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Abdulai AG. Overcoming the constraints of competitive clientelism? Explaining the success of Ghana's poorest region in reducing maternal mortality. Int J Health Plann Manage 2024; 39:363-379. [PMID: 37926799 DOI: 10.1002/hpm.3728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 09/12/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023] Open
Abstract
Maternal mortality remains a health challenge that many developing countries struggle to address. Drawing on 64 key informant interviews, this article shows how Ghana's most impoverished administrative region, the Upper East, emerged as a bureaucratic 'pocket of effectiveness' in reducing maternal mortality in a context where national political settlement dynamics are undermining progress in improving maternal health. At the national level, Ghana's progress in reducing maternal mortality has been disappointing because public investments are disproportionately directed to reforms that contribute to the short-term political survival of ruling elites. Competitive electoral pressures have contributed to greater elite commitment towards health sector investments with visual impact, while weakening elite incentives for dedicating resources to interventions that are necessary for enhancing the quality of health. The relatively better performance of the Upper East Region in reducing maternal mortality has been driven by a hybrid form of accountability that combines top-down pressures from the regional health directorate with horizontal forms of accountability that result in a competitive spirit among health workers. These findings show that even in contexts where resources are limited, the capacity of sub-national leaders in devising local solutions to local problems can lead to improved performance of health systems at the sub-national level. The findings also suggest the need for academic debates to go beyond the binary distinctions regarding the usefulness of top-down versus bottom-up accountability measures and focus on building effective and legitimate forms of accountability that run both top-down and bottom-up when seeking to improve health service delivery.
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Shafiq Y, Rubini E, Fazal ZZ, Bukhari MM, Zakaria M, Zeeshan NUH, Muhammad A, Ragazzoni L, Barone-Adesi F, Valente M. Impact of Ebola and COVID-19 on maternal, neonatal, and child health care among populations affected by conflicts: a scoping review exploring demand and supply-side barriers and solutions. Confl Health 2024; 18:12. [PMID: 38291492 PMCID: PMC10829480 DOI: 10.1186/s13031-024-00572-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/19/2024] [Indexed: 02/01/2024] Open
Abstract
INTRODUCTION Armed conflicts have a severe impact on the health of women and children. Global health emergencies such as pandemics and disease outbreaks further exacerbate the challenges faced by vulnerable populations in accessing maternal, neonatal, and child healthcare (MNCH). There is a lack of evidence that summarizes the challenges faced by conflict-affected pregnant women, mothers, and children in accessing MNCH services during global health emergencies, mainly the Ebola and COVID-19 pandemics. This scoping review aimed to analyze studies evaluating and addressing barriers to accessing comprehensive MNCH services during Ebola and COVID-19 emergencies in populations affected by conflict. METHODS The search was conducted on PubMed, Scopus, and Web of Science databases using terms related to Ebola and COVID-19, conflicts, and MNCH. Original studies published between 1990 and 2022 were retrieved. Articles addressing the challenges in accessing MNCH-related services during pandemics in conflict-affected settings were included. Thematic analysis was performed to categorize the findings and identify barriers and solutions. RESULTS Twenty-nine studies met the inclusion criteria. Challenges were identified in various MNCH domains, including antenatal care, intrapartum care, postnatal care, vaccination, family planning, and the management of childhood illnesses. Ebola-related supply-side challenges mainly concerned accessibility issues, health workforce constraints, and the adoption of stringent protocols. COVID-19 has resulted in barriers related to access to care, challenges pertaining to the health workforce, and new service adoption. On the demand-side, Ebola- and COVID-19-related risks and apprehensions were the leading barriers in accessing MNCH care. Community constraints on utilizing services during Ebola were caused by a lack of trust and awareness. Demand-side challenges of COVID-19 included fear of disease, language barriers, and communication difficulties. Strategies such as partnerships, strengthening of health systems, service innovation, and community-based initiatives have been employed to overcome these barriers. CONCLUSION Global health emergencies amplify the barriers to accessing MNCH services faced by conflict-affected populations. Cultural, linguistic, and supply-side factors are key challenges affecting various MNCH domains. Community-sensitive initiatives enhancing primary health care (PHC), mobile clinics, or outreach programs, and the integration of MNCH into PHC delivery should be implemented. Efforts should prioritize the well-being and empowerment of vulnerable populations. Addressing these barriers is crucial for achieving universal health coverage and the Sustainable Development Goals.
