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Sieleunou I, Enok Bonong RP. Does health voucher intervention increase antenatal consultations and skilled birth attendances in Cameroon? Results from an interrupted time series analysis. BMC Health Serv Res 2024; 24:602. [PMID: 38720364 PMCID: PMC11080306 DOI: 10.1186/s12913-024-10962-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Limited access to health services during the antenatal period and during childbirth, due to financial barriers, is an obstacle to reducing maternal and child mortality. To improve the use of health services in the three regions of Cameroon, which have the worst reproductive, maternal, neonatal, child and adolescent health indicators, a health voucher project aiming to reduce financial barriers has been progressively implemented since 2015 in these three regions. Our research aimed to assess the impact of the voucher scheme on first antenatal consultation (ANC) and skilled birth attendance (SBA). METHODS Routine aggregated data by month over the period January 2013 to May 2018 for each of the 33 and 37 health facilities included in the study sample were used to measure the effect of the voucher project on the first ANC and SBA, respectively. We estimated changes attributable to the intervention in terms of the levels of outcome indicators immediately after the start of the project and over time using an interrupted time series regression. A meta-analysis was used to obtain the overall estimates. RESULTS Overall, the voucher project contributed to an immediate and statistically significant increase, one month after the start of the project, in the monthly number of ANCs (by 26%) and the monthly number of SBAs (by 57%). Compared to the period before the start of the project, a statistically significant monthly increase was observed during the project implementation for SBAs but not for the first ANCs. The results at the level of health facilities (HFs) were mixed. Some HFs experienced an improvement, while others were faced with the status quo or a decrease. CONCLUSIONS Unlike SBAs, the voucher project in Cameroon had mixed results in improving first ANCs. These limited effects were likely the consequence of poor design and implementation challenges.
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Affiliation(s)
- Isidore Sieleunou
- The Global Financing Facility (GFF), Dakar, Senegal.
- Research for Development International, 30883, Yaoundé, Cameroon.
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Ladak Z, Grewal N, Kim MO, Small S, Leber A, Hemani M, Sun Q, Hamza DM, Laur C, Ivers NM, Falenchuk O, Volpe R. Equity in prenatal healthcare services globally: an umbrella review. BMC Pregnancy Childbirth 2024; 24:191. [PMID: 38468220 PMCID: PMC10926563 DOI: 10.1186/s12884-024-06388-0] [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: 11/30/2023] [Accepted: 03/04/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Timely, appropriate, and equitable access to quality healthcare during pregnancy is proven to contribute to better health outcomes of birthing individuals and infants following birth. Equity is conceptualized as the absence of differences in healthcare access and quality among population groups. Healthcare policies are guides for front-line practices, and despite merits of contemporary policies striving to foster equitable healthcare, inequities persist. The purpose of this umbrella review is to identify prenatal healthcare practices, summarize how equities/inequities are reported in relation to patient experiences or health outcomes when accessing or using services, and collate equity reporting characteristics. METHODS For this umbrella review, six electronic databases were searched (Medline, EMBASE, APA PsychInfo, CINAHL, International Bibliography of the Social Sciences, and Cochrane Library). Included studies were extracted for publication and study characteristics, equity reporting, primary outcomes (prenatal care influenced by equity/inequity) and secondary outcomes (infant health influenced by equity/inequity during pregnancy). Data was analyzed deductively using the PROGRESS-Plus equity framework and by summative content analysis for equity reporting characteristics. The included articles were assessed for quality using the Risk of Bias Assessment Tool for Systematic Reviews. RESULTS The search identified 8065 articles and 236 underwent full-text screening. Of the 236, 68 systematic reviews were included with first authors representing 20 different countries. The population focus of included studies ranged across prenatal only (n = 14), perinatal (n = 25), maternal (n = 2), maternal and child (n = 19), and a general population (n = 8). Barriers to equity in prenatal care included travel and financial burden, culturally insensitive practices that deterred care engagement and continuity, and discriminatory behaviour that reduced care access and satisfaction. Facilitators to achieve equity included innovations such as community health workers, home visitation programs, conditional cash transfer programs, virtual care, and cross-cultural training, to enhance patient experiences and increase their access to, and use of health services. There was overlap across PROGRESS-Plus factors. CONCLUSIONS This umbrella review collated inequities present in prenatal healthcare services, globally. Further, this synthesis contributes to future solution and action-oriented research and practice by assembling evidence-informed opportunities, innovations, and approaches that may foster equitable prenatal health services to all members of diverse communities.
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Affiliation(s)
- Zeenat Ladak
- University of Toronto, Toronto, Canada.
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, Canada.
| | | | | | | | | | | | - Qiuyu Sun
- University of Alberta, Edmonton, Canada
| | | | - Celia Laur
- University of Toronto, Toronto, Canada
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, Canada
| | - Noah M Ivers
- University of Toronto, Toronto, Canada
- Women's College Hospital Institute for Health System Solutions & Virtual Care, Toronto, Canada
- Women's College Hospital, Toronto, Canada
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George J, Jack S, Gauld R, Colbourn T, Stokes T. Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review. BMJ Open 2023; 13:e073669. [PMID: 38081664 PMCID: PMC10729209 DOI: 10.1136/bmjopen-2023-073669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs. METHODS We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed. RESULTS The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation. CONCLUSIONS We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.
