients and health providers' attitudes. However, the Nepalese case facilities with (1) good intra- and inter-facility relationships, (2) adequate staffing, (3) well-oriented providers and (4) previously trained, better-informed and skilled health management committees experienced higher utilization and better-quality indicators over time.

CONCLUSIONS

Through its detailed analysis of Nepal's experience in removing user fees, the study highlights the importance of addressing the 'people' and 'organizational' factors in health-policy development and implementation.

Uptake of evidence in policy development: the case of user fees for health care in public health facilities in Uganda

Background

Several countries in Sub Saharan Africa have abolished user fees for health care but the extent to which such a policy decision is guided by evidence needs further exploration. We explored the barriers and facilitating factors to uptake of evidence in the process of user fee abolition in Uganda and how the context and stakeholders involved shaped the uptake of evidence. This study builds on previous work in Uganda that led to the development of a middle range theory (MRT) outlining the main facilitating factors for knowledge translation (KT). Application of the MRT to the case of abolition of user fees contributes to its refining.

Methods

Employing a theory-driven inquiry and case study approach given the need for in-depth investigation, we reviewed documents and conducted interviews with 32 purposefully selected key informants. We assessed whether evidence was available, had or had not been considered in policy development and the reasons why and; assessed how the actors and the context shaped the uptake of evidence.

Results

Symbolic, conceptual and instrumental uses of evidence were manifest. Different actors were influenced by different types of evidence. While technocrats in the ministry of health (MoH) relied on formal research, politicians relied on community complaints. The capacity of the MoH to lead the KT process was weak and the partnerships for KT were informal. The political window and alignment of the evidence with overall government discourse enhanced uptake of evidence. Stakeholders were divided, seemed to be polarized for various reasons and had varying levels of support and influence impacting the uptake of evidence.

Conclusion

Evidence will be taken up in policy development in instances where the MoH leads the KT process, there are partnerships for KT in place, and the overall government policy and the political situation can be expected to play a role. Different actors will be influenced by different types of evidence and their level of support and influence will impact the uptake of evidence. In addition, the extent to which a policy issue is contested and, whether stakeholders share similar opinions and preferences will impact the uptake of evidence.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-014-0639-5) contains supplementary material, which is available to authorized users.

Constraints to applying systems thinking concepts in health systems: A regional perspective from surveying stakeholders in Eastern Mediterranean countries

BACKGROUND

Systems Thinking (ST) has recently been promoted as an important approach to health systems strengthening. However, ST is not common practice, particularly in Low- and Middle-Income Countries (LMICs). This paper seeks to explore the barriers that may hinder its application in the Eastern Mediterranean Region (EMR) and possible strategies to mitigate them.

METHODS

A survey consisting of open-ended questions was conducted with a purposive sample of health policy-makers such as senior officials from the Ministry of Health (MoH), researchers, and other stakeholders such as civil society groups and professional associations from ten countries in the region. A total of 62 respondents participated in the study. Thematic analysis was conducted.

RESULTS

There was strong recognition of the relevance and usefulness of ST to health systems policy-making and research, although misconceptions about what ST means were also identified. Experience with applying ST was very limited. Approaches to designing health policies in the EMR were perceived as reactive and fragmented (66%). Commonly perceived constraints to application of ST were: a perceived notion of its costliness combined with lack of the necessary funding to operationalize it (53%), competing political interests and lack of government accountability (50%), lack of awareness about relevance and value (47%), limited capacity to apply it (45%), and difficulty in coordinating and managing stakeholders (39%).

CONCLUSION

While several strategies have been proposed to mitigate most of these constraints, they emphasized the importance of political endorsement and adoption of ST at the leadership level, together with building the necessary capacity to apply it and apply the learning in research and practice.

Governing the implementation of emergency obstetric care: experiences of rural district health managers, Tanzania

Background

Many health policies developed internationally often become adopted at the national level and are implemented locally at the district level. A decentralized district health system led by a district health management team becomes responsible for implementing such policies. This study aimed at exploring the experiences of a district health management team in implementing Emergency Obstetric Care (EmOC) related policies and identifying emerging governance aspects.

Methods

The study used a qualitative approach in which data was obtained from thirteen individual interviews and one focus group discussion (FGD). Interviews were conducted with members of the district health management team, district health service boards and NGO representatives. The FGD included key informants who were directly involved in the work of implementing EmOC services in the district. Documentary reviews and observation were done to supplement the data. All the materials were analysed using a qualitative content analysis approach.