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Affiliation(s)
- Yasir Shafiq
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy.
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
- Centre of Excellence for Trauma and Emergencies (CETE) & Community Health Science, The Aga Khan University, Karachi, Pakistan.
- Harvard Humanitarian Initiative, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Bostan, USA.
- Department of Pediatrics, Brigham and Women's Hospital, Global Advancement of Infants and Mothers, Boston, USA.
| | - Elena Rubini
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | | | | | | | | | | | - Luca Ragazzoni
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Francesco Barone-Adesi
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Martina Valente
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
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Garcia LP, Schneider IJC, de Oliveira C, Traebert E, Traebert J. What is the impact of national public expenditure and its allocation on neonatal and child mortality? A machine learning analysis. BMC Public Health 2023; 23:793. [PMID: 37118765 PMCID: PMC10141942 DOI: 10.1186/s12889-023-15683-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 04/15/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND Understanding the impact of national public expenditure and its allocation on child mortality may help governments move towards target 3.2 proposed in the 2030 Agenda. The objective of this study was to estimate the impacts of governmental expenditures, total, on health, and on other sectors, on neonatal mortality and mortality of children aged between 28 days and five years. METHODS This study has an ecological design with a population of 147 countries, with data between 2012 and 2019. Two steps were used: first, the Generalized Propensity Score of public spending was calculated; afterward, the Generalized Propensity Score was used to estimate the expenditures' association with mortality rates. The primary outcomes were neonatal mortality rates (NeoRt) and mortality rates in children between 28 days and 5 years (NeoU5Rt). RESULTS The 1% variation in Int$ Purchasing Power Parity (Int$ PPP) per capita in total public expenditures, expenditure in health, and in other sectors were associated with a variation of -0.635 (95% CI -1.176, -0.095), -2.17 (95% CI -3.051, -1.289) -0.632 (95% CI -1.169, -0.095) in NeoRt, respectively The same variation in public expenditures in sectors other than health, was associates with a variation of -1.772 (95% CI -6.219, -1.459) on NeoU5Rt. The results regarding the impact of total and health public spending on NeoU5Rt were not consistent. CONCLUSION Public investments impact mortality in children under 5 years of age. Likely, the allocation of expenditures between the health sector and the other social sectors will have different impacts on mortality between the NeoRt and the NeoU5Rt.
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Affiliation(s)
- Leandro Pereira Garcia
- Graduate Program in Health Sciences, Universidade do Sul de Santa Catarina, Avenida Pedra Branca, 25, Palhoça, Santa Catarina, 88132-260, Brazil
| | - Ione Jayce Ceola Schneider
- Graduate Program in Rehabilitation Science, Public Health and Neuroscience, Universidade Federal de Santa Catarina, Rodovia Governador Jorge Lacerda, 3201, Araranguá, SC, 88906-072, Brazil
| | - Cesar de Oliveira
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 6BT, UK
| | - Eliane Traebert
- Graduate Program in Health Sciences, Universidade do Sul de Santa Catarina, Avenida Pedra Branca, 25, Palhoça, Santa Catarina, 88132-260, Brazil
- School of Medicine, Universidade do Sul de Santa Catarina, Avenida Pedra Branca, 25, Palhoça, SC, 88132-260, Brazil
| | - Jefferson Traebert
- Graduate Program in Health Sciences, Universidade do Sul de Santa Catarina, Avenida Pedra Branca, 25, Palhoça, Santa Catarina, 88132-260, Brazil.