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Affiliation(s)
- Joby George
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
| | - Susan Jack
- Te Whatu Ora - Southern, National Public Health Service, Dunedin, New Zealand
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
- Otago Business School, University of Otago, Dunedin, New Zealand
| | | | - Tim Stokes
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
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Abraham JM, Melendez-Torres GJ. A realist review of interventions targeting maternal health in low- and middle-income countries. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231205687. [PMID: 37899651 PMCID: PMC10617292 DOI: 10.1177/17455057231205687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 09/04/2023] [Accepted: 09/19/2023] [Indexed: 10/31/2023]
Abstract
Maternal mortality is disproportionately higher in low- and middle-income countries compared to other parts of the world. International research efforts are reflective of the urgency to improve global maternal outcomes. The existing literature of maternal health interventions in low- and middle-income countries targets a variety of populations and intervention types. However, there is a notable lack of systemic reviews that examine the wider contextual and mechanistic factors that have contributed to the outcomes produced by interventions. This article aims to use realist synthesis design to identify and examine the relationships between the contexts, mechanisms and outcomes of maternal health interventions conducted in low- and middle-income countries. This will inform evidence-based practice for future maternal health interventions. In May 2022, we searched four electronic databases for systematic reviews of maternal health interventions in low- and middle-income countries published in the last 5 years. We used open and axial coding of contexts, mechanisms and outcomes to develop an explanatory framework for intervention effectiveness. After eligibility screening and full-text analysis, 44 papers were included. The majority of effective interventions reported good healthcare system contexts, especially the importance of infrastructural capacity to implement and sustain the intervention. Most intervention designs used increasing knowledge and awareness at an individual and healthcare-provider level to produce intended outcomes. The majority of outcomes reported related to uptake of healthcare services by women. All mechanism themes had a relationship with this outcome. Health system infrastructure must be considered in interventions to ensure effective implementation and sustainability. Healthcare-seeking behaviours are embedded within social and cultural norms, environmental conditions, family influences and provider attitudes. Therefore, effective engagement with communities and families is important to create new norms surrounding pregnancy and delivery. Future research should explore community mobilization and involvement to enable tailored interventions with optimal contextual fit.
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Shamanna BR, Murthy G, Ravilla T, Jones I. Demand-side financing: can it help deliver eye care for all? COMMUNITY EYE HEALTH 2022; 35:27-28. [PMID: 36425859 PMCID: PMC9680598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- B R Shamanna
- School of Medical Sciences, University of Hyderabad, Hyderabad, India
| | - Gvs Murthy
- Director - Indian Institute of Public Health, Hyderabad, India
| | - Thulsiraj Ravilla
- Executive Director: Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System, Madurai, India
| | - Iain Jones
- Senior Global Technical Lead Economics Research: Sightsavers, UK
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Greenberg JL, Bateisibwa J, Ngonzi J, Donato K. Demand-Side Factors in Maternal Health Outcomes: Evidence from a Community Health Worker Programme in Uganda. THE JOURNAL OF DEVELOPMENT STUDIES 2022; 59:114-132. [PMID: 36714168 PMCID: PMC9879266 DOI: 10.1080/00220388.2022.2120805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 06/18/2023]
Abstract
While community health workers (CHWs) are a core feature of many low-resource healthcare systems, evidence on both their health impacts and the mechanisms behind these impacts remains limited. Using a difference-in-differences design with a control and treatment group, this study evaluated a CHW programme in southwestern Uganda aimed at improving maternal health outcomes. We found relatively little evidence of an overall programme effect on health behaviours, including antenatal care attendance and delivery under skilled supervision. Analysis of heterogeneity by gestational age at first antenatal visit - which should have modulated exposure to the intervention - provided suggestive evidence that treatment effects varied predictably with gestational age. Altogether, the absence of strong programme effects may have been due to suboptimal performance by CHWs, thus highlighting the importance of studying and instituting appropriate monitoring and incentive schemes for such programmes. Additionally, in contrast to the weak treatment effect findings, analysis of the entire study sample between the pre- and post-intervention periods showed large improvements in healthcare-seeking behaviour across both the treatment and control groups. These changes may have arisen from concurrent supply-side health facility improvements affecting the entire study population, spillover effects from the CHWs, or background health trends.
