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Barsosio HC, Webster J, Omiti F, K'Oloo A, Odero IA, Ojuok MA, Odiwa D, Omondi B, Okello E, Dodd J, Taegtmeyer M, Kuile FOT, Lesosky M, Kariuki S, Hill J. Delivery effectiveness of and adherence to intermittent preventive treatment for malaria in pregnancy with dihydroartemisinin-piperaquine with or without targeted information transfer or sulfadoxine-pyrimethamine in western Kenya: a three-armed, pragmatic, open-label, cluster-randomised trial. Lancet Glob Health 2024; 12:e1660-e1672. [PMID: 39304238 DOI: 10.1016/s2214-109x(24)00261-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 05/21/2024] [Accepted: 06/10/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND High-level resistance to sulfadoxine-pyrimethamine threatens the efficacy of WHO-recommended intermittent preventive treatment in pregnancy (IPTp) with single-dose sulfadoxine-pyrimethamine to prevent malaria. Monthly IPTp with dihydroartemisinin-piperaquine, a 3-day regimen, is an emerging alternative, but this regimen poses potential implementation and adherence challenges. We aimed to assess adherence to a multiday IPTp with dihydroartemisinin-piperaquine regimen and its delivery effectiveness in routine antenatal care settings in western Kenya. METHODS We conducted a pragmatic, three-armed, open-label, cluster-randomised trial in antenatal clinics in 18 health-care facilities (six facilities per group) in Kisumu County and Homa Bay County in western Kenya. Clusters were facilities offering routine antenatal care services provided by trained Ministry of Health staff with 100 or more antenatal clinic attendances per month between July, 2018, and June, 2019. Private or mission hospitals, dispensaries, referral hospitals, and trial sites were excluded. Individuals in their first trimester, living with HIV, or who were not attending a scheduled antenatal clinic visit were excluded. The 18 antenatal clinics were grouped into matched triplets stratified by location and clinics in each matched triplet were randomly assigned to one of the three study groups (1:1:1). Masking was not possible. Two groups were given IPTp with dihydroartemisinin-piperaquine (one group with a targeted information transfer intervention and one group without any additional interventions) and one group was given the standard of care (ie, IPTp with sulfadoxine-pyrimethamine). The primary endpoint, adherence, was defined as the proportion of participants completing their most recent 3-day IPTp with dihydroartemisinin-piperaquine regimen. This completion was verified by pill counts during home visits no more than 2 days after participants' 3-day regimens ended. The secondary endpoint, delivery effectiveness, was defined as the proportion of participants who received the correct number of IPTp tablets and correctly repeated dosing instructions (ie, correctly recalled the instructions they received about self-administered dihydroartemisinin-piperaquine doses and the number of sulfadoxine-pyrimethamine tablets they had received) at their exit from the antenatal clinic. Individuals receiving treatment for malaria, visiting a clinic for registration only, or interviewed during IPTp drug stock-outs were excluded from analyses. We used generalised linear mixed models to compare endpoints among the IPTp with dihydroartemisinin-piperaquine groups. This trial was registered with ClinicalTrials.gov, NCT04160026, and is complete. FINDINGS 15 facilities (five per group) completed the trial, with 1189 participants having exit interviews (377 in the IPTp with sulfadoxine-pyrimethamine group, 408 in the IPTp with dihydroartemisinin-piperaquine only group, and 404 in the IPTp with dihydroartemisinin-piperaquine plus targeted information transfer intervention group) and 586 participants having home visits (267 in the IPTp with dihydroartemisinin-piperaquine only group and 319 in the IPTp with dihydroartemisinin-piperaquine plus targeted information transfer intervention group) from Sept 8 to Dec 10, 2020. Relative to the IPTp with dihydroartemisinin-piperaquine only group, adherence was 16% higher in the IPTp with dihydroartemisinin-piperaquine plus targeted information transfer intervention group (266 [83%] of 319 participants vs 196 [73%] of 267 participants; adjusted relative risk [RR] 1·16, 95% CI 1·03-1·31; p=0·0140). Delivery effectiveness in the IPTp with dihydroartemisinin-piperaquine plus targeted information transfer intervention group was not significantly different from that in the IPTp with sulfadoxine-pyrimethamine group (352 [87%] of 403 participants vs 335 [89%] of 375 participants; adjusted RR 0·97, 95% CI 0·90-1·05; p=0·4810). However, delivery effectiveness in the IPTp with dihydroartemisinin-piperaquine only group was significantly lower than in the IPTp with sulfadoxine-pyrimethamine group (300 [74%] of 404 participants vs 335 [89%] of 375 participants; 0·84, 0·75-0·95; p=0·0030). INTERPRETATION Targeted information transfer interventions to health-care providers and pregnant individuals boost antenatal care delivery adherence to a multiday regimen with dihydroartemisinin-piperaquine. FUNDING European and Developing Countries Clinical Trials Partnership 2, UK Joint Global Health Trials Scheme of the Foreign, Commonwealth and Development Office, Medical Research Council, National Institute for Health and Care Research, and Wellcome Trust; and Swedish International Development Cooperation Agency.
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Affiliation(s)
- Hellen C Barsosio
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya.
| | - Jayne Webster
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Frederick Omiti
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Alloys K'Oloo
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Isdorah A Odero
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Michael A Ojuok
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Dawn Odiwa
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Benson Omondi
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Elizabeth Okello
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - James Dodd
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK; Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Maia Lesosky
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Mukherji A, Rao M, Desai S, Subramanian SV, Kang G, Patel V. District-level monitoring of universal health coverage, India. Bull World Health Organ 2024; 102:630-638B. [PMID: 39219770 PMCID: PMC11362688 DOI: 10.2471/blt.23.290854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/19/2024] [Accepted: 05/20/2024] [Indexed: 09/04/2024] Open
Abstract
Objective To develop a framework and index for measuring universal health coverage (UHC) at the district level in India and to assess progress towards UHC in the districts. Methods We adapted the framework of the World Health Organization and World Bank to develop a district-level UHC index (UHC d ). We used routinely collected health survey and programme data in India to calculate UHC d for 687 districts from geometric means of 24 tracer indicators in five tracer domains: reproductive, maternal, newborn and child health; infectious diseases; noncommunicable diseases; service capacity and access; and financial risk protection. UHC d is on a scale of 0% to 100%, with higher scores indicating better performance. We also assessed the degree of inequality within districts using a subset of 14 tracer indicators. The disadvantaged subgroups were based on four inequality dimensions: wealth quintile, urban-rural location, religion and social group. Findings The median UHC d was 43.9% (range: 26.4 to 69.4). Substantial geographical differences existed, with districts in southern states having higher UHC d than elsewhere in India. Service coverage indicator levels were greater than 60%, except for noncommunicable diseases and for service capacity and access. Health insurance coverage was limited, with about 10% of the population facing catastrophic and impoverishing health expenditure. Substantial wealth-based disparities in UHC were seen within districts. Conclusion Our study shows that UHC can be measured at the local level and can help national and subnational government develop prioritization frameworks by identifying health-care delivery and geographic hotspots where limited progress towards UHC is being made.
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Affiliation(s)
- Arnab Mukherji
- Centre for Public Policy, Indian Institute of Management, IIM Bangalore, Bengaluru, Karnataka560076, India
| | - Megha Rao
- Centre for Health Economics, University of York, York, England
| | - Sapna Desai
- Population Council Institute, New Delhi, India
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, United States of America (USA)
| | - Gagandeep Kang
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Cambridge, USA
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Ahsan A, Amalia N, Rahmayanti KP, Adani N, Wiyono NH, Endawansa A, Utami MG, Miranti Yuniar A, Anastasia EV, Pertiwi YBA. Political economy analysis of health taxes (tobacco, alcohol drink and sugar-sweteened beverage): qualitative study of three provinces in Indonesia. BMJ Open 2024; 14:e085863. [PMID: 39107020 PMCID: PMC11308894 DOI: 10.1136/bmjopen-2024-085863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 07/22/2024] [Indexed: 08/09/2024] Open
Abstract
OBJECTIVE Efforts to implement health tax policies to control the consumption of harmful commodities and enhance public health outcomes have garnered substantial recognition globally. However, their successful adoption remains a complex endeavour. This investigates the challenges and opportunities surrounding health tax implementation, with a particular focus on subnational government in Indonesia, where the decentralisation context of health tax remains understudied. DESIGN Employing a qualitative methodology using a problem-driven political economy analysis approach. SETTING We are collecting data from a total of 12 focus group discussions (FGDs) conducted between July and September 2022 in three provinces-Lampung, Special Region of/Daerah Istimewa Yogyakarta and Bali, each chosen to represent a specific commodity: tobacco, sugar-sweetened beverages (SSBs) and alcoholic beverages-we explore the multifaceted dynamics of health tax policies. PARTICIPANT These FGDs involved a mean of 10 participants in each FGD, representing governmental institutions, non-governmental organisations and consumers. RESULTS Our findings reveal that health tax policies have the potential to contribute significantly to public health. Consumers understand tobacco's health risks, and cultural factors influence both tobacco and alcohol consumption. For SSBs, the consumers lack awareness of long-term health risks is concerning. Finally, bureaucratic complexiting and decentralised government hinder implementation for all three commodities. CONCLUSION Furthermore, this study underscores the importance of effective policy communication. It highlights the importance of earmarking health tax revenues for public health initiatives. It also reinforces the need to see health taxes as one intervention as part of a comprehensive public health approach including complementary non-fiscal measures like advertising restrictions and standardised packaging. Addressing these challenges is critical for realising the full potential of health tax policies.