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Jacobs C, Musukuma M, Sikapande B, Chooye O, Wehrmeister FC, Boerma T, Michelo C, Blanchard AK. How Zambia reduced inequalities in under-five mortality rates over the last two decades: a mixed-methods study. BMC Health Serv Res 2023; 23:170. [PMID: 36805693 PMCID: PMC9940360 DOI: 10.1186/s12913-023-09086-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 01/19/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Zambia experienced a major decline in under-five mortality rates (U5MR), with one of the fastest declines in socio-economic disparities in sub-Saharan Africa in the last two decades. We aimed to understand the extent to which, and how, Zambia has reduced socio-economic inequalities in U5MR since 2000. METHODS Using nationally-representative data from Zambia Demographic Health Surveys (2001/2, 2007, 2013/14 and 2018), we examined trends and levels of inequalities in under-five mortality, intervention coverage, household water and sanitation, and fertility. This analysis was integrated with an in-depth review of key policy and program documents relevant to improving child survival in Zambia between 1990 and 2020. RESULTS The under-five mortality rate (U5MR) declined from 168 to 64 deaths per 1000 live births between 2001/2 and 2018 ZDHS rounds, particularly in the post-neonatal period. There were major reductions in U5MR inequalities between wealth, education and urban-rural residence groups. Yet reduced gaps between wealth groups in estimated absolute income or education levels did not simultaneously occur. Inequalities reduced markedly for coverage of reproductive, maternal, newborn and child health (RMNCH), malaria and human immunodeficiency virus interventions, but less so for water or sanitation and fertility levels. Several policy and health systems drivers were identified for reducing RMNCH inequalities: policy commitment to equity in RMNCH; financing with a focus on disadvantaged groups; multisectoral partnerships and horizontal programming; expansion of infrastructure and human resources for health; and involvement of community stakeholders and service providers. CONCLUSION Zambia's major progress in reducing inequalities in child survival between the poorest and richest people appeared to be notably driven by government policies and programs that centrally valued equity, despite ongoing gaps in absolute income and education levels. Future work should focus on sustaining these gains, while targeting families that have been left behind to achieve the sustainable development goal targets.
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Affiliation(s)
- Choolwe Jacobs
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia.
| | - Mwiche Musukuma
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia
| | | | | | | | | | - Charles Michelo
- School of Public Health, University of Zambia, Box 50110, Lusaka, Zambia
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Lewin S, Lehmann U, Perry HB. Community health workers at the dawn of a new era: 3. Programme governance. Health Res Policy Syst 2021; 19:129. [PMID: 34641914 PMCID: PMC8506073 DOI: 10.1186/s12961-021-00749-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Community health workers (CHWs) can play a critical role in primary healthcare and are seen widely as important to achieving the health-related Sustainable Development Goals (SDGs). The COVID-19 pandemic has emphasized the key role of CHWs. Improving how CHW programmes are governed is increasingly recognized as important for achieving universal access to healthcare and other health-related goals. This paper, the third in a series on "Community Health Workers at the Dawn of a New Era", aims to raise critical questions that decision-makers need to consider for governing CHW programmes, illustrate the options for governance using examples of national CHW programmes, and set out a research agenda for understanding how CHW programmes are governed and how this can be improved. METHODS We draw from a review of the literature as well as from the knowledge and experience of those involved in the planning and management of CHW programmes. RESULTS Governing comprises the processes and structures through which individuals, groups, programmes, and organizations exercise rights, resolve differences, and express interests. Because CHW programmes are located between the formal health system and communities, and because they involve a wide range of stakeholders, their governance is complex. In addition, these programmes frequently fall outside of the governance structures of the formal health system or are poorly integrated with it, making governing these programmes more challenging. We discuss the following important questions that decision-makers need to consider in relation to governing CHW programmes: (1) How and where within political structures are policies made for CHW programmes? (2) Who implements decisions regarding CHW programmes and at what levels of government? (3) What laws and regulations are needed to support the programme? (4) How should the programme be adapted across different settings or groups within the country or region? CONCLUSION The most appropriate and acceptable models for governing CHW programmes depend on communities, on local health systems, and on the political system in which the programme is located. Stakeholders in each setting need to consider what systems are currently in place and how they might be adapted to local needs and systems.
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Affiliation(s)
- Simon Lewin
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Henry B Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Uneke CJ, Sombie I, Johnson E, Uneke BI. Lessons Learned from Strategies for Promotion of Evidence-to-Policy Process in Health Interventions in the ECOWAS Region: A Rapid Review. Niger Med J 2021; 61:227-236. [PMID: 33487844 PMCID: PMC7808283 DOI: 10.4103/nmj.nmj_188_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/04/2020] [Accepted: 09/03/2020] [Indexed: 11/25/2022] Open
Abstract
Context: The West African Health Organization (WAHO) is vigorously supporting evidence-informed policymaking (EIPM) in the countries of West Africa. EIPM is increasingly recognized as one of the key strategies that can contribute to health systems strengthening and the improvement of health outcomes. The purpose of this rapid review is to examine two key examples of evidence-based strategies used to successfully implement health interventions in each of the West African countries and to highlight the lessons learned. Methods: A rapid review technique, defined as a type of knowledge synthesis in which systematic review processes are accelerated and methods are streamlined to complete the review more quickly, was used. A PubMed search was conducted using the combination of the following keywords: Health, policy making, evidence, plus name of each of the 15 countries to identify studies that described the process of use of evidence in policymaking in health interventions. Two examples of the publications that fulfilled the study inclusion criteria were selected. Results: Among the key processes used by the countries to promote EIPM in health interventions include policy cycle mechanism and political prioritization, rapid response services, technical advisory group and steering committees (SCs), policy dialog, capacity-strengthening mechanisms, local context evidence and operational guidelines, multisectoral action and consultative process. Conclusion: Various degrees of success have been achieved in by West African countries in the promotion of EIPM. As the science of EIPM continues to evolve and better understanding of the process is gained among policymakers, more studies on effective strategies to improve the evidence-to-policy process are advocated.