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Affiliation(s)
- Joshua L. Greenberg
- Medical School and Department of Economics, University of Michigan, Ann Arbor, MI, USA
| | | | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
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Perera C, Bakrania S, Ipince A, Nesbitt‐Ahmed Z, Obasola O, Richardson D, Van de Scheur J, Yu R. Impact of social protection on gender equality in low- and middle-income countries: A systematic review of reviews. CAMPBELL SYSTEMATIC REVIEWS 2022; 18:e1240. [PMID: 36913187 PMCID: PMC9133545 DOI: 10.1002/cl2.1240] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Background More than half of the global population is not effectively covered by any type of social protection benefit and women's coverage lags behind. Most girls and boys living in low-resource settings have no effective social protection coverage. Interest in these essential programmes in low and middle-income settings is rising and in the context of the COVID-19 pandemic the value of social protection for all has been undoubtedly confirmed. However, evidence on whether the impact of different social protection programmes (social assistance, social insurance and social care services and labour market programmes) differs by gender has not been consistently analysed. Evidence is needed on the structural and contextual factors that determine differential impacts. Questions remain as to whether programme outcomes vary according to intervention implementation and design. Objectives This systematic review aims to collect, appraise, and synthesise the evidence from available systematic reviews on the differential gender impacts of social protection programmes in low and middle-income countries. It answers the following questions: 1.What is known from systematic reviews on the gender-differentiated impacts of social protection programmes in low and middle-income countries?2.What is known from systematic reviews about the factors that determine these gender-differentiated impacts?3.What is known from existing systematic reviews about design and implementation features of social protection programmes and their association with gender outcomes? Search Methods We searched for published and grey literature from 19 bibliographic databases and libraries. The search techniques used were subject searching, reference list checking, citation searching and expert consultations. All searches were conducted between 10 February and 1 March 2021 to retrieve systematic reviews published within the last 10 years with no language restrictions. Selection Criteria We included systematic reviews that synthesised evidence from qualitative, quantitative or mixed-methods studies and analysed the outcomes of social protection programmes on women, men, girls, and boys with no age restrictions. The reviews included investigated one or more types of social protection programmes in low and middle-income countries. We included systematic reviews that investigated the effects of social protection interventions on any outcomes within any of the following six core outcome areas of gender equality: economic security and empowerment, health, education, mental health and psychosocial wellbeing, safety and protection and voice and agency. Data Collection and Analysis A total of 6265 records were identified. After removing duplicates, 5250 records were screened independently and simultaneously by two reviewers based on title and abstract and 298 full texts were assessed for eligibility. Another 48 records, identified through the initial scoping exercise, consultations with experts and citation searching, were also screened. The review includes 70 high to moderate quality systematic reviews, representing a total of 3289 studies from 121 countries. We extracted data on the following areas of interest: population, intervention, methodology, quality appraisal, and findings for each research question. We also extracted the pooled effect sizes of gender equality outcomes of meta-analyses. The methodological quality of the included systematic reviews was assessed, and framework synthesis was used as the synthesis method. To estimate the degree of overlap, we created citation matrices and calculated the corrected covered area. Main Results Most reviews examined more than one type of social protection programme. The majority investigated social assistance programmes (77%, N = 54), 40% (N = 28) examined labour market programmes, 11% (N = 8) focused on social insurance interventions and 9% (N = 6) analysed social care interventions. Health was the most researched (e.g., maternal health; 70%, N = 49) outcome area, followed by economic security and empowerment (e.g., savings; 39%, N = 27) and education (e.g., school enrolment and attendance; 24%, N = 17). Five key findings were consistent across intervention and outcomes areas: (1) Although pre-existing gender differences should be considered, social protection programmes tend to report higher impacts on women and girls in comparison to men and boys; (2) Women are more likely to save, invest and share the benefits of social protection but lack of family support is a key barrier to their participation and retention in programmes; (3) Social protection programmes with explicit objectives tend to demonstrate higher effects in comparison to social protection programmes without broad objectives; (4) While no reviews point to negative impacts of social protection programmes on women or men, adverse and unintended outcomes have been attributed to design and implementation features. However, there are no one-size-fits-all approaches to design and implementation of social protection programmes and these features need to be gender-responsive and adapted; and (5) Direct investment in individuals and families' needs to be accompanied by efforts to strengthen health, education, and child protection systems. Social assistance programmes may increase labour participation, savings, investments, the utilisation of health care services and contraception use among women, school enrolment among boys and girls and school attendance among girls. They reduce unintended pregnancies among young women, risky sexual behaviour, and symptoms of sexually transmitted infections among women. Social insurance programmes increase the utilisation of sexual, reproductive, and maternal health services, and knowledge of reproductive health; improve changes in attitudes towards family planning; increase rates of inclusive and early initiation of breastfeeding and decrease poor physical wellbeing among mothers. Labour market programmes increase labour participation among women receiving benefits, savings, ownership of assets, and earning capacity among young women. They improve knowledge and attitudes towards sexually transmitted infections, increase self-reported condom use among boys and girls, increase child nutrition and overall household dietary intake, improve subjective wellbeing among women. Evidence on the impact of social care programmes on gender equality outcomes is needed. Authors' Conclusions Although effectiveness gaps remain, current programmatic interests are not matched by a rigorous evidence base demonstrating how to appropriately design and implement social protection interventions. Advancing current knowledge of gender-responsive social protection entails moving beyond effectiveness studies to test packages or combinations of design and implementation features that determine the impact of these interventions on gender equality. Systematic reviews investigating the impact of social care programmes, old age pensions and parental leave on gender equality outcomes in low and middle-income settings are needed. Voice and agency and mental health and psychosocial wellbeing remain under-researched gender equality outcome areas.
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Affiliation(s)
| | | | | | | | | | | | | | - Ruichuan Yu
- UNICEF Office of Research—InnocentiFlorenceItaly
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The effect of conditional cash transfers on the control of neglected tropical disease: a systematic review. Lancet Glob Health 2022; 10:e640-e648. [PMID: 35427521 DOI: 10.1016/s2214-109x(22)00065-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Neglected tropical diseases (NTDs) are diseases of poverty and affect 1·5 billion people globally. Conditional cash transfer (CCTs) programmes alleviate poverty in many countries, potentially contributing to improved NTD outcomes. This systematic review examines the relationship between CCTs and screening, incidence, or treatment outcomes of NTDs. METHODS In this systematic review we searched MEDLINE, Embase, Lilacs, EconLit, Global Health, and grey literature websites on Sept 17, 2020, with no date or language restrictions. Controlled quantitative studies including randomised controlled trials (RCTs) and observational studies evaluating CCT interventions in low-income and middle-income countries were included. Any outcome measures related to WHO's 20 diseases classified as NTDs were included. Studies from high-income countries were excluded. Two authors (AA and TH) extracted data from published studies and appraised risk of biases using the Risk of Bias in Non-Randomised Studies of Interventions and Risk of Bias 2 tools. Results were analysed narratively. This study is registered with PROSPERO, CRD42020202480. FINDINGS From the search, 5165 records were identified; of these, 11 studies were eligible for inclusion covering four CCTs in Brazil, the Philippines, Mexico, and Zambia. Most studies were either RCTs or quasi-experimental studies and ten were assessed to be of moderate quality. Seven studies reported improved NTD outcomes associated with CCTs, in particular, reduced incidence of leprosy and increased uptake of deworming treatments. There was some evidence of greater benefit of CCTS in lower socioeconomic groups but subgroup analysis was scarce. Methodological weaknesses include self-reported outcomes, missing data, improper randomisation, and differences between CCT and comparator populations in observational studies. The available evidence is currently limited, covering a small proportion of CCTs and NTDs. INTERPRETATION CCTs can be associated with improved NTD outcomes, and could be driven by both improvements in living standards from cash benefits and direct health effects from conditionalities related to health-care use. This evidence adds to the knowledge of health-improving effects from CCTs in poor and vulnerable populations. FUNDING None.