Results

Implementation of EmOC was considered to be a process accompanied by achievements and challenges. Achievements included increased institutional delivery, increased number of ambulances, training service providers in emergency obstetric care and building a new rural health centre that provides comprehensive emergency obstetric care. These achievements were associated with good leadership skills of the team together with partnerships that existed between different actors such as the Non-Governmental Organization (NGO), development partners, local politicians and Traditional Birth Attendants (TBAs). Most challenges faced during the implementation of EmOC were related to governance issues at different levels and included delays in disbursement of funds from the central government, shortages of health workers, unclear mechanisms for accountability, lack of incentives to motivate overburdened staffs and lack of guidelines for partnership development.

Conclusion

The study revealed that implementing EmOC is a process accompanied by challenges that require an approach with multiple partners to address them and that, for effective partnership, the roles and responsibilities of each partner should be well stipulated in a clear working framework within the district health system. Partnerships strengthen health system governance and therefore ensure effective implementation of health policies at a local level.

Local barriers and solutions to improve care-seeking for childhood pneumonia, diarrhoea and malaria in Kenya, Nigeria and Niger: a qualitative study

We present qualitative research findings on care-seeking and treatment uptake for pneumonia, diarrhoea and malaria among children under 5 in Kenya, Nigeria and Niger. The study aimed to determine the barriers caregivers face in accessing treatment for these conditions; to identify local solutions that facilitate more timely access to treatment; and to present these findings as a platform from which to develop context-specific strategies to improve care-seeking for childhood illness. Kenya, Nigeria and Niger are three high burden countries with low rates of related treatment coverage, particularly in underserved areas. Data were collected in Homa Bay County in Nyanza Province, Kenya; in Kebbi and Cross River States, Nigeria; and in the Maradi and Tillabéri regions of Niger. Primary caregivers of children under 5 who did not regularly engage with health services or present their child at a health facility during illness episodes were purposively selected for interview. Data underwent rigorous thematic analysis. We organise the identified barriers and related solutions by theme: financial barriers; distance/location of health facilities; socio-cultural barriers and gender dynamics; knowledge and information barriers; and health facility deterrents. The relative importance of each differed by locality. Participant suggested solutions ranged from community-level actions to facility-level and more policy-oriented actions, plus actions to change underlying problems such as social perceptions and practices and gender dynamics. We discuss the feasibility and implications of these suggested solutions. Given the high burden of childhood morbidity and mortality due to pneumonia, diarrhoea and malaria in Kenya, Nigeria and Niger, this study provides important insights relating to demand-side barriers and locally proposed solutions. Significant advancements are possible when communities participate in both problem identification and resolution, and are engaged as important partners in improving child health and survival.

Studying complex interventions: reflections from the FEMHealth project on evaluating fee exemption policies in West Africa and Morocco

BACKGROUND

The importance of complexity in health care policy-making and interventions, as well as research and evaluation is now widely acknowledged, but conceptual confusion reigns and few applications of complexity concepts in research design have been published. Taking user fee exemption policies as an entry point, we explore the methodological consequences of 'complexity' for health policy research and evaluation. We first discuss the difference between simple, complicated and complex and introduce key concepts of complex adaptive systems theory. We then apply these to fee exemption policies.

DESIGN

We describe how the FEMHealth research project attempts to address the challenges of complexity in its evaluation of fee exemption policies for maternal care. We present how the development of a programme theory for fee exemption policies was used to structure the overall design. This allowed for structured discussions on the hypotheses held by the researchers and helped to structure, integrate and monitor the sub-studies. We then show how the choice of data collection methods and tools for each sub-study was informed by the overall design.

DISCUSSION

Applying key concepts from complexity theory proved useful in broadening our view on fee exemption policies and in developing the overall research design. However, we encountered a number of challenges, including maintaining adaptiveness of the design during the evaluation, and ensuring cohesion in the disciplinary diversity of the research teams. Whether the programme theory can fulfil its claimed potential to help making sense of the findings is yet to be tested. Experience from other studies allows for some moderate optimism. However, the biggest challenge complexity throws at health system researchers may be to deal with the unknown unknowns and the consequence that complex issues can only be understood in retrospect. From a complexity theory point of view, only plausible explanations can be developed, not predictive theories. Yet here, theory-driven approaches may help.

Perceived quality of care for common childhood illnesses: facility versus community based providers in Uganda

OBJECTIVE

To compare caretakers' perceived quality of care (PQC) for under-fives treated for malaria, pneumonia and diarrhoea by community health workers (CHWs) and primary health facility workers (PHFWs).