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Affiliation(s)
- Chigozie Jesse Uneke
- Department of Health Policy/Systems, African Institute for Health Policy and Health Systems, Ebonyi State University, CAS Campus, Abakaliki, Nigeria
| | - Issiaka Sombie
- Department of Public Health and Research, West African Health Organisation, 175, Avenue Ouezzin Coulibaly, Bobo Dioulasso 01 01 BP 153, Burkina Faso
| | - Ermel Johnson
- Department of Public Health and Research, West African Health Organisation, 175, Avenue Ouezzin Coulibaly, Bobo Dioulasso 01 01 BP 153, Burkina Faso
| | - Bilikis Iyabo Uneke
- Department of Health Policy/Systems, African Institute for Health Policy and Health Systems, Ebonyi State University, CAS Campus, Abakaliki, Nigeria
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Brault MA, Mwinga K, Kipp AM, Kennedy SB, Maimbolwa M, Moyo P, Ngure K, Haley CA, Vermund SH. Measuring child survival for the Millennium Development Goals in Africa: what have we learned and what more is needed to evaluate the Sustainable Development Goals? Glob Health Action 2020; 13:1732668. [PMID: 32114967 PMCID: PMC7067162 DOI: 10.1080/16549716.2020.1732668] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Reducing child mortality is a key global health challenge. We examined reasons for greater or lesser success in meeting under-five mortality rate reductions, i.e. Millennium Development Goal #4, between 1990 and 2015 in Sub-Saharan Africa where child mortality remains high. We first examined factors associated with child mortality from all World Health Organization African Region nations during the Millennium Development Goal period. This analysis was followed by case studies of the facilitators and barriers to Millennium Development Goal #4 in four countries – Kenya, Liberia, Zambia, and Zimbabwe. Quantitative indicators, policy documents, and qualitative interviews and focus groups were collected from each country to examine factors within and across countries related to child mortality. We found familiar themes that highlighted the need for both specific services (e.g. primary care access, emergency obstetric and neonatal care) and general management (e.g. strong health governance and leadership, increasing community health workers, quality of care). We also identified methodological opportunities and challenges to assessing progress in child health, which can provide insights to similar efforts during the Sustainable Development Goal period. Specifically, it is important for countries to adapt general international goals and measurements to their national context, considering baseline mortality rates and health information systems, to develop country-specific goals. It will also be critical to develop more rigorous measurement tools and indicators to accurately characterize maternal, neonatal, and child health systems, particularly in the area of governance and leadership. Valuable lessons can be learned from Millennium Development Goal successes and failures, as well as how they are evaluated. As countries seek to lower child mortality further during the Sustainable Development Goal period, it will be necessary to prioritize and support countries in quantitative and qualitative data collection to assess and contextualize progress, identifying areas needing improvement.
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Affiliation(s)
- Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Kasonde Mwinga
- Rwanda Country Office, World Health Organization, Kigali, Rwanda (Formerly, WHO African Regional Office, Brazzaville, Congo)
| | - Aaron M Kipp
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, TN, USA.,Department of Medicine, Division of Epidemiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephen B Kennedy
- University of Liberia-Pacific Institute for Research & Evaluation (UL-PIRE) Africa Center, University of Liberia, Monrovia, Liberia
| | - Margaret Maimbolwa
- Department of Nursing Sciences, University of Zambia School of Medicine, Lusaka, Zambia
| | - Precious Moyo
- Collaborative Research Program, University of Zimbabwe-University of California, San Francisco, Harare, Zimbabwe
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Connie A Haley
- Division of Infectious Diseases and Global Medicine, University of Florida, Gainesville, FL, USA
| | - Sten H Vermund
- Office of the Dean, Yale School of Public Health, New Haven, CT, USA
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