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Affiliation(s)
- Abdillah Ahsan
- Department of Economics, University of Indonesia Faculty of Economics and Business, Depok, Jawa Barat, Indonesia
| | - Nadira Amalia
- Department of Economics, Faculty of Economics and Administration, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Krisna Puji Rahmayanti
- Department of Public Administration, Faculty of Administrative Science, Universitas Indonesia, Depok, Jawa Barat, Indonesia
| | - Nadhila Adani
- Department of Economics, University of Indonesia Faculty of Economics and Business, Depok, Jawa Barat, Indonesia
| | - Nur Hadi Wiyono
- Faculty of Economics, University of Indonesia, Demographic Institute, Depok, Jawa Barat, Indonesia
| | - Althof Endawansa
- Faculty of Economics, University of Indonesia, Demographic Institute, Depok, Jawa Barat, Indonesia
| | - Maulida Gadis Utami
- Department of Economics, University of Indonesia Faculty of Economics and Business, Depok, Jawa Barat, Indonesia
| | - Adela Miranti Yuniar
- Department of Economics, University of Indonesia Faculty of Economics and Business, Depok, Jawa Barat, Indonesia
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Mukiga AK, Boadu ES, Edson T. Perceived Public Participation and Health Delivery in Local Government Districts in Uganda. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:820. [PMID: 39063398 PMCID: PMC11276518 DOI: 10.3390/ijerph21070820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/13/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024]
Abstract
Citizen participation is a crucial aspect of the national health system, empowering individuals to contribute to improving local health services through Health Committees (HCs). HCs promote the participation of citizens in the delivery of primary healthcare services. The study explores the perceptions of citizen participation in the context of the Ruhama County Ntungamo local government area, Uganda. This study aims to understand the impact of HCs on healthcare service delivery. Using a qualitative approach of inquiry grounded in thematic analysis and rooted in principal-agent theory in a single case study, this study examined citizens' participation in the delivery of a local healthcare service. The study is based on interviews with 66 participants comprising health workers, patients, residents, health administrators, local councillors, and HC members. The findings reveal a notable absence of a health committee in healthcare delivery in Ruhama County. The absence is attributed to a need for a formalised citizen participation structure in managing health facilities and service delivery. It raises concerns about the limited influence of citizens in shaping healthcare policies and decision-making processes. The study recommends the incorporation of health committees into the local health systems to enhance participation and grant communities greater influence over the management of health facilities and service delivery. Incorporating health committees into local health systems strengthens citizen participation and leads to more effective and sustainable healthcare services aligned with people's needs and preferences. Integrating health committees within Itojo Hospital and similar facilities can grant citizens a meaningful role in shaping the future of their healthcare.
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Affiliation(s)
- Alex Kihehere Mukiga
- Centre for Development Support, University of Free State, Bloemfontein 9300, South Africa
| | - Evans Sakyi Boadu
- School of Governance, University of the Witwatersrand, Johannesburg 2050, South Africa;
- School of Sustainable Development, University of Environment and Sustainable Development (UESD), Somanya 00233, Ghana
| | - Tayebwa Edson
- Department of Surgery, Mbarara University of Science and Technology, Mbarara 1410, Uganda
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Sapkota S, Dhakal A, Rushton S, van Teijlingen E, Marahatta SB, Balen J, Lee AC. The impact of decentralisation on health systems: a systematic review of reviews. BMJ Glob Health 2023; 8:e013317. [PMID: 38135299 DOI: 10.1136/bmjgh-2023-013317] [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: 07/04/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Decentralisation is a common mechanism for health system reform; yet, evidence of how it impacts health systems remains fragmented. Despite published findings from primary and secondary research illustrating range of impacts, a comprehensive and clear understanding is currently lacking. This review synthesised the existing evidence to assess how decentralisation (by devolution) impacts each of the six WHO building blocks, and the health system. METHOD We systematically searched five electronic databases for reviews exploring impact of decentralisation on health systems, globally. Reviews, both systematic and non-systematic, published in the English language from January 1990 to February 2022 were included. Data were synthesised across each of six building blocks. Quality assessment of the reviews was conducted using Critical Appraisal Skills Program for systematic and Scale for Assessment of Narrative Review Articles for non-systematic reviews. RESULTS Nine reviews, each addressing somewhat different questions, contexts and issues, were included. A range of positive and negative impacts of decentralisation on health system building blocks were identified; yet, overall, the impacts were more negative. Although inconclusive, evidence suggested that the impacts on leadership and governance and financing components in particular shape the impact on overall health system. Assessment of how the impact on building blocks translates to the broader impact on health systems is challenged by the dynamic complexities related to contexts, process and the health system itself. CONCLUSIONS Decentralisation, even if well intentioned, can have unintended consequences. Despite the difficulty of reaching universally applicable conclusions about the pros and cons of decentralisation, this review highlights some of the common potential issues to consider in advance. PROSPERO REGISTRATION NUMBER CRD42022302013.
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Affiliation(s)
- Sujata Sapkota
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Amshu Dhakal
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Simon Rushton
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- The University of Sheffield, Sheffield, UK
| | - Edwin van Teijlingen
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- Bournemouth University, Poole, UK
| | - Sujan B Marahatta
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- Nepal Open University, Lalitpur, Nepal
| | - Julie Balen
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- The University of Sheffield, Sheffield, UK
- Canterbury Christ Church University, Canterbury, UK
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Cartmell KB, Doherty EA, Gikaara N, Ali Z, Qanungo S, Melikam ES, Powell RA. Kenyan palliative care providers' and leaders' perceptions of palliative care research needs and support to facilitate rigorous research. BMC Palliat Care 2023; 22:135. [PMID: 37697339 PMCID: PMC10496291 DOI: 10.1186/s12904-023-01199-0] [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: 09/21/2022] [Accepted: 06/20/2023] [Indexed: 09/13/2023] Open
Abstract
BACKGROUND Palliative care (PC) can reduce symptom distress and improve quality of life for patients and their families experiencing life-threatening illness. While the need for PC in Kenya is high, PC service delivery and research is limited. Qualitative research is needed to explore potential areas for PC research and support needed to enable that research. This insight is critical for informing a national PC research agenda and mobilizing limited resources for conducting rigorous PC research in Kenya. OBJECTIVES To explore perceptions of priority areas for PC research and support needed to facilitate rigorous research from the perspective of Kenyan PC providers and leaders. METHODS Focus groups (FGs) were conducted in November and December of 2018 using a semi-structured interview guide. FGs were audio-recorded, transcribed, and analyzed using a thematic content analysis approach. RESULTS Three FGs were conducted (n = 22 participants). Ten themes related to PC research emerged, including research on: 1) beliefs about death, disease, and treatment to inform PC; 2) awareness about PC, 3) integration of PC within the health system; 4) understanding caregiver experiences and needs; 5) community health volunteers (CHVs) and volunteer programs; 6) evaluation of costs and benefits of PC; 7) treatment approaches, including complementary and alternative medicine (CAM) and advanced diagnostics at end of life; 8) other suggestions for research, 9) populations in need of PC research; and 10) resources for enabling research. CONCLUSIONS Kenyan PC providers and leaders identified key areas requiring increased scientific inquiry and critical resources needed to enable this research. These findings can help to focus future PC research in Kenya and encourage funding agencies to prioritize the issues identified.
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Affiliation(s)
- K B Cartmell
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA.
| | - E A Doherty
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - N Gikaara
- Department of Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Z Ali
- Kenyan Hospice and Palliative Care Association, Nairobi, Kenya
| | - S Qanungo
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - E S Melikam
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - R A Powell
- Department of Primary Care and Public Health, Faculty of Medicine, Imperial College London, London, England
- Ethnicity and Health Unit, NIHR Applied Research Collaboration Northwest London, London, England
- MWAPO Health Development Group, Nairobi, Kenya
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Tshabalala K, Rispel LC. Piercing the veil on the functioning and effectiveness of district health system governance structures: perspectives from a South African province. Health Res Policy Syst 2023; 21:89. [PMID: 37653433 PMCID: PMC10469879 DOI: 10.1186/s12961-023-01044-z] [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: 06/19/2023] [Accepted: 08/11/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures. METHODS This was a mixed-methods, cross-sectional study in GP's five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members' perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively. RESULTS Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities. CONCLUSION In light of South Africa's move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms.
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Affiliation(s)
- Khanyisile Tshabalala
- Department of Public Health Medicine, School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, 31 Bophelo Rd, Prinshof, Pretoria, South Africa.
- Department of Community Health, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 27 St Andrew's Road, Parktown, 2193, South Africa.
| | - Laetitia C Rispel
- Centre for Health Policy & South African Research Chairs Initiative (SARChI), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 27 St Andrew's Road, Parktown, 2193, South Africa
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Li B, Alharbi M, Allender S, Swinburn B, Peters R, Foster C. Comprehensive application of a systems approach to obesity prevention: a scoping review of empirical evidence. Front Public Health 2023; 11:1015492. [PMID: 37614454 PMCID: PMC10442543 DOI: 10.3389/fpubh.2023.1015492] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 06/12/2023] [Indexed: 08/25/2023] Open
Abstract
A systems approach to obesity prevention is increasingly urged. However, confusion exists on what a systems approach entails in practice, and the empirical evidence on this new approach is unclear. This scoping review aimed to identify and synthesise studies/programmes that have comprehensively applied a systems approach to obesity prevention in intervention development, delivery/implementation, and evaluation. By searching international databases and grey literature, only three studies (10 publications) met inclusion criteria, which might be explained partially by suboptimal reporting. No conclusion on the effectiveness of this approach can be drawn yet due to the limited evidence base. We identified common features shared by the included studies, such as measuring ongoing changes, in addition to endpoint outcomes, and supporting capacity building. Some facilitators and barriers to applying a comprehensive systems approach in practice were identified. More well-designed and reported studies are needed, especially from low- and middle-income countries.