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Bhatia D, Mishra S, Kirubarajan A, Yanful B, Allin S, Di Ruggiero E. Identifying priorities for research on financial risk protection to achieve universal health coverage: a scoping overview of reviews. BMJ Open 2022; 12:e052041. [PMID: 35264342 PMCID: PMC8915291 DOI: 10.1136/bmjopen-2021-052041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Financial risk protection (FRP) is an indicator of the Sustainable Development Goal 3 universal health coverage (UHC) target. We sought to characterise what is known about FRP in the UHC context and to identify evidence gaps to prioritise in future research. DESIGN Scoping overview of reviews using the Arksey & O'Malley and Levac & Colquhoun framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guidelines. DATA SOURCES MEDLINE, PsycINFO, CINAHL-Plus and PAIS Index were systematically searched for studies published between 1 January 1995 and 20 July 2021. ELIGIBILITY CRITERIA Records were screened by two independent reviewers in duplicate using the following criteria: (1) literature review; (2) focus on UHC achievement through FRP; (3) English or French language; (4) published after 1995 and (5) peer-reviewed. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted data using a standard form and descriptive content analysis was performed to synthesise findings. RESULTS 50 studies were included. Most studies were systematic reviews focusing on low-income and middle-income countries. Study periods spanned 1990 and 2020. While FRP was recognised as a dimension of UHC, it was rarely defined as a concept. Out-of-pocket, catastrophic and impoverishing health expenditures were most commonly used to measure FRP. Pooling arrangements, expansion of insurance coverage and financial incentives were the main interventions for achieving FRP. Evidence gaps pertained to the effectiveness, cost-effectiveness and equity implications of efforts aimed at increasing FRP. Methodological gaps related to trade-offs between single-country and multicountry analyses; lack of process evaluations; inadequate mixed-methods evidence, disaggregated by relevant characteristics; lack of comparable and standardised measurement and short follow-up periods. CONCLUSIONS This scoping overview of reviews characterised what is known about FRP as a UHC dimension and found evidence gaps related to the effectiveness, cost-effectiveness and equity implications of FRP interventions. Theory-informed mixed-methods research using high-quality, longitudinal and disaggregated data is needed to address these objectives.
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Affiliation(s)
- Dominika Bhatia
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sujata Mishra
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Abirami Kirubarajan
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Bernice Yanful
- Public Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara Allin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Erica Di Ruggiero
- Public Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Lee S, Adam AJ. Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:295. [PMID: 35010561 PMCID: PMC8744962 DOI: 10.3390/ijerph19010295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/25/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.
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Affiliation(s)
- Seohyun Lee
- Department of Global Public Administration, Mirae Campus, Yonsei University, Wonju 26493, Korea
| | - Abdul-jabiru Adam
- Department of Public Administration, Mirae Campus, Yonsei University Graduate School, Wonju 26493, Korea;
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Kc A, Målqvist M, Bhandari A, Gurung R, Basnet O, Sunny AK. Payment mechanism for institutional births in Nepal. ACTA ACUST UNITED AC 2021; 79:163. [PMID: 34503572 PMCID: PMC8427872 DOI: 10.1186/s13690-021-00680-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 08/23/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Since the Millennium Development Goal era, there have been several efforts to increase institutional births using demand side financing. Since 2005, Government of Nepal has implemented Maternity Incentive Scheme (MIS) to reduce out of pocket expenditure (OOPE) for institutional birth. We aim to assess OOPE among women who had institutional births and coverage of MIS in Nepal. METHOD We conducted a prospective cohort study in 12 hospitals of Nepal for a period of 18 months. All women who were admitted in the hospital for delivery and consented were enrolled into the study. Research nurses conducted pre-discharge interviews with women on costs paid for medical services and non-medical services. We analysed the out of pocket expenditure by mode of delivery, duration of stay and hospitals. We also analysed the coverage of maternal incentive scheme in these hospitals. RESULTS Among the women (n-21,697) reporting OOPE, the average expenditure per birth was 41.5 USD with 36 % attributing to transportation cost. The median OOPE was highest in Bheri hospital (60.3 USD) in comparison with other hospitals. The OOPE increased by 1.5 USD (1.2, 1.8) with each additional day stay in the hospital. There was a difference in the OOPE by mode of delivery, duration of hospital-stay and hospital of birth. The median OOPE was high among the caesarean birth with 43.3 USD in comparison with vaginal birth, 32.6 USD. The median OOPE was 44.7 USD, if the women stayed for 7 days and 33.5 USD if the women stayed for 24 h. The OOPE increased by 1.5 USD with each additional day of hospital stay after 24 h. The coverage of maternal incentive was 96.5 % among the women enrolled in the study. CONCLUSIONS Families still make out of pocket expenditure for institutional birth with a large proportion attributed to hospital care. OOPE for institutional births varied by duration of stay and mode of birth. Given the near universal coverage of incentive scheme, there is a need to review the amount of re-imbursement done to women based on duration of stay and mode of birth.