METHODS

Caretaker rated PQC for children aged (2-59) months treated by either CHWs or PHFWs for a bought of malaria, pneumonia or diarrhoea was cross-sectionally compared in quality domains of accessibility, continuity, comprehensiveness, integration, clinical interaction, interpersonal treatment and trust. Child samples were randomly drawn from CHW (419) and clinic (399) records from eight Midwestern Uganda districts. An overall PQC score was predicted through factor analysis. PQC scores were compared for CHWs and PHFWs using Wilcoxon rank-sum test. Multinomial logistic regression models were used to specify the association between categorized PQC and service providers for each quality domain. Finally, overall PQC was dichotomized into "high" and "low" based on median score and relative risks (RR) for PQC-service provider association were modeled in a "modified" Poisson regression model.

RESULTS

Mean (SD) overall PQC was significantly higher for CHWs 0.58 (0 .66) compared to PHFWs -0.58 (0.94), p<0.0001. In "modified" Poisson regression, the proportion of caretakers reporting high PQC was higher for CHWS compared to PHFWs, RR=3.1, 95%CI(2.5-3.8). In multinomial models PQC was significantly higher for CHWs compared to PHFWs in all domains except for continuity.

CONCLUSION

PQC was significantly higher for CHWs compared to PHFWs in this resource constrained setting. CHWs should be tapped human resources for universal health coverage while scaling up basic child intervention as PQC might improve intervention utilization.

Hidden costs: the direct and indirect impact of user fees on access to malaria treatment and primary care in Mali

About 20 years after initial calls for the introduction of user fees in health systems in sub-Saharan Africa, a growing coalition is advocating for their removal. Several African countries have abolished user fees for health care for some or all of their citizens. However, fee-for-service health care delivery remains a primary health care funding model in many countries in sub-Saharan Africa. Although the impact of user fees on utilization of health services and household finances has been studied extensively, further research is needed to characterize the multi-faceted health and social problems associated with charging user fees. This ethnographic study aims to identify consequences of user fees on gender inequality, food insecurity, and household decision-making for a group of women living in poverty. Ethnographic life history interviews were conducted with 24 women in Yirimadjo, Mali in 2007. Purposive sampling selected participants across a broad socio-economic spectrum. Semi-structured interviews addressed participants' past medical history, socio-economic status, social and family history, and access to health care. Interview transcripts were coded using the guiding analytical framework of structural violence. Interviews revealed that user fees for health care not only decreased utilization of health services, but also resulted in delayed presentation for care, incomplete or inadequate care, compromised food security and household financial security, and reduced agency for women in health care decision making. The effects of user fees were amplified by conditions of poverty, as well as gender and health inequality; user fees in turn reinforced the inequalities created by those very conditions. The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances. As many countries consider user fee abolition policies, these findings indicate the need to create a broader evaluation framework-one that can measure the health and socioeconomic impacts of user fee polices and of their removal.

Intermittent preventive treatment of malaria in children: a qualitative study of community perceptions and recommendations in Burkina Faso and Mali

Background

Intermittent preventive treatment of malaria in children (IPTc) is a highly efficacious method of malaria control where malaria transmission is highly seasonal. However, no studies published to date have examined community perceptions of IPTc.

Methods

A qualitative study was undertaken in parallel with a double-blind, placebo-controlled, randomized trial of IPTc conducted in Mali and Burkina Faso in 2008–2009 to assess community perceptions of and recommendations for IPTc. Caregivers and community health workers (CHWs) were purposively sampled. Seventy-two in-depth individual interviews and 23 focus group discussions were conducted.

Findings

Widespread perceptions of health benefits for children led to enthusiasm for the trial and for IPTc specifically. Trust in and respect for those providing the tablets and a sense of obligation to the community to participate in sanctioned activities favoured initial adoption. IPTc fits in well with existing understandings of childhood illness. Participants did not express concerns about the specific drugs used for IPTc or about providing tablets to children without symptoms of malaria. There was no evidence that IPTc was perceived as a substitute for bed net usage, nor did it inhibit care seeking. Participants recommended that distribution be “closer to the population”, but expressed concern over caregivers' ability to administer tablets at home.

Conclusions

The trial context mediated perceptions of IPTc. Nonetheless, the results indicate that community perceptions of IPTc in the settings studied were largely favourable and that the delivery strategy rather than the tablets themselves presented the main areas of concern for caregivers and CHWs. The study identifies a number of key questions to consider in planning an IPTc distribution strategy. Single-dose formulations could increase the success of IPTc implementation, as could integration of IPTc within a package of activities, such as bed net distribution and free curative care, for which demand is already high.