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Affiliation(s)
- Bai Li
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, United Kingdom
| | - Mohammed Alharbi
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, United Kingdom
| | - Steve Allender
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Boyd Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand
| | - Remco Peters
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, United Kingdom
| | - Charlie Foster
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, United Kingdom
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Brennan E, Abimbola S. The impact of decentralisation on health systems in fragile and post-conflict countries: a narrative synthesis of six case studies in the Indo-Pacific. Confl Health 2023; 17:31. [PMID: 37340483 DOI: 10.1186/s13031-023-00528-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/14/2023] [Indexed: 06/22/2023] Open
Abstract
A health system has three key stakeholders, the State-at national and subnational levels-the health service providers and the citizens. In most settings and especially in peacetime, these stakeholders are typically well-defined. In contrast, during conflict and crisis as well as during ceasefire and post-conflict peacebuilding, stakeholders in the health system are often more diverse and contested. Health systems in such settings tend to be more decentralised, de facto-often in addition to de jure decentralisation. Despite much debate on the potential benefits of decentralisation, assessing its impact on health system performance remains difficult and its effect is open to dispute in the literature. This narrative synthesis aims to support efforts to assess and make sense of how decentralisation impacts health system performance in fragile and post-conflict countries-by synthesising evidence on the impact of decentralisation on health system performance from six country case studies: Papua New Guinea, the Philippines, Indonesia, Pakistan, Myanmar and Nepal. The impact of decentralisation on health system performance is optimised when combining centralisation (e.g., the benefits of central coordination in improving efficiency) with decentralisation (e.g., the benefits of local decision making in improving equity and resilience). The findings may inform efforts to think through what to centralise or decentralise, the impacts of those choices, and how the impact may change over time as countries go through and emerge from conflict-and as they go through and recover from the Covid-19 pandemic and prepare for future pandemics.
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Affiliation(s)
- Elliot Brennan
- Sydney School of Public Health Sydney Medical School, University of Sydney, Edward Ford Building A27, Sydney, NSW, 2006, Australia.
| | - Seye Abimbola
- Sydney School of Public Health Sydney Medical School, University of Sydney, Edward Ford Building A27, Sydney, NSW, 2006, Australia
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Karuga R, Dieleman M, Mbindyo P, Ozano K, Wairiuko J, Broerse JEW, Kok M. Community participation in the health system: analyzing the implementation of community health committee policies in Kenya. Prim Health Care Res Dev 2023; 24:e33. [PMID: 37114463 PMCID: PMC10156468 DOI: 10.1017/s1463423623000208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Community health committees (CHCs) are a mechanism for communities to voluntarily participate in making decisions and providing oversight of the delivery of community health services. For CHCs to succeed, governments need to implement policies that promote community participation. Our research aimed to analyze factors influencing the implementation of CHC-related policies in Kenya. METHODS Using a qualitative study design, we extracted data from policy documents and conducted 12 key informant interviews with health workers and health managers in two counties (rural and urban) and the national Ministry of Health. We applied content analysis for both the policy documents and interview transcripts and summarized the factors that influenced the implementation of CHC-related policies. FINDINGS Since the inception of the community health strategy, the roles of CHCs in community participation have been consistently vague. Primary health workers found the policy content related to CHCs challenging to translate into practice. They also had an inadequate understanding of the roles of CHCs, partly because policy content was not adequately disseminated at the primary healthcare level. It emerged that actors involved in organizing and providing community health services did not perceive CHCs as valuable mechanisms for community participation. County governments did not allocate funds to support CHC activities, and policies focused more on incentivizing community health volunteers (CHVs) who, unlike CHCs, provide health services at the household level. CHVs are incorporated in CHCs. CONCLUSION Kenya's community health policy inadvertently created role conflict and competition for resources and recognition between community health workers involved in service delivery and those involved in overseeing community health services. Community health policies and related bills need to clearly define the roles of CHCs. County governments can promote the implementation of CHC policies by including CHCs in the agenda during the annual review of performance in the health sector.
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Affiliation(s)
- Robinson Karuga
- LVCT Health, Nairobi, Kenya
- Athena Institute, Vrije University, Amsterdam, The Netherlands
| | | | - Patrick Mbindyo
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Kim Ozano
- The SCL Agency, Five Fords Gate, Wrexham, Wales, UK
| | - Judy Wairiuko
- Directorate of Preventive and Promotive Health, Nairobi City County, City Hall Way, Nairobi, Kenya
| | | | - Maryse Kok
- KIT Royal Tropical Institute, Amsterdam, Netherlands
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Delamou A, Grovogui FM, Miller L, Nye A, Kourouma M, Kolié D, Goumou T, Bossert TJ. Implementation research protocol on the national community health policy in Guinea: A sequential mixed-methods study using a decision space approach. PLoS One 2023; 18:e0280651. [PMID: 36662762 PMCID: PMC9858093 DOI: 10.1371/journal.pone.0280651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 01/05/2023] [Indexed: 01/21/2023] Open
Abstract
The overall goal of this study is to explore the rollout of the community health policy in Guinea in the context of decentralization, and the role of decision space (the decision authority, capacities, and accountability of local officials) in explaining gaps between the policy's conceptualization and actual implementation. The implementation research study will employ a sequential explanatory mixed-methods design. The study will be conducted in 27 communes purposefully selected across the country and include communes where the national community health policy is fully, partially, and not yet being implemented. The quantitative component, based on a survey questionnaire and secondary data, will use ordinary least squares (OLS) multiple regression to compare maternal and child health (MCH) coverage indicators according to the level of policy implementation in the commune. An interrupted time series analysis will be conducted to assess changes in routine MCH service delivery indicators associated with implementation of the community health policy, comparing indicators from one year prior to implementation. OLS regression will be conducted to assess the association between decision space and MCH indicators; all analyses will be carried out in Stata. Findings from the quantitative study will be used to inform the key qualitative questions and areas to explore in greater depth, to develop the interview and focus group guides, and to generate an initial codebook. Qualitative data will be double coded in NVivo by two qualitative analysts, and results generated using thematic analysis. Findings from the quantitative and qualitative components will be integrated and triangulated for interpretation and reporting. Findings and recommendations of this study will inform revisions to the National Community Health Policy to improve its rollout and effectiveness.
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Affiliation(s)
- Alexandre Delamou
- African Centre for Excellence (CEA-PCMT), University Gamal Abdel Nasser of Conakry, Conakry, Guinea
- Maferinyah Training and Research Center in Rural Health, Forécariah, Guinea
| | - Fassou Mathias Grovogui
- African Centre for Excellence (CEA-PCMT), University Gamal Abdel Nasser of Conakry, Conakry, Guinea
- Maferinyah Training and Research Center in Rural Health, Forécariah, Guinea
| | - Lior Miller
- Results for Development Institute, Washington, D.C., United States of America
| | - Amy Nye
- Results for Development Institute, Washington, D.C., United States of America
| | - Mamadi Kourouma
- National Directorate of Community Health and Traditional Medicine, Ministry of Health and Public Hygiene, Conakry, Guinea
| | - Delphin Kolié
- African Centre for Excellence (CEA-PCMT), University Gamal Abdel Nasser of Conakry, Conakry, Guinea
- Maferinyah Training and Research Center in Rural Health, Forécariah, Guinea
| | - Tohanizé Goumou
- National Directorate of Community Health and Traditional Medicine, Ministry of Health and Public Hygiene, Conakry, Guinea
| | - Thomas J. Bossert
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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12
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Mulupi S, Ayakaka I, Tolhurst R, Kozak N, Shayo EH, Abdalla E, Osman R, Egere U, Mpagama SG, Chinouya M, Chikaphupha KR, ElSony A, Meme H, Oronje R, Ntinginya NE, Obasi A, Taegtmeyer M. What are the barriers to the diagnosis and management of chronic respiratory disease in sub-Saharan Africa? A qualitative study with healthcare workers, national and regional policy stakeholders in five countries. BMJ Open 2022; 12:e052105. [PMID: 35906045 PMCID: PMC9345041 DOI: 10.1136/bmjopen-2021-052105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Chronic respiratory diseases (CRD) are among the top four non-communicable diseases globally. They are associated with poor health and approximately 4 million deaths every year. The rising burden of CRD in low/middle-income countries will strain already weak health systems. This study aimed to explore the perspectives of healthcare workers and other health policy stakeholders on the barriers to effective diagnosis and management of CRD in Kenya, Malawi, Sudan, Tanzania and Uganda. STUDY DESIGN Qualitative descriptive study. SETTINGS Primary, secondary and tertiary health facilities, government agencies and civil society organisations in five sub-Saharan African countries. PARTICIPANTS We purposively selected 60 national and district-level policy stakeholders, and 49 healthcare workers, based on their roles in policy decision-making or health provision, and conducted key informant interviews and in-depth interviews, respectively, between 2018 and 2019. Data were analysed through framework approach. RESULTS We identified intersecting vicious cycles of neglect of CRD at strategic policy and healthcare facility levels. Lack of reliable data on burden of disease, due to weak information systems and diagnostic capacity, negatively affected inclusion in policy; this, in turn, was reflected by low budgetary allocations for diagnostic equipment, training and medicines. At the healthcare facility level, inadequate budgetary allocations constrained diagnostic capacity, quality of service delivery and collection of appropriate data, compounding the lack of routine data on burden of disease. CONCLUSION Health systems in the five countries are ill-equipped to respond to CRD, an issue that has been brought into sharp focus as countries plan for post-COVID-19 lung diseases. CRD are underdiagnosed, under-reported and underfunded, leading to a vicious cycle of invisibility and neglect. Appropriate diagnosis and management require health systems strengthening, particularly at the primary healthcare level.