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Affiliation(s)
- Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, Sweden. .,Society of Public Health Physicians Nepal, Kathmandu, Nepal.
| | - Mats Målqvist
- Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, Sweden
| | - Amit Bhandari
- Society of Public Health Physicians Nepal, Kathmandu, Nepal.,Golden Community, Lalitpur, Nepal
| | - Rejina Gurung
- Department of Women's and Children's Health, Uppsala University, Dag Hammarskjölds väg 14B, Uppsala, Sweden.,Golden Community, Lalitpur, Nepal
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Ezenwaka U, Manzano A, Onyedinma C, Ogbozor P, Agbawodikeizu U, Etiaba E, Ensor T, Onwujekwe O, Ebenso B, Uzochukwu B, Mirzoev T. Influence of Conditional Cash Transfers on the Uptake of Maternal and Child Health Services in Nigeria: Insights From a Mixed-Methods Study. Front Public Health 2021; 9:670534. [PMID: 34307277 PMCID: PMC8297950 DOI: 10.3389/fpubh.2021.670534] [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: 02/21/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Increasing access to maternal and child health (MCH) services is crucial to achieving universal health coverage (UHC) among pregnant women and children under-five (CU5). The Nigerian government between 2012 and 2015 implemented an innovative MCH programme to reduce maternal and CU5 mortality by reducing financial barriers of access to essential health services. The study explores how the implementation of a financial incentive through conditional cash transfer (CCT) influenced the uptake of MCH services in the programme. Methods: The study used a descriptive exploratory approach in Anambra state, southeast Nigeria. Data was collected through qualitative [in-depth interviews (IDIs), focus group discussions (FGDs)] and quantitative (service utilization data pre- and post-programme) methods. Twenty-six IDIs were conducted with respondents who were purposively selected to include frontline health workers (n = 13), National and State policymakers and programme managers (n = 13). A total of sixteen FGDs were conducted with service users and their family members, village health workers, and ward development committee members from four rural communities. We drew majorly upon Skinner's reinforcement theory which focuses on human behavior in our interpretation of the influence of CCT in the uptake of MCH services. Manual content analysis was used in data analysis to pull together core themes running through the entire data set. Results: The CCTs contributed to increasing facility attendance and utilization of MCH services by reducing the financial barrier to accessing healthcare among pregnant women. However, there were unintended consequences of CCT which included a reduction in birth spacing intervals, and a reduction of trust in the health system when the CCT was suddenly withdrawn by the government. Conclusion: CCT improved the utilization of MCH, but the sudden withdrawal of the CCT led to the opposite effect because people were discouraged due to lack of trust in government to keep using the MCH services. Understanding the intended and unintended outcomes of CCT will help to build sustainable structures in policy designs to mitigate sudden programme withdrawal and its subsequent effects on target beneficiaries and the health system at large.
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Affiliation(s)
- Uchenna Ezenwaka
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, United Kingdom
| | - Chioma Onyedinma
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Pamela Ogbozor
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Uju Agbawodikeizu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Enyi Etiaba
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Tim Ensor
- Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria.,Department of Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria Enugu, Nsukka, Nigeria
| | - Bassey Ebenso
- Centre for International Health and Development, University of Leeds, Leeds, United Kingdom
| | - Benjamin Uzochukwu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu, Nsukka, Nigeria
| | - Tolib Mirzoev
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Belaid L, Atim P, Atim E, Ochola E, Ogwang M, Bayo P, Oola J, Wonyima Okello I, Sarmiento I, Rojas-Rozo L, Zinszer K, Zarowsky C, Andersson N. Communities and service providers address access to perinatal care in postconflict Northern Uganda: socialising evidence for participatory action. Fam Med Community Health 2021; 9:fmch-2020-000610. [PMID: 33731319 PMCID: PMC7978070 DOI: 10.1136/fmch-2020-000610] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objectives Describe participatory codesign of interventions to improve access to perinatal care services in Northern Uganda. Study design Mixed-methods participatory research to codesign increased access to perinatal care. Fuzzy cognitive mapping, focus groups and a household survey identified and documented the extent of obstructions to access. Deliberative dialogue focused stakeholder discussions of this evidence to address the obstacles to access. Most significant change stories explored the participant experience of this process. Setting Three parishes in Nwoya district in the Gulu region, Northern Uganda. Participants Purposively sampled groups of women, men, female youth, male youth, community health workers, traditional midwives and service providers. Each of seven stakeholder categories included 5–8 participants in each of three parishes. Results Stakeholders identified several obstructions to accessing perinatal care: lack of savings in preparation for childbirth in facility costs, lack of male support and poor service provider attitudes. They suggested joining saving groups, practising saving money and income generation to address the short-term financial shortfall. They recommended increasing spousal awareness of perinatal care and they proposed improving service provider attitudes. Participants described their own improved care-seeking behaviour and patient–provider relationships as short-term gains of the codesign. Conclusion Participatory service improvement is feasible and acceptable in postconflict settings like Northern Uganda. Engaging communities in identifying perinatal service delivery issues and reflecting on local evidence about these issues generate workable community-led solutions and increases trust between community members and service providers.
