'It was hell in the community': a qualitative study of maternal and child health care during health care worker strikes in Kenya

A look back at the strike by Mozambican doctors in 2013: what can we learn?

BACKGROUND

The occurrence of strikes in the health sector has been an increasing concern around the world, given their negative impact on the provision of services and care to patients. The Mozambican doctors' strike in 2013 2013 is considered by many to be the largest of a kind in the country's history, and marked the changes which are still a matter of debate. The aim of this study is to understand the causes, strategies and perceived impact of this strike from the perspective of the main actors involved, taking a look back at everything that happened, including the backstage and tense moments during the negotiations. These details have been little covered in similar studies and are important for a better understanding and management of this type of movement.

METHODS

This is a qualitative study with a phenomelogical approach that consisted of semi-structured interviews with the main players involved in the strike movement, and analysis of documents produced around this movement. Non-probabilistic snowball sampling was used to select participants until data saturation was reached. The interviews were transcribed and imported into Nvivo version 12, and the data was analysed using content analysis to identify themes related to the research questions.

RESULTS

The doctors were demanding better salaries, career prospects and working conditions. Failure to fulfil agreements, threats from the government and a lack of communication are believed to have precipitated the strike. Faced with staff shortages, the government restricted services, prioritised urgent cases, and patients saw services slowed down, their care delayed, a lack of medicines in health units and a loss of confidence in the healthcare system. Although the strike contributed to the approval of the Doctors' Statute, it led to the interruption of postgraduate studies, transfers and suspensions of professionals.

CONCLUSION

The strike was motivated by aspects associated with salaries and working conditions. Some of the approaches adopted further distanced the parties and delayed consensus. The strike had negative consequences for everyone, especially patients. This study provides important lessons for improving strike prevention and management strategies in the health sector.

Impacts of industrial actions, protests, strikes and lockouts by health and care workers during COVID-19 and other pandemic contexts: a systematic review

BACKGROUND

Public health emergencies of international concern (PHEICs) as the COVID-19 pandemic and others that have occurred since the early 2000s put enormous pressure on health and care systems. This is being a context for protests by health and care workers (HCWs) because of additional workload, working conditions and effects on mental and physical health. In this paper, we intended to analyze the demands of HCWs associated with industrial actions, protests, strikes and lockouts (IAPSLs) which occurred during COVID-19 pandemic and other PHEICs; to identify the impact of these grievances; and describe the relevant interventions to address these IAPSLs.

METHODS

We included studies published between January 2000 and March 2022 in PubMed, Embase, Scopus, BVS/LILACS, WHO's COVID-19 Research Database, ILO, OECD, HSRM, and Google Scholar for grey literature. Eligibility criteria were HCWs as participants, IAPSLs as phenomenon of interest occurring in the context of COVID-19 and other PHEICs. GRADE CERQual was used to assess risk of bias and confidence of evidence.

RESULTS

1656 records were retrieved, and 91 were selected for full-text screening. We included 18 publications. A system-wide approach, rather than a limited approach to institutions on strike, makes it possible to understand the full impact of the strike on health and care services. PHEICs tend to aggravate already adverse working conditions of HCWs, acting as drivers for HCWs strikes, leading to staff shortages, and financial issues, both in the North and in the Global South, particularly evident in Asia and Africa. In addition, issues related to deficiencies in leadership and governance in heath sector and lack of medical products and technologies (e.g., lack of personal protective equipment) were the main drivers of strikes, each contributing 25% of the total drivers identified.

CONCLUSIONS

It is necessary to focus on the preparedness of health and care systems to respond adequately to PHEICs, and this includes being prepared for HCWs' IAPSLs, talked much in the context of COVID-19 pandemic. Evidence to assist policymakers in defining strategies to respond adequately to the health and care needs of the population during IAPSLs is crucial. The main impact of strikes is on the disruption of health care services' provision. Gender inequality being a major issue among HCWs, a proper understanding of the full impact of the strike on health and care services will only be possible if gender lens is combined with a systemic approach, rather than gender-undifferentiated approaches limited to the institutions on strike.

Strikes of physicians and other health care workers in sub-Saharan African countries: a systematic review

Introduction

Strikes in the health sector have been of growing concern, given their disruptive nature, negatively impacting the provision of health care and jeopardizing the well-being of patients. This study aims to identify the main actors, the reasons behind industrial actions protests, strikes and lockouts (IAPSL) in sub-Saharan African countries and their impact on health care workers (specifically doctors) and health services, as well as to identify the main strategies adopted to reduce their impact on healthcare services.

Methods

Studies published between January 2000 and December 2021 and archived in MEDLINE, Google Scholar, Scopus, ProQuest, and Science Direct were included. Quantitative, observational (i.e., cohort, case-control, cross-sectional, and ecological) and experimental studies, as well as mixed methods, quasi-experimental, and qualitative studies were eligible.

Results

A total of 5521 studies were identified and after eliminating duplicates, applying the inclusion criteria, and assessing the risk of bias, a total of 11 studies were included in the review. Nurses and doctors are the actors most commonly involved in strikes. The main causes of strikes were salary claims and poor working conditions. The main strategies adopted to mitigate the strike consequences were to restrict services and prioritize emergency and chronic care, greater cooperation with the private sector and rearrange tasks of the available staff. The strikes led to a reduction in hospitalizations and in the number of women giving birth in health units, an increase in maternal and child morbidities and delays in the immunization process. Increased mortality was only reported in faith-based hospitals.