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Affiliation(s)
- Stephen Mulupi
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Irene Ayakaka
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Lung Institute, Makerere University, Kampala, Uganda
| | - Rachel Tolhurst
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicole Kozak
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Health Systems and Policy Research Unit, REACH Trust Malawi, Lilongwe, Malawi
| | - Elizabeth Henry Shayo
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- National Institute of Medical Research, Mbeya, United Republic of Tanzania
| | | | - Rashid Osman
- Lung Health Department, Epi-Lab, Khartoum, Sudan
| | - Uzochukwu Egere
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stellah G Mpagama
- Medical Department, Kibong'oto Infectious Diseases Hospital/Kilimanjaro Christian Medical University, Kilimanjaro, United Republic of Tanzania
| | - Martha Chinouya
- Education Department, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Asma ElSony
- Lung Health Department, Epi-Lab, Khartoum, Sudan
| | - Helen Meme
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Rose Oronje
- African Institute for Development Policy (AFIDEP), Nairobi, Kenya
| | - Nyanda Elias Ntinginya
- National Institute for Medical Research (NIMR), Mbeya Medical Research Centre, Mbeya, Tanzania, United Republic of
| | - Angela Obasi
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- AXESS Sexual Health, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Miriam Taegtmeyer
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Sripad P, Merritt MW, Kerrigan D, Abuya T, Ndwiga C, Warren CE. Determining a Trusting Environment for Maternity Care: A Framework Based on Perspectives of Women, Communities, Service Providers, and Managers in Peri-Urban Kenya. Front Glob Womens Health 2022; 3:818062. [PMID: 35528311 PMCID: PMC9069110 DOI: 10.3389/fgwh.2022.818062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/17/2022] [Indexed: 11/18/2022] Open
Abstract
Trust in health service providers and facilities is integral to health systems accountability. Understanding determinants of trust, a relational construct, in maternity settings necessitates exploring hierarchical perspectives of users, providers, and influencers in the care environment. We used a theoretically driven qualitative approach to explore trust determinants in a maternity setting across patient-provider, inter-provider, and community-policymaker interactions and relationships in peri-urban Kenya. Focus groups (n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews (n = 33) with WRB, health care providers and managers, and community health workers (CHWs) were conducted in 2013, soon after the national government's March 2013 introduction of a policy mandate for "Free Maternity Care." We used thematic coding, memo writing, and cross-perspective triangulation to develop a multi-faceted trust determinants framework. We found that determinants of trust in a maternity setting can be broadly classified into six types of factors, where each type of factor represents a cluster of determinants that may each positively or negatively influence trust: patient, provider, health facility, community, accountability, and structural. Patient factors are prior experiences, perceived risks and harms, childbirth outcomes, and maternal health literacy. Provider factors are empathy and respect, responsiveness, and perceived capability of providers. Health facility factors are "good services" as perceived by patients, physical environment, process navigability, provider collaboration and oversight, discrimination, and corruption. Community factors are facility reputation and history, information channels, and maternal health literacy. Accountability factors are alignment of actions with expectations, adaptations to policy changes, and voice and feedback. Structural factors are institutional hierarchies and policies in the form of professional codes. Trust determinants are complex, nuanced and reflect power dynamics across relationships. Findings offer insight into socio-political maternity norms and demand a more equitable care interface between users and providers.
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Affiliation(s)
- Pooja Sripad
- Population Council, Washington, DC, United States
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Maria W. Merritt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
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Duminy J, Cleland J, Harpham T, Montgomery MR, Parnell S, Speizer IS. Urban Family Planning in Low- and Middle-Income Countries: A Critical Scoping Review. Front Glob Womens Health 2021; 2:749636. [PMID: 34816250 PMCID: PMC8593933 DOI: 10.3389/fgwh.2021.749636] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/29/2021] [Indexed: 11/17/2022] Open
Abstract
Health agendas for low- and middle-income countries (LMICs) should embrace and afford greater priority to urban family planning to help achieve a number of the global Sustainable Development Goals. The urgency of doing so is heightened by emerging evidence of urban fertility stalls and reversals in some sub-Saharan African contexts as well as the significance of natural increase over migration in driving rapid urban growth. Moreover, there is new evidence from evaluations of large programmatic interventions focused on urban family planning that suggest ways to inform future programmes and policies that are adapted to local contexts. We present the key dimensions and challenges of urban growth in LMICs, offer a critical scoping review of recent research findings on urban family planning and fertility dynamics, and highlight priorities for future research.
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Affiliation(s)
- James Duminy
- School of Geographical Sciences, University of Bristol, Bristol, United Kingdom
- African Centre for Cities, University of Cape Town, Cape Town, South Africa
| | - John Cleland
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Trudy Harpham
- School of Law and Social Sciences, London South Bank University, London, United Kingdom
| | - Mark R. Montgomery
- Department of Economics, Stony Brook University, Stony Brook, NY, United States
- Population Council, New York, NY, United States
| | - Susan Parnell
- School of Geographical Sciences, University of Bristol, Bristol, United Kingdom
- African Centre for Cities, University of Cape Town, Cape Town, South Africa
| | - Ilene S. Speizer
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States
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15
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Bünder T, Karekezi C, Wirtz V. Governing industry involvement in the non-communicable disease response in Kenya. Global Health 2021; 17:123. [PMID: 34670570 PMCID: PMC8527303 DOI: 10.1186/s12992-021-00776-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In low- and middle-income countries (LMICs), multinational companies have become increasingly involved in addressing public health challenges. Dealing with companies as partners in health sector development creates new challenges for governments. We sought to develop an approach to assess the existence and effectiveness of governance structures that can ensure that industry-led public health initiatives contribute to development. METHODS We developed a governance assessment tool based on the principles of the Paris Declaration for Aid Effectiveness and other related agreements. We applied it to the case of pharmaceutical companies' involvement in the Kenyan response to non-communicable diseases (NCDs). We gathered data for analysis through 46 stakeholder interviews and reviewing documents. RESULTS The Kenyan government has informal norms in place regarding program governance and strategy, but it has yet to issue formal regulations. While enabling elements exist that support initiatives to develop in alignment with these norms, implementation is often hindered by a lack of resources. Currently, broad stakeholder support for filling these gaps has created a window of opportunity for action. CONCLUSION The application of the proposed assessment tool illustrates its viability for assisting companies and governments alike in defining governance needs for industry-led public health initiatives. Our findings in Kenya provide example considerations for LMICs working to integrate industry-led public health programs into the health system. Bilateral and multilateral donors also have important roles in strengthening LMICs' capacities to govern multinational corporations' contributions to NCDs in particular, and development in general.
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Affiliation(s)
- Tobias Bünder
- Hertie School, Friedrichstraße 180, Berlin, 10117, Germany.
| | - Catherine Karekezi
- Non-communicable Diseases Alliance Kenya (NCDAK), KMA Plaza Apartments, Block C Unit 5.2, Mara Road - Upper Hill, P. O Box 5337, Nairobi, Kenya
- Kenya Diabetes Management & Information Centre, Jadala Place, 2nd Floor Office 2.1, Ngong Lane, Ngong Road, P. O. Box 45099 -, Nairobi, 00100, Kenya
| | - Veronika Wirtz
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA
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16
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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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17
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Scanlon ML, Maldonado LY, Ikemeri JE, Jumah A, Anusu G, Chelagat S, Keter JC, Songok J, Ruhl LJ, Christoffersen-Deb A. 'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya. Int J Equity Health 2021; 20:210. [PMID: 34556148 PMCID: PMC8461886 DOI: 10.1186/s12939-021-01549-5] [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: 05/31/2021] [Accepted: 09/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health care workers in Kenya have launched major strikes in the public health sector in the past decade but the impact of strikes on health systems is under-explored. We conducted a qualitative study to investigate maternal and child health care and services during nationwide strikes by health care workers in 2017 from the perspective of pregnant women, community health volunteers (CHVs), and health facility managers. METHODS We conducted in-depth interviews and focus group discussions (FGDs) with three populations: women who were pregnant in 2017, CHVs, and health facility managers. Women who were pregnant in 2017 were part of a previous study. All participants were recruited using convenience sampling from a single County in western Kenya. Interviews and FGDs were conducted in English or Kiswahili using semi-structured guides that probed women's pregnancy experiences and maternal and child health services in 2017. Interviews and FGDs were audio-recorded, translated, and transcribed. Content analysis followed a thematic framework approach using deductive and inductive approaches. RESULTS Forty-three women and 22 CHVs participated in 4 FGDs and 3 FGDs, respectively, and 8 health facility managers participated in interviews. CHVs and health facility managers were majority female (80%). Participants reported that strikes by health care workers significantly impacted the availability and quality of maternal and child health services in 2017 and had indirect economic effects due to households paying for services in the private sector. Participants felt it was the poor, particularly poor women, who were most affected since they were more likely to rely on public services, while CHVs highlighted their own poor working conditions in response to strikes by physicians and nurses. Strikes strained relationships and trust between communities and the health system that were identified as essential to maternal and child health care. CONCLUSION We found that the impacts of strikes by health care workers in 2017 extended beyond negative health and economic effects and exacerbated fundamental inequities in the health system. While this study was conducted in one County, our findings suggest several potential avenues for strengthening maternal and child health care in Kenya that were highlighted by nationwide strikes in 2017.