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Affiliation(s)
- Loubna Belaid
- CIET/ PRAM Family Medicine, McGill University, Montreal, Québec, Canada
| | - Pamela Atim
- Public Health, Gulu University, Gulu, Uganda
| | - Eunice Atim
- Maternal and child health, Nwoya Health District, Nwoya, Uganda
| | | | | | | | - Janet Oola
- Maternal and child health, Nwoya Health District, Nwoya, Uganda
| | | | - Ivan Sarmiento
- Family Medicine, McGill University, Montreal, Québec, Canada
| | | | - Kate Zinszer
- Preventive and social medicine, University of Montreal, Montreal, Québec, Canada
| | - Christina Zarowsky
- Preventive and social medicine, University of Montreal, Montreal, Québec, Canada
| | - Neil Andersson
- CIET/ PRAM Family Medicine, McGill University, Montreal, Québec, Canada.,Universidad Autónoma de Guerrero, Centro de Investigación de Enfermedades Tropicales, Acapulco, Mexico
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Feng XL, Wen C. Evaluation of a pilot program that integrated prenatal screening into routine antenatal care in western rural China: an interrupted time-series study. LANCET REGIONAL HEALTH-WESTERN PACIFIC 2020; 6:100075. [PMID: 34327408 PMCID: PMC8315490 DOI: 10.1016/j.lanwpc.2020.100075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 11/29/2022]
Abstract
Background We evaluated a large-scale pilot program in Shaanxi Province, western rural China, which integrated prenatal screening interventions for congenital abnormalities into routine antenatal programs. Methods We surveyed 1,597 mothers who gave birth between 2009 and 2016. Adopting the interrupted time-series design, we evaluated the program's impact on awareness, coverage, and cost, by comparing two counties with only supply-side policies, and two counties from the neighbouring province with no policies; and among the two counties with both supply- and demand-side policies and the two counties with only supply-side policies. We adjusted the sampling procedure and women's background characteristics. We conducted subgroup analyses by women's education. Findings After one year of implementation, the coverage of prenatal foetal aneuploidies and B-ultrasound screening rose by 25.0% and 23.5%. The program's supply-side policies attributed to 17.2 percentage points (90%CI 7.8–26.6%) and 27.3 percentage points (90%CI 16.2–38.5%) in coverage, and contributed to a higher median cost of 796.5RMB (90%CI 595.5–997.5). These significantly affected women with secondary education and above. However, the program's demand-side measures, that is, vouchers, seemed to be effective only in the mountainous regions, which raised awareness, and increased coverage of prenatal foetal aneuploidies screening by 28.6 percentage points (90%CI 13.4–43.8%), while not increasing costs. These significantly affected women with primary education and below. Education-related inequalities widened post-program in counties with only supply-side policies, but no inequalities existed in counties with demand-side policies. Interpretation Shaanxi's program made a pilot study to other provinces of China to integrate antenatal services. Government subsidies might be more effective in targeting specific geographic locations and people with primary education and lower.
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Affiliation(s)
- Xing Lin Feng
- Department of Health Policy and Management, School of Public Health, Peking University, China
| | - Chunmei Wen
- Department head, Department of Maternal and Child Health, Health Commission of the Shaanxi Province, China
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15
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Risk factors affecting maternal health outcomes in Rivers State of Nigeria: Towards the PRISMA model. Soc Sci Med 2020; 265:113520. [PMID: 33250317 DOI: 10.1016/j.socscimed.2020.113520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/14/2020] [Accepted: 11/10/2020] [Indexed: 12/29/2022]
Abstract
Existing research suggests that Nigeria accounts for about 23% of the world's maternal mortality ratio, with negative impacts on women's wellbeing and the country's socio-economic development. The underlying risk factors can be categorized into political influences, poor access to healthcare, inadequate utilization of health facilities, poor family planning support and complex pregnancy-related illness. Yet, the complex interrelations amongst the factors makes it difficult to ascertain the riskiest ones that affect women's reproduction and child death, with the existing intervening strategies failing to address the problem. This study identifies maternal health risk factors and prioritizes their management in Rivers State of Nigeria, using the Prevention and Recovery Information System for Monitoring and Analysis (PRISMA) model. Taking a quantitative turn, we applied exploratory factor analysis to analyze 174 returned questionnaires from healthcare professionals working in Rivers State and used the results to establish relationships between maternal health risk factors, prioritizing the riskiest factors. The outcomes indicate that the PRISMA model provides an effective framework for identifying and managing maternal mortality risks that can enable healthcare experts and managers to address the avoidable risk factors and mitigate the unavoidable patient-related risk factors in Nigeria. The implications for theory, practice and policy are discussed.
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16
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Okeke EN, Abubakar IS. Healthcare at the Beginning of Life and Child Survival: Evidence from a Cash Transfer Experiment in Nigeria. JOURNAL OF DEVELOPMENT ECONOMICS 2020; 143:102426. [PMID: 32863533 PMCID: PMC7450787 DOI: 10.1016/j.jdeveco.2019.102426] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Households in poor countries are encouraged (and sometimes coerced) to increase investments in formal health care services during pregnancy and childbirth. Is this good policy? The answer to a large extent depends on its effects on child welfare. We study the effects of a cash transfer program in Nigeria in which households were offered a payment of $14 conditioned on uptake of health services. We show that the transfer led to a large increase in uptake and a substantial increase in child survival driven by a decrease in in-utero child deaths. We present evidence suggesting that the key driver is prenatal health investments.