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Affiliation(s)
- Michael L Scanlon
- Indiana University Center for Global Health, 702 Rotary Circle, Suite RO 101, Indianapolis, IN, USA. .,Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - Lauren Y Maldonado
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Justus E Ikemeri
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Anjellah Jumah
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Getrude Anusu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sheilah Chelagat
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Julia Songok
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Child Health and Paediatrics, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Laura J Ruhl
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Astrid Christoffersen-Deb
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
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18
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Scanlon ML, Maldonado LY, Ikemeri JE, Jumah A, Anusu G, Bone JN, Chelagat S, Keter JC, Ruhl L, Songok J, Christoffersen-Deb A. A retrospective study of the impact of health worker strikes on maternal and child health care utilization in western Kenya. BMC Health Serv Res 2021; 21:898. [PMID: 34465317 PMCID: PMC8408013 DOI: 10.1186/s12913-021-06939-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There have been dozens of strikes by health workers in Kenya in the past decade, but there are few studies of their impact on maternal and child health services and outcomes. We conducted a retrospective survey study to assess the impact of nationwide strikes by health workers in 2017 on utilization of maternal and child health services in western Kenya. METHODS We utilized a parent study to enroll women who were pregnant in 2017 when there were prolonged strikes by health workers ("strike group") and women who were pregnant in 2018 when there were no major strikes ("control group"). Trained research assistants administered a close-ended survey to retrospectively collect demographic and pregnancy-related health utilization and outcomes data. Data were collected between March and July 2019. The primary outcomes of interest were antenatal care (ANC) visits, delivery location, and early child immunizations. Generalized estimating equations were used to estimate risk ratios between the strike and control groups, adjusting for socioeconomic status, health insurance status, and clustering. Adjusted risk ratios (ARR) were calculated with 95% confidence intervals (95%CI). RESULTS Of 1341 women recruited in the parent study in 2017 (strike group), we re-consented 843 women (63%) to participate. Of 924 women recruited in the control arm of the parent study in 2018 (control group), we re-consented 728 women (79%). Women in the strike group were 17% less likely to attend at least four ANC visits during their pregnancy (ARR 0.83, 95%CI 0.74, 0.94) and 16% less likely to deliver in a health facility (ARR 0.84, 95%CI 0.76, 0.92) compared to women in the control group. Whether a child received their first oral polio vaccine did not differ significantly between groups, but children of women in the strike group received their vaccine significantly longer after birth (13 days versus 7 days, p = 0.002). CONCLUSION We found that women who were pregnant during nationwide strikes by health workers in 2017 were less likely to receive WHO-recommended maternal child health services. Strategies to maintain these services during strikes are urgently needed.
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Affiliation(s)
- Michael L Scanlon
- Indiana University Center for Global Health, 702 Rotary Circle, Suite RO 101, Indianapolis, Indiana, USA.
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - Lauren Y Maldonado
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Justus E Ikemeri
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Anjellah Jumah
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Getrude Anusu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
| | - Sheilah Chelagat
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Laura Ruhl
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Julia Songok
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Child Health and Paediatrics, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Astrid Christoffersen-Deb
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
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Siy Van VT, Uy J, Bagas J, Ulep VGT. National multisectoral governance challenges of implementing the Philippines' Reproductive Health Law. Health Policy Plan 2021; 37:269-280. [PMID: 34346488 DOI: 10.1093/heapol/czab092] [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: 05/04/2021] [Revised: 06/17/2021] [Accepted: 07/21/2021] [Indexed: 11/14/2022] Open
Abstract
In recognition of the role of reproductive health in individual and national development, the Responsible Parenthood and Reproductive Health (RPRH) Law of 2012 was passed in the Philippines after 30 years of opposition and debate. Seven years later, this article examined the cohesiveness of national multi-sectoral governance among state and non-state actors and identified challenges in coordination as part of the first comprehensive evaluation of the landmark policy. Using a qualitative intrinsic case study design and guided by the World Health Organization's systems checklist for governing health equity as our theoretical perspective, we conducted 20 semi-structured interviews with national implementers from health agencies (n = 11), non-health agencies (n = 6) and non-state actors (n = 3) that included civil society organizations (CSOs). Key themes identified through thematic analysis were supported with document reviews of policy issuances, accomplishment reports and meeting transcripts of the RPRH National Implementation Team (NIT). The study found that despite aspirations for vibrant multi-sectoral coordination, the implementation of the RPRH Law in the Philippines was incohesive. National leaders, particularly the health sector, were neither able to rally non-health sector actors around RPRH nor strategically harness the power of CSOs. Local resource limitations associated with decentralization were exacerbated by paternalistic financing, coordination, and monitoring. The absence of multi-agency plans fostered a culture of siloed opportunism, without consideration to integrated implementation. This case study shows that for neutral policies without conflicts in sector objectives, the interest and buy-in of non-health state actors, even with a national law, cannot be assumed. Moreover, possible conflicts in interests and perspectives between state and civil society actors must be managed in national governance bodies. Overall, there is need for participatory policymaking and health-sector advocacy to set health equity as an intersectoral goal, involving subnational leaders in developing concrete action plans, and strengthening NIT's formal accountability systems.
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Affiliation(s)
- Vanessa T Siy Van
- Health Sciences Program, School of Science and Engineering, Ateneo de Manila University, Katipunan Avenue, Loyola Heights, Quezon City, Metro Manila 1108, Philippines
| | - Jhanna Uy
- Health Sciences Program, School of Science and Engineering, Ateneo de Manila University, Katipunan Avenue, Loyola Heights, Quezon City, Metro Manila 1108, Philippines.,Philippine Institute for Development Studies, Research Department, 18th Floor Three Cyberpod Centris-North Tower, Quezon Avenue, Diliman Quezon City, Metro Manila 1100, Philippines
| | - Joy Bagas
- Philippine Institute for Development Studies, Research Department, 18th Floor Three Cyberpod Centris-North Tower, Quezon Avenue, Diliman Quezon City, Metro Manila 1100, Philippines
| | - Valerie Gilbert T Ulep
- Philippine Institute for Development Studies, Research Department, 18th Floor Three Cyberpod Centris-North Tower, Quezon Avenue, Diliman Quezon City, Metro Manila 1100, Philippines.,Ateneo Policy Center, School of Government, Ateneo de Manila University, Katipunan Avenue, Loyola Heights, Quezon City, Metro Manila 1108, Philippines
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Kenny L, Bhatia A, Lokot M, Hassan R, Hussein Aden A, Muriuki A, Ahmed Osman I, Kanyuuru L, Pryor S, Bacchus LJ, Cislaghi B, Hossain M. Improving provision of family planning among pastoralists in Kenya: Perspectives from health care providers, community and religious leaders. Glob Public Health 2021; 17:1594-1610. [PMID: 34182886 DOI: 10.1080/17441692.2021.1944263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women's decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access.
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Affiliation(s)
- Leah Kenny
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK.,Centre for Women, Peace & Security, London School of Economics and Political Science, UK
| | - Amiya Bhatia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - Michelle Lokot
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | | | | | | | | | | | | | - Loraine J Bacchus
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - Beniamino Cislaghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK
| | - Mazeda Hossain
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, UK.,Centre for Women, Peace & Security, London School of Economics and Political Science, UK
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Zakumumpa H, Paina L, Wilhelm J, Ssengooba F, Ssegujja E, Mukuru M, Bennett S. The impact of loss of PEPFAR support on HIV services at health facilities in low-burden districts in Uganda. BMC Health Serv Res 2021; 21:302. [PMID: 33794880 PMCID: PMC8017884 DOI: 10.1186/s12913-021-06316-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/25/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Although donor transitions from HIV programs are more frequent, little research exists seeking to understand the perceptions of patients and providers on this process. Between 2015 and 2017, PEPFAR implemented the ´geographic prioritization´ (GP) policy in Uganda whereby it shifted support from 734 'low-volume' facilities and 10 districts with low HIV burden and intensified support in select facilities in high-burden districts. Our analysis intends to explore patient and provider perspectives on the impact of loss of PEPFAR support on HIV services in transitioned health facilities in Uganda. METHODS We report qualitative findings from a larger mixed-methods evaluation. Six facilities were purposefully selected as case studies seeking to ensure diversity in facility ownership, size, and geographic location. Five out of the six selected facilities had experienced transition. A total of 62 in-depth interviews were conducted in June 2017 (round 1) and November 2017 (round 2) with facility in-charges (n = 13), ART clinic managers (n = 12), representatives of PEPFAR implementing organizations (n = 14), district health managers (n = 23) and 12 patient focus group discussions (n = 72) to elicit perceived effects of transition on HIV service delivery. Data were analyzed using thematic analysis. RESULTS While core HIV services, such as testing and treatment, offered by case-study facilities prior to transition were sustained, patients and providers reported changes in the range of HIV services offered and a decline in the quality of HIV services offered post-transition. Specifically, in some facilities we found that specialized pediatric HIV services ceased, free HIV testing services stopped, nutrition support to HIV clients ended and the 'mentor mother' ART adherence support mechanism was discontinued. Patients at three ART-providing facilities reported that HIV service provision had become less patient-centred compared to the pre-transition period. Patients at some facilities perceived waiting times at clinics to have become longer, stock-outs of anti-retroviral medicines to have been more frequent and out-of-pocket expenditure to have increased post-transition. CONCLUSIONS Participants perceived transition to have had the effect of narrowing the scope and quality of HIV services offered by case-study facilities due to a reduction in HIV funding as well as the loss of the additional personnel previously hired by the PEPFAR implementing organizations for HIV programming. Replacing the HIV programming gap left by PEPFAR in transition districts with Uganda government services is critical to the attainment of 90-90-90 targets in Uganda.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Jess Wilhelm
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | | | - Eric Ssegujja
- School of Public Health, Makerere University, Kampala, Uganda
| | - Moses Mukuru
- School of Public Health, Makerere University, Kampala, Uganda
| | - Sara Bennett
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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Sitienei J, Manderson L, Nangami M. Community participation in the collaborative governance of primary health care facilities, Uasin Gishu County, Kenya. PLoS One 2021; 16:e0248914. [PMID: 33788868 PMCID: PMC8011762 DOI: 10.1371/journal.pone.0248914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/08/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Community participation in the governance of health services is an important component in engaging stakeholders (patients, public and partners) in decision-making and related activities in health care. Community participation is assumed to contribute to quality improvement and goal attainment but remains elusive. We examined the implementation of community participation, through collaborative governance in primary health care facilities in Uasin Gishu County, Western Kenya, under the policy of devolved governance of 2013. METHODS Utilizing a multiple case study methodology, five primary health care facilities were purposively selected. Study participants were individuals involved in the collaborative governance of primary health care facilities (from health service providers and community members), including in decision-making, management, oversight, service provision and problem solving. Data were collected through document review, key informant interviews and observations undertaken from 2017 to 2018. Audio recording, notetaking and a reflective journal aided data collection. Data were transcribed, cleaned, coded and analysed iteratively into emerging themes using a governance attributes framework. FINDINGS A total of 60 participants representing individual service providers and community members participated in interviews and observations. The minutes of all meetings of five primary health care facilities were reviewed for three years (2014-2016) and eight health facility committee meetings were observed. Findings indicate that in some cases, structures for collaborative community engagement exist but functioning is ineffective for a number of reasons. Health facility committee meetings were most frequent when there were project funds, with discussions focusing mainly on construction projects as opposed to the day-to-day functioning of the facility. Committee members with the strongest influence and power had political connections or were retired government workers. There were no formal mechanisms for stakeholder forums and how these worked were unclear. Drug stock outs, funding delays and unclear operational guidelines affected collaborative governance performance. CONCLUSION Implementing collaborative governance effectively requires that the scope of focus for collaboration include both specific projects and the routine functioning of the primary health care facility by the health facility committee. In the study area, structures are required to manage effective stakeholder engagement.
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Affiliation(s)
- Jackline Sitienei
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Health Policy and Management Department, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Lenore Manderson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Anthropology, School of Social Sciences, Monash University, Clayton, Australia
| | - Mabel Nangami
- Health Policy and Management Department, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
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Taghizadeh S, Zarnag RK, Farhangi MA. Stakeholder analysis of childhood obesity prevention policies in Iran. ACTA ACUST UNITED AC 2021; 79:36. [PMID: 33731204 PMCID: PMC7967965 DOI: 10.1186/s13690-021-00557-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 03/04/2021] [Indexed: 01/23/2023]
Abstract
Background Childhood obesity is one of the most serious health challenges and risk factors for various diseases. International health organizations, such as the World Health Organization (WHO), recommend more stakeholder engagement to discuss this health problem. Therefore, this study aims to identify and analyze the stakeholders of childhood obesity prevention (COP) policy making process in Iran. Methods In this study, semi-structured interviews were conducted with 24 Iranian stakeholders in the field of COP from February 2019 to May 2020. PolicyMaker V.4 and MAXQDA V.10 software were used for the analysis of stakeholders. Results Out of 24 interviewed stakeholders, 17 were active and seven were inactive. The most powerful and supportive stakeholders were the Ministry of Health and Medical Education (MoHME) and the national and regional Offices of Community Nutrition Improvement. Although stakeholders like the Ministry of Sports and Youth, the municipalities, the Secretariat of the Health and Food Safety, the Islamic Republic of Iran Broadcasting (IRIB), and Student Organization were among powerful bodies, they showed the least support for COP policies. The remaining stakeholders showed medium or low support and power in the policy making process. Conclusions Disconnect between stakeholders, less attention to prevention strategies, and high advertising of unhealthy foods were among the main challenges facing the COP policies in Iran and worldwide. Insufficient financial resources, little attention to the young people under 18, non-aligned policies of the Student Organization and the IRIB, and insufficient support of COP policies were among the key challenges to be handled.
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Affiliation(s)
- Shahnaz Taghizadeh
- Student Research Committee, Faculty of Nutrition, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rahim Khodayari Zarnag
- Department of Health Policy and Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahdieh Abbasalizad Farhangi
- Department of Community Nutrition, Nutrition Faculty, Tabriz University of Medical Sciences, POBOX: 14711, Attar Nishabouri St., Tabriz, 5166614711, Iran.
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Kumar MB, Madan JJ, Auguste P, Taegtmeyer M, Otiso L, Ochieng CB, Muturi N, Mgamb E, Barasa E. Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya. BMJ Glob Health 2021; 6:e002452. [PMID: 33658302 PMCID: PMC7931757 DOI: 10.1136/bmjgh-2020-002452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Improvements in maternal and infant health outcomes are policy priorities in Kenya. Achieving these outcomes depends on early identification of pregnancy and quality of primary healthcare. Quality improvement interventions have been shown to contribute to increases in identification, referral and follow-up of pregnant women by community health workers. In this study, we evaluate the cost-effectiveness of using quality improvement at community level to reduce maternal and infant mortality in Kenya. METHODS We estimated the cost-effectiveness of quality improvement compared with standard of care treatment for antenatal and delivering mothers using a decision tree model and taking a health system perspective. We used both process (antenatal initiation in first trimester and skilled delivery) and health outcomes (maternal and infant deaths averted, as well as disability-adjusted life years (DALYs)) as our effectiveness measures and actual implementation costs, discounting costs only. We conducted deterministic and probabilistic sensitivity analyses. RESULTS We found that the community quality improvement intervention was more cost-effective compared with standard community healthcare, with incremental cost per DALY averted of $249 under the deterministic analysis and 76% likelihood of cost-effectiveness under the probabilistic sensitivity analysis using a standard threshold. The deterministic estimate of incremental cost per additional skilled delivery was US$10, per additional early antenatal care presentation US$155, per maternal death averted US$5654 and per infant death averted US$37 536 (2017 dollars). CONCLUSIONS This analysis shows that the community quality improvement intervention was cost-effective compared with the standard community healthcare in Kenya due to improvements in antenatal care uptake and skilled delivery. It is likely that quality improvement interventions are a good investment and may also yield benefits in other health areas.
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Affiliation(s)
- Meghan Bruce Kumar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
| | - Jason J Madan
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Peter Auguste
- University of Warwick, Warwick Medical School, Coventry, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | | | | | - Nelly Muturi
- Research and Strategic Information, LVCT Health, Nairobi, Kenya
| | - Elizabeth Mgamb
- Department of Health, Migori County Government, Migori, Kenya
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
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Munywoki J, Kagwanja N, Chuma J, Nzinga J, Barasa E, Tsofa B. Tracking health sector priority setting processes and outcomes for human resources for health, five-years after political devolution: a county-level case study in Kenya. Int J Equity Health 2020; 19:165. [PMID: 32958000 PMCID: PMC7507677 DOI: 10.1186/s12939-020-01284-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Health sector priority setting in Low and Middle-Income Countries (LMICs) entails balancing between a high demand and low supply of scarce resources. Human Resources for Health (HRH) consume the largest allocation of health sector resources in LMICs. Health sector decentralization continues to be promoted for its perceived ability to improve efficiency, relevance and participation in health sector priority setting. Following the 2013 devolution in Kenya, both health service delivery and human resource management were decentralized to county level. Little is known about priority setting practices and outcomes of HRH within decentralized health systems in LMICs. Our study sought to examine if and how the Kenyan devolution has improved health sector priority setting practices and outcomes for HRH. METHODS We used a mixed methods case study design to examine health sector priority setting practices and outcomes at county level in Kenya. We used three sources of data. First, we reviewed all relevant national and county level policy and guidelines documents relating to HRH management. We then accessed and reviewed county records of HRH recruitment and distribution between 2013 and 2018. We finally conducted eight key informant interviews with various stakeholder involved in HRH priority setting within our study county. RESULTS We found that HRH numbers in the county increased by almost two-fold since devolution. The county had two forms of HRH recruitment: one led by the County Public Services Board as outlined by policy and guidelines and a parallel, politically-driven recruitment done directly by the County Department of Health. Though there were clear guidelines on HRH recruitment, there were no similar guidelines on allocation and distribution of HRH. Since devolution, the county has preferentially staffed higher level hospitals over primary care facilities. Additionally, there has been local county level innovations to address some HRH management challenges, including recruiting doctors and other highly specialized staff on fixed term contract as opposed to permanent basis; and implementation of local incentives to attract and retain HRH to remote areas within the county. CONCLUSION Devolution has significantly increased county level decision-space for HRH priority setting in Kenya. However, HRH management and accountability challenges still exist at the county level. There is need for interventions to strengthen county level HRH management capacity and accountability mechanisms beyond additional resources allocation. This will boost the realization of the country's efforts for promoting service delivery equity as a key goal - both for the devolution and the country's quest towards Universal Health Coverage (UHC).
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Affiliation(s)
- Joshua Munywoki
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya.