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Affiliation(s)
- Edward N Okeke
- Department of Economics, Sociology and Statistics, RAND, 1200 South Hayes, Arlington, VA 22202
| | - Isa S Abubakar
- Department of Community Medicine, Bayero University Kano and Aminu Kano Teaching Hospital
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17
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Shatilwe JT, Mashamba-Thompson TP. Mapping evidence on access to healthcare information by women of reproductive age in low-and-middle-income countries: scoping review protocol. Syst Rev 2019; 8:328. [PMID: 31843003 PMCID: PMC6913006 DOI: 10.1186/s13643-019-1203-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/16/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Research shows that there are inadequate interventions in resource-limited settings that could enable women of reproductive age to access and use health services in those settings. The main objective of this scoping review is to map the evidence on access to healthcare information by women of reproductive age in LMICs. METHOD AND ANALYSIS The primary search will include Google Scholar, Science Direct, PubMed, EBSCOhost (Academic search complete, CINAHL with full text, MEDLINE with full text, MEDLINE), Emerald, Embase, CDSR, PsycINFO, published and peer review journals, organisational projects, conference papers, reference list, grey literature sources, as well as reports related to this objective will be included in the study. Identified keywords will be used to search articles from the studies. The articles and abstracts will be screened by two independent reviewers (JS and TPMT). Inclusion and exclusion criteria will be considered to guide the screening. A thematic content analysis will be used to present the narrative account of the reviews, using NVivo computer software (version 11). DISCUSSIONS The scoping review will focus on women of reproductive age in LMICs. We anticipate finding relevant literature on the interventions aimed at accessing health care services in LMICs. The study findings will help reveal research gaps to guide future research. SCOPING REVIEW REGISTRATION Not registered with PROSPERO (not needed). PROTOCOL AND REGISTRATION This scoping review was not registered.
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Affiliation(s)
- Joyce T Shatilwe
- Displine of Public Health Medicine and School of Nursing, University of KwaZulu-Natal, Durban, South Africa.
| | - Tivani P Mashamba-Thompson
- Displine of Public Health Medicine and School of Nursing, University of KwaZulu-Natal, Durban, South Africa
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18
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King R, Jones L. Key factors deterring women's engagement with skilled birth attendants in three districts of Timor-Leste. A qualitative descriptive study. Midwifery 2019; 79:102555. [PMID: 31634757 DOI: 10.1016/j.midw.2019.102555] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 09/25/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To describe the barriers to women's access to maternity services in three districts of Timor-Leste. Research design/setting: Focused ethnography with data collection methods commensurate with a qualitative research design. SETTING AND PARTICIPANTS Data was collected in three districts in Timor-Leste. Participants included seventeen stakeholders, health professionals and managers providing skilled birth attendance (SBA) in Timor-Leste and thirty women who have given birth and are competent to give consent. FINDINGS Access to SBA services is seriously impeded by poor roads and lack of transportation, the poor condition and amenity of services, restricted hours of opening, the lack of availability of skilled SBA professionals and medical resources. Participants also commented upon the lack of privacy and multiple caregivers. Timorese patriarchal family structures, intergenerational decision-making and cultural attitudes towards reproductive health information and services potentially reduce women's access to reproductive health services. CONCLUSION This data provides a comprehensive record of the multiple structural barriers to women's access to SBA services. The modified AAAQA framework provides categories and an organisational structure to these barriers to SBA services. IMPLICATIONS FOR PRACTICE Maternity care in Timor-Leste is extremely poorly resourced. Midwives and other SBA will need to provide innovative low cost solutions if they are to consistently provide respectful culturally safe midwifery care. This includes the provision of privacy and a one to one midwifery relationship `with woman'. In addition, many women are unable to access SBA, where possible the MoH can consider strategies to improve the provision of SBA services to women birthing in community.
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Affiliation(s)
- Rosemary King
- Federation University, 61353279861 P.O. Box 665, Ballarat, Victoria 3353, Australia.
| | - Linda Jones
- Federation University, 1800 333 864 100 Clyde Rd, Berwick, Victoria 3806, Australia.
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19
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Assessing the operational effectiveness of a maternal and child health (MCH) conditional cash transfer pilot programme in Nigeria. BMC Pregnancy Childbirth 2019; 19:298. [PMID: 31419952 PMCID: PMC6697912 DOI: 10.1186/s12884-019-2418-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 07/19/2019] [Indexed: 12/01/2022] Open
Abstract
Background This paper provides insights into design and implementation of a Conditional Cash Transfer (CCT) pilot programme under the Subsidy Reinvestment and Empowerment Programme on Maternal and Child Health (SURE-P MCH) in Nigeria. The CCT day to day operations were independently assessed, from design to enrollment and pay out, in order to inform future CCT designs and implementation. Methods This study combined a desk review of SURE-P MCH CCT operational documents and retrospective, descriptive cross-sectional survey of 314 primary beneficiaries of the CCT scheme from 29 SURE-P MCH CCT designated health facilities between June – July 2015. The programme implementation manual (PIM) and several CCT monthly reports and articles obtained from the project implementation unit (PIU) were reviewed while structured questionnaire of (16) questions was used for face-to-face interviews with (30–33) CCT beneficiaries drawn from each of eight (8) participating states of Anambra, Bauchi, Bayelsa, Ebonyi, Kaduna, Niger, Ogun, and Zamfara and the Federal Capital Territory (FCT)-Abuja. Findings were analyzed and reported using R* statistical package (version 3.1.2). Subsequently a strengths, weaknesses, opportunities and threats (SWOT) analysis was conducted to identify key challenges and possible recommendations. Results The SWOT analysis indicated a robust design for the CCT programme, which would have enhanced operational effectiveness if implemented as designed. However, the programme faced several implementation challenges. For instance, though 65% of beneficiaries perceived CCT pay-out events to be orderly and well-organized, in some of the pilot states the events were marred with inconsistencies resulting in large crowds and increased waiting time for some beneficiaries. Similarly, only 40% of beneficiaries received the complete N5,000 (USD30) cash incentive, 28% received N1,000 (USD6) while others received either N2000 (USD12), N3000 (USD18) or N4000 (USD24). Conclusion The CCT pilot had a robust design as a result of a successful proof of concept which preceded the pilot roll-out. However, its implementation was marred with several challenges ranging from untimely release of funds, limited monitoring and evaluation and other operational challenges. Future CCT programmes should understudy the SWOT analysis presented in this paper to improve the design and implementation of CCT programmes in Nigeria and other settings.
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20
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Larson E, Gage AD, Mbaruku GM, Mbatia R, Haneuse S, Kruk ME. Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania. Trop Med Int Health 2019; 24:636-646. [PMID: 30767422 PMCID: PMC6499631 DOI: 10.1111/tmi.13220] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Objectives Reduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub‐optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth. Methods In this cluster‐randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in‐service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference‐in‐differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation. Results The intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup. Conclusions We attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality.
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Affiliation(s)
- Elysia Larson
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Anna D Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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21
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Kuwawenaruwa A, Ramsey K, Binyaruka P, Baraka J, Manzi F, Borghi J. Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation. Soc Sci Med 2019; 225:17-25. [DOI: 10.1016/j.socscimed.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 01/24/2019] [Accepted: 02/03/2019] [Indexed: 11/25/2022]
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Tahsina T, Ali NB, Siddique MAB, Ahmed S, Rahman M, Islam S, Rahman MM, Amena B, Hoque DME, Huda TM, Arifeen SE. Determinants of hardship financing in coping with out of pocket payment for care seeking of under five children in selected rural areas of Bangladesh. PLoS One 2018; 13:e0196237. [PMID: 29758022 PMCID: PMC5951548 DOI: 10.1371/journal.pone.0196237] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 04/09/2018] [Indexed: 12/22/2022] Open
Abstract
Background Around 63% of total health care expenditure in Bangladesh is mitigated through out of pocket payment (OOP). Heavy reliance on OOP at the time of care seeking poses great threat for financial impoverishment of the households. Households employ different strategies to cope with the associated financial hardship. Objective The aim of this paper is to understand the determinants of hardship financing in coping with OOP adopted for health care seeking of under five childhood illnesses in rural setting of Bangladesh. Methods A community based cross sectional survey was conducted during August to October, 2014 in 15 low performing sub-districts of northern and north-east regions of Bangladesh. Of the 7039 mothers of under five children surveyed, 1895 children who suffered from illness and sought care for their illness episodes were reported in this study. Descriptive statistics and ordinal regression analysis were conducted. Results A total number of 7,039 under five children reported to have suffered illness by their mothers. Among these children 37% suffered from priority illness. Care was sought for 88% children suffering from illnesses. Among them 26% went to a public or private sector medically trained provider. 5% of households incurred illness cost more than 10% of the household’s monthly expenditure. The need for assistance was higher among those compared to others (31% vs 13%). Different financing mechanisms adopted to meet OOP are loan with interest (6%), loan without interest (9%) and financial help from relatives (6%) Need for financial assistance varied from 19% among households in the lowest quintile to 9% in the highest wealth. Ordinal regression analysis revealed that burden of hardship financing increases by 2.17 times when care is sought from a private trained provider compared to care seeking from untrained provider (CI: 1.49, 3.17). Similarly, for families that incur a health care expenditure that is more than 10% of their total monthly expenditure (CI:1.46, 3.88), the probability of falling into more severe financial burden increases by 2.4 times. We also found severity of the hardship financing to be around half for households with monthly income of more than BDT 7500 (OR = 0.56, CI: 0.37, 0.86). The burden increased by 2.10 times for households with a deficit (CI: 1.53, 2.88) between their monthly income and expenditure. The interaction between family income and severity of illness showed to significantly affect the scale of hardship financing. Children suffering from priority illness belonging to poor households were found have two times (CI: 1.09, 3.47) higher risks of suffering from hardship financing. Conclusion and policy implications Findings from this study will help the policy makers to identify the target groups and thereby design effective health financing programs.
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Affiliation(s)
- Tazeen Tahsina
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
- * E-mail:
| | - Nazia Binte Ali
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
| | | | - Sameen Ahmed
- Department of Economics, George Washington University, Washington DC, United Sates of America
| | | | - Sajia Islam
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
| | | | - Bushra Amena
- Nobokoli Program, World Vision, Dhaka, Bangladesh
| | | | - Tanvir M. Huda
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
| | - Shams El Arifeen
- Maternal and Child Health Division (MCHD), icddr,b, Dhaka, Bangladesh
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Improving implementation of health promotion interventions for maternal and newborn health. BMC Pregnancy Childbirth 2017; 17:280. [PMID: 28854895 PMCID: PMC5577836 DOI: 10.1186/s12884-017-1450-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/04/2017] [Indexed: 11/17/2022] Open
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Hunter BM, Harrison S, Portela A, Bick D. The effects of cash transfers and vouchers on the use and quality of maternity care services: A systematic review. PLoS One 2017; 12:e0173068. [PMID: 28328940 PMCID: PMC5362260 DOI: 10.1371/journal.pone.0173068] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cash transfers and vouchers are forms of 'demand-side financing' that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years. METHODS This systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637). RESULTS Data from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes. CONCLUSION Future research should use multiple intervention arms to compare cost-effectiveness with similar investment in public services, and should look beyond short- to medium-term service utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects.
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Affiliation(s)
- Benjamin M. Hunter
- Department of International Development, King’s College London, London, United Kingdom
| | - Sean Harrison
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Debra Bick
- Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, United Kingdom
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