- Department of Public Health, School of Human and Health Sciences, Pwani University, Kilifi, Kenya.
| | - Nancy Kagwanja
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Jane Chuma
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
- The World Bank Group, Kenya Country Office, Nairobi, Kenya
| | - Jacinta Nzinga
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Edwine Barasa
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya
| | - Benjamin Tsofa
- KEMRI Wellcome Trust Research Programme, KEMRI Centre for Geographic Medicine Research Coast, Kilifi, Kenya.
- Department of Public Health, School of Human and Health Sciences, Pwani University, Kilifi, Kenya.
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Cherop F, Korir M, Bagire V, Wachira J. Patient loyalty to HIV care in an HIV facility in Eldoret, Kenya: A mediated mediation. AAS Open Res 2020. [DOI: 10.12688/aasopenres.13121.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Patient loyalty is the continuous commitment and engagement in care where patients can improve and sustain quality of life through continuous use of medical care. Identifying strengths and weaknesses in providing excellent quality care is a key measure of success of healthcare professionals and hospital management. However, few studies have examined patient loyalty from a strategic leadership perspective within HIV health care systems. The purpose of this study is to determine how patient loyalty to HIV care is influenced by multiple factors in a healthcare system environment. The study employs a mixed-methods approach guided by the complexity theory and the theory of planned behavior. A total of 444 surveys with (50 healthcare providers and 394 adult HIV-infected patients) currently on antiretroviral drugs, as well as 22 in-depth interviews with healthcare providers will be conducted. The study will be done at AMPATH Eldoret Kenya. We will use stratified proportionate and census sampling methods to select study participants for the survey while purposive and convenient sampling techniques will be used for in-depth interviews. Structured questionnaires and interviewer guides will guide data collection. Quantitative data analysis will entail hierarchical regression to test direct effects while multiple regression will test the mediation effects using the Hayes PROCESS Model No.6 in SPSS. Qualitative data analysis will be conducted using a thematic analytical method.
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Nabwera HM, Wright JL, Patil M, Dickinson F, Godia P, Maua J, Sammy MK, Naimoi BC, Warfa OH, Dewez JE, Murila F, Manu A, Smith H, Mathai M. 'Sometimes you are forced to play God…': a qualitative study of healthcare worker experiences of using continuous positive airway pressure in newborn care in Kenya. BMJ Open 2020; 10:e034668. [PMID: 32792424 PMCID: PMC7430418 DOI: 10.1136/bmjopen-2019-034668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE: To explore the experiences of using continuous positive airway pressure (CPAP) in newborn care among healthcare workers in Kenya, and to identify factors that would promote successful scale-up. DESIGN AND SETTING: A qualitative study using key informant interviews and focus group discussions, based at secondary and tertiary level hospitals in Kenya. PARTICIPANTS: Healthcare workers in the newborn units providing CPAP. PRIMARY AND SECONDARY OUTCOME MEASURE: Facilitators and barriers of CPAP use in newborn care in Kenya. RESULTS: 16 key informant interviews and 15 focus group discussions were conducted across 19 hospitals from September 2017 to February 2018. Main barriers reported were: (1) inadequate infrastructure to support the effective delivery of CPAP, (2) shortage of skilled staff rendering it difficult for the available staff to initiate or monitor infants on CPAP and (3) inadequate knowledge and training of staff that inhibited the safe care of infants on CPAP. Key facilitators reported were positive patient outcomes after CPAP use that increased staff confidence and partnership with caregivers in the management of newborns on CPAP. Healthcare workers in private/mission hospitals had more positive experiences of using CPAP in newborn care as the relevant support and infrastructure were available. CONCLUSION: CPAP use in newborn care is valued by healthcare workers in Kenya. However, we identified key challenges that threaten its safe use and sustainability. Further scale-up of CPAP in newborn care should ensure that staff members have ready access to optimal training on CPAP and that there are enough resources and infrastructure to support its use. ETHICS: This study was approved through the appropriate ethics committees in Kenya and the UK (see in text) with written informed consent for each participant.
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Affiliation(s)
- Helen M Nabwera
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Jemma L Wright
- Paediatrics Department, Betsi Cadwaladr CHC, Wrexham, UK
| | - Manasi Patil
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Fiona Dickinson
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Pamela Godia
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Judith Maua
- International Public Health, Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Mercy K Sammy
- General Paediatrics, Gertrude's Garden Children's Hospital, Nairobi, Kenya
| | | | - Osman H Warfa
- Neonatal, Child and Adolescent Health, Kenya Ministry of Health, Nairobi, Kenya
| | - Juan Emmanuel Dewez
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Florence Murila
- Paediatrics and Child Health, University of Nairobi School of Medicine, Nairobi, Kenya
| | - Alexander Manu
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Smith
- Maternal and Newborn Health, International Health Consulting Services Ltd, Liverpool, UK
| | - Matthews Mathai
- International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Kumar MB, Taegtmeyer M, Madan J, Ndima S, Chikaphupha K, Kea A, Barasa E. How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries. Health Policy Plan 2020; 35:799-809. [PMID: 32516361 PMCID: PMC7487332 DOI: 10.1093/heapol/czaa027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2020] [Indexed: 11/29/2022] Open
Abstract
Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies towards UHC. Yet despite resource mobilization towards this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries. Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision-making, as well as evidentiary needs related to community health data for decision-making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context, and second, much existing economic evidence does not deal with what decision-makers value when it comes to community health systems-i.e. coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision-maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision-making, empowering national decision-makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.
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Affiliation(s)
- Meghan Bruce Kumar
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- MARCH Centre, London School of Hygiene and Tropical Medicine, London, UK
| | - Miriam Taegtmeyer
- Community Health Systems Group, Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
- Tropical Infectious Disease Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Jason Madan
- Centre for Health Economics at Warwick, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sozinho Ndima
- Community Health Department, Faculty of Medicine, University Eduardo Mondlane, Maputo, Mozambique
| | | | - Aschenaki Kea
- School of Public and Environmental Health, Hawassa University, Hawassa, Ethiopia
- Center for International Health, University of Bergen, Bergen, Norway
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Baker C, Limato R, Tumbelaka P, Rewari BB, Nasir S, Ahmed R, Taegtmeyer M. Antenatal testing for anaemia, HIV and syphilis in Indonesia - a health systems analysis of low coverage. BMC Pregnancy Childbirth 2020; 20:326. [PMID: 32471383 PMCID: PMC7257553 DOI: 10.1186/s12884-020-02993-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 05/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy. METHODS Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, sub-district, district and national level as relevant to role. RESULTS We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps. CONCLUSIONS Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.
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Affiliation(s)
- C Baker
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - R Limato
- Eijkman Institute for Molecular Biology, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia
| | - P Tumbelaka
- Eijkman Institute for Molecular Biology, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia
| | - B B Rewari
- Division of Communicable Disease, World Health Organization Regional Office for the Western Pacific, Manila, Philippines
| | - S Nasir
- Faculty of Public Health, Universitas Hasanuddin, Makassar, Indonesia
| | - R Ahmed
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.,Eijkman Institute for Molecular Biology, Jl. Diponegoro No. 69, Jakarta, 10430, Indonesia
| | - M Taegtmeyer
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
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Liwanag HJ, Wyss K. Who should decide for local health services? A mixed methods study of preferences for decision-making in the decentralized Philippine health system. BMC Health Serv Res 2020; 20:305. [PMID: 32293432 PMCID: PMC7158124 DOI: 10.1186/s12913-020-05174-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 03/31/2020] [Indexed: 11/29/2022] Open
Abstract
Background The Philippines decentralized government health services through devolution to local governments in 1992. Over the years, opinions varied on the impact of devolved governance to decision-making for local health services. The objective of this study was to analyze decision-makers’ perspectives on who should be making decisions for local health services and on their preferred structure of health service governance should they be able to change the situation. Methods We employed a mixed methods approach that included an online survey in one region and in-depth interviews with purposively-selected decision-makers in the Philippine health system. Study participants were asked about their perspectives on decision-making in the functions of planning, health financing, resource management, human resources for health, health service delivery, and data management and monitoring. Analysis of survey results through visualization of data on charts was complemented by the themes that emerged from the qualitative analysis of in-depth interviews based on the Framework Method. Results We received 24 online survey responses and interviewed 27 other decision-makers. Survey respondents expressed a preference to shift decision-making away from the local politician in favor of the local health officer in five functions. Most survey participants also preferred re-centralization. Analysis of the interviews suggested that the preferences expressed were likely driven by an expectation that re-centralization would provide a solution to the perceived politicization in decision-making and the reliance of local governments on central support. Conclusions Rather than re-centralize the health system, one policy option for consideration for the Philippines would be to maintain devolution but with a revitalized role for the central level to maintain oversight over local governments and regulate their decision-making for the functions. Decentralization, whether in the Philippines or elsewhere, must not only transfer decision-making responsibility to local levels but also ensure that those granted with the decision space could perform decision-making with adequate capacities and could grasp the importance of health services.
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Affiliation(s)
- Harvy Joy Liwanag
- Swiss Tropical and Public Health Institute, Basel, Switzerland. .,Balik Scientist Program, Department of Science and Technology Philippine Council for Health Research and Development (DOST PCHRD), Metro Manila, Philippines. .,Ateneo de Manila University School of Medicine and Public Health, Metro Manila, Philippines.
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Nyirenda L, Kumar MB, Theobald S, Sarker M, Simwinga M, Kumwenda M, Johnson C, Hatzold K, Corbett EL, Sibanda E, Taegtmeyer M. Using research networks to generate trustworthy qualitative public health research findings from multiple contexts. BMC Med Res Methodol 2020; 20:13. [PMID: 31964333 PMCID: PMC6975029 DOI: 10.1186/s12874-019-0895-5] [Citation(s) in RCA: 8] [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: 01/24/2019] [Accepted: 12/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Qualitative research networks (QRNs) bring together researchers from diverse contexts working on multi-country studies. The networks may themselves form a consortium or may contribute to a wider research agenda within a consortium with colleagues from other disciplines. The purpose of a QRN is to ensure robust methods and processes that enable comparisons across contexts. Under the Self-Testing Africa (STAR) initiative and the REACHOUT project on community health systems, QRNs were established, bringing together researchers across countries to coordinate multi-country qualitative research and to ensure robust methods and processes allowing comparisons across contexts. QRNs face both practical challenges in facilitating this iterative exchange process across sites and conceptual challenges interpreting findings between contexts. This paper distils key lessons and reflections from both QRN experiences on how to conduct trustworthy qualitative research across different contexts with examples from Bangladesh, Ethiopia, Kenya, Indonesia, Malawi, Mozambique, Zambia and Zimbabwe. METHODS The process of generating evidence for this paper followed a thematic analysis method: themes initially identified were refined during several rounds of discussions in an iterative process until final themes were agreed upon in a joint learning process. RESULTS Four guiding principles emerged from our analysis: a) explicit communication strategies that sustain dialogue and build trust and collective reflexivity; b) translation of contextually embedded concepts; c) setting parameters for contextualizing, and d) supporting empirical and conceptual generalisability. Under each guiding principle, we describe how credibility, dependability, confirmability and transferability can be enhanced and share good practices to be considered by other researchers. CONCLUSIONS Qualitative research is often context-specific with tools designed to explore local experiences and understandings. Without efforts to synthesise and systematically share findings, common understandings, experiences and lessons are missed. The logistical and conceptual challenges of qualitative research across multiple partners and contexts must be actively managed, including a shared commitment to continuous 'joint learning' by partners. Clarity and agreement on concepts and common methods and timelines at an early stage is critical to ensure alignment and focus in intercountry qualitative research and analysis processes. Building good relationships and trust among network participants enhance the quality of qualitative research findings.
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Affiliation(s)
- Lot Nyirenda
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Malabika Sarker
- BRAC James P. Grant School of Public Health, Dhaka, Bangladesh
- Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | | | | | | | - Karin Hatzold
- Population Services International, Johannesburg, South Africa
| | - Elizabeth L. Corbett
- Malawi Liverpool Wellcome Trust, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Euphemia Sibanda
- Centre for Sexual Health and HIV AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Miriam Taegtmeyer
- Department of International Public Health, LSTM, Pembroke Place, Liverpool, L3 5QA UK
- Tropical Infectious Diseases Unit, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP UK
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Feldhaus I, Schütte C, Mwansa FD, Undi M, Banda S, Suharlim C, Menzies NA, Brenzel L, Resch SC, Kinghorn A. Incorporating costing study results into district and service planning to enhance immunization programme performance: a Zambian case study. Health Policy Plan 2019; 34:327-336. [PMID: 31157376 PMCID: PMC6736183 DOI: 10.1093/heapol/czz039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2019] [Indexed: 11/13/2022] Open
Abstract
Donors, researchers and international agencies have made significant investments in collection of high-quality data on immunization costs, aiming to improve the efficiency and sustainability of services. However, improved quality and routine dissemination of costing information to local managers may not lead to enhanced programme performance. This study explored how district- and service-level managers can use costing information to enhance planning and management to increase immunization outputs and coverage. Data on the use of costing information in the planning and management of Zambia's immunization programme was obtained through individual and group semi-structured interviews with planners and managers at national, provincial and district levels. Document review revealed the organizational context within which managers operated. Qualitative results described managers' ability to use costing information to generate cost and efficiency indicators not provided by existing systems. These, in turn, would allow them to understand the relative cost of vaccines and other resources, increase awareness of resource use and management, benchmark against other facilities and districts, and modify strategies to improve performance. Managers indicated that costing information highlighted priorities for more efficient use of human resources, vaccines and outreach for immunization programming. Despite decentralization, there were limitations on managers' decision-making to improve programme efficiency in practice: major resource allocation decisions were made centrally and planning tools did not focus on vaccine costs. Unreliable budgets and disbursements also undermined managers' ability to use systems and information. Routine generation and use of immunization cost information may have limited impact on managing efficiency in many Zambian districts, but opportunities were evident for using existing capacity and systems to improve efficiency. Simpler approaches, such as improving reliability and use of routine immunization and staffing indicators, drawing on general insights from periodic costing studies, and focusing on maximizing coverage with available resources, may be more feasible in the short-term.
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Affiliation(s)
- Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Carl Schütte
- Strategic Development Consultants, Pietermaritzburg, South Africa
| | - Francis D Mwansa
- Department of Public Health, Ministry of Health, Plot 12193, Woodlands Chalala, Lusaka, Zambia
| | - Masauso Undi
- Independent consultant, 35 Nalikwanda Road, Woodlands, Lusaka, Zambia
| | - Stanley Banda
- Independent consultant, Plot 34270, Shantumbu Road, Hillview Park, Lusaka, Zambia
| | - Chris Suharlim
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, Boston, MA, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, Boston, MA, USA
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, 500 Fifth Avenue N, Seattle, WA, USA
| | - Stephen C Resch
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, 718 Huntington Ave, Boston, MA, USA
| | - Anthony Kinghorn
- Perinatal HIV Research Unit, Chris Hani Baragwanath Academic Hospital, Chris Hani Road, Diepkloof, Soweto, South Africa
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McCollum R, Taegtmeyer M, Otiso L, Tolhurst R, Mireku M, Martineau T, Karuga R, Theobald S. Applying an intersectionality lens to examine health for vulnerable individuals following devolution in Kenya. Int J Equity Health 2019; 18:24. [PMID: 30700299 PMCID: PMC6352384 DOI: 10.1186/s12939-019-0917-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 01/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Power imbalances are a key driver of avoidable, unfair and unjust differences in health. Devolution shifts the balance of power in health systems. Intersectionality approaches can provide a 'lens' for analysing how power relations contribute to complex and multiple forms of health advantage and disadvantage. These approaches have not to date been widely used to analyse health systems reforms. While the stated objectives of devolution often include improved equity, efficiency and community participation, past evidence demonstrates that that there is a need to create space and capacity for people to transform existing power relations these within specific contexts. METHODS We carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from across the health system in ten counties, 14 focus group discussions with community members in two of these counties and photovoice participatory research with nine young people. We adopted an intersectionality lens to reveal how power relations intersect to produce vulnerabilities for specific groups in specific contexts, and to identify examples of the tacit knowledge about these vulnerabilities held by priority-setting stakeholders, in the wake of the introduction of devolution reforms in Kenya. RESULTS Our study identified a range of ways in which longstanding social forces and discriminations limit the power and agency individuals can exercise, but are mediated by their unique circumstances at a given point in their life. These are the social determinants of health, influencing an individual's exposure to risk of ill health from their living environment, their work, or their social context, including social norms relating to their gender, age, geographical residence or socio-economic status. While a range of policy measures have been introduced to encourage participation by typically 'unheard voices', devolution processes have yet to adequately challenge the social norms, and intersecting power relations which contribute to discrimination and marginalisation. CONCLUSIONS If key actors in devolved decision-making structures are to ensure progress towards universal health coverage, there is need for intersectoral policy action to address social determinants, promote equity and identify ways to challenge and shift power imbalances in priority-setting processes.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | - Rachel Tolhurst
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
| | | | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK
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McCollum R, Taegtmeyer M, Otiso L, Muturi N, Barasa E, Molyneux S, Martineau T, Theobald S. "Sometimes it is difficult for us to stand up and change this": an analysis of power within priority-setting for health following devolution in Kenya. BMC Health Serv Res 2018; 18:906. [PMID: 30486867 PMCID: PMC6264027 DOI: 10.1186/s12913-018-3706-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 11/12/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Practices of power lie at the heart of policy processes. In both devolution and priority-setting, actors seek to exert power through influence and control over material, human, intellectual and financial resources. Priority-setting arises as a consequence of the needs and demand exceeding the resources available, requiring some means of choosing between competing demands. This paper examines the use of power within priority-setting processes for healthcare resources at sub-national level, following devolution in Kenya. METHODS We interviewed 14 national level key informants and 255 purposively selected respondents from across the health system in ten counties. These qualitative data were supplemented by 14 focus group discussions (FGD) involving 146 community members in two counties. We conducted a power analysis using Gaventa's power cube and Veneklasen's expressions of power to interpret our findings. RESULTS We found Kenya's transition towards devolution is transforming the former centralised balance of power, leading to greater ability for influence at the county level, reduced power at national and sub-county (district) levels, and limited change at community level. Within these changing power structures, politicians are felt to play a greater role in priority-setting for health. The interfaces and tensions between politicians, health service providers and the community has at times been felt to undermine health related technical priorities. Underlying social structures and discriminatory practices generally continue unchanged, leading to the continued exclusion of the most vulnerable from priority-setting processes. CONCLUSIONS Power analysis of priority-setting at county level after devolution in Kenya highlights the need for stronger institutional structures, processes and norms to reduce the power imbalances between decision-making actors and to enable community participation.
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Affiliation(s)
- Rosalind McCollum
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Miriam Taegtmeyer
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Edwine Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640-00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sassy Molyneux
- KEMRI Centre for Geographic Medicine Research - Coast, and Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine, University of Oxford, Oxford, UK
| | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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