Discussion

This evidence can assist decision-makers in developing strategies and interventions to address IAPSL by health care workers, contributing to strengthen the health system. Strikes in the health sector disrupt healthcare services provision and compromise the well-being of patients, especially the most disadvantaged, with consequences that may be difficult to overcome ever. The potential health impacts of strikes highlights the importance of their prevention or timely resolution through regulation and negotiations to balance the rights of health care workers and the rights of patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=334173, identifier CRD42022334173.

Public-Private engagement and health systems resilience in times of health worker strikes: a Ghanaian case study

In low and middle-income countries like Ghana, private providers, particularly the grouping of faith-based non-profit health providers networked by the Christian Health Association of Ghana (CHAG), play a crucial role in maintaining service continuity during health worker strikes. Poor engagement with the private sector during such strikes could compromise care quality and impose financial hardships on populations, especially the impoverished. This study delves into the engagement between CHAG and the Government of Ghana (GoG) during health worker strikes from 2010 to 2016, employing a qualitative descriptive and exploratory case study approach. By analysing evidence from peer-reviewed literature, media archives, grey literature and interview transcripts from a related study using a qualitative thematic analysis approach, this study identifies health worker strikes as a persistent chronic stressor in Ghana. Findings highlight some system-level interactions between CHAG and GoG, fostering adaptive and absorptive resilience strategies, influenced by CHAG's non-striking ethos, unique secondment policy between the two actors and the presence of a National Health Insurance System. However, limited support from the government to CHAG member facilities during strikes and systemic challenges with the National Health Insurance System pose threats to CHAG's ability to provide quality, affordable care. This study underscores private providers' pivotal role in enhancing health system resilience during strikes in Ghana, advocating for proactive governmental partnerships with private providers and joint efforts to address human-resource-related challenges ahead of strikes. It also recommends further research to devise and evaluate effective strategies for nations to respond to strikes, ensuring preparedness and sustained quality healthcare delivery during such crises.

"I don't like to be seen by a male provider": health workers' strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria

BACKGROUND

Ending maternal mortality has been a significant global health priority for decades. Many sub-Saharan African countries introduced user fee removal policies to attain this goal and ensure universal access to health facility delivery. However, many women in Nigeria continue to deliver at home. We examined the reasons for home birth in settings with free maternal healthcare in Southwestern and North Central Nigeria.

METHODS

We adopted a fully mixed, sequential, equal-status design. For the quantitative study, we drew data from 211 women who reported giving birth at home from a survey of 1227 women of reproductive age who gave birth in the 5 y before the survey. The qualitative study involved six focus group discussions and 68 in-depth interviews. Data generated through the interviews were coded and subjected to inductive thematic analysis, while descriptive statistics were used to analyse the quantitative data.

RESULTS

Women faced several barriers that limited their use of skilled birth attendants. These barriers operate at multiple levels and could be grouped as economic, sociocultural and health facility-related factors. Despite the user fee removal policy, lack of transportation, birth unpreparedness and lack of money pushed women to give birth at home. Also, sociocultural reasons such as hospital delivery not being deemed necessary in the community, women not wanting to be seen by male health workers, husbands not motivated and husbands' disapproval hindered the use of health facilities for childbirth.

CONCLUSIONS

This study has demonstrated that free healthcare does not guarantee universal access to healthcare. Interventions, especially in the Nasarawa state of Nigeria, should focus on the education of mothers on the importance of health facility-based delivery and birth preparedness.

The impact of strike action by Ghana registered nurses and midwives on the access to and utilization of healthcare services

BACKGROUND

As the largest professional group, nurses and midwives play instrumental roles in healthcare delivery, supporting the smooth administration and operation of the health system. Consequently, the withdrawal of nursing and midwifery services via strike action has direct and indirect detrimental effects on access to healthcare.

OBJECTIVE

The current study examined the impact of strike action by nurses and midwives with respect to access to and use of health services.

METHOD

Data were collected retrospectively from a total of 181 health facilities from all the 16 administrative regions of Ghana, with the support of field officers. Because the strike lasted for 3 days, the data collection span three consecutive days before the strike, three days of the strike and three consecutive days after the strike. Data analysis was focused comparing the utilization of healthcare services before, during and after strike. Data were analysed and presented on the various healthcare services. This was done separately for the health facility type and the 16 administrative regions.

FINDINGS

The results showed that; (1) the average number of patients or clients who accessed healthcare services reduced drastically during the strike period, compared with before the strike. Majority of the regions recorded more than 70% decrease in service use during the strike period; (2) the average number of patients or clients who accessed healthcare services after the strike increased by more than 100% across majority of the regions.

CONCLUSION

The study showed that strike action by nurses and midwives negatively affected access to and utilization of healthcare services.

Trust, Care Avoidance, and Care Experiences among Kenyan Women Who Delivered during the COVID-19 Pandemic

We explore how the COVID-19 pandemic was associated with avoidance of, and challenges with, antenatal, childbirth and postpartum care among women in Kiambu and Nairobi counties, Kenya; and whether this was associated with a report of declined trust in the health system due to the pandemic. Women who delivered between March and November 2020 were invited to participate in a phone survey about their care experiences (n = 1122 respondents). We explored associations between reduced trust and care avoidance, delays and challenges with healthcare seeking, using logistic regression models adjusted for women's characteristics. Approximately half of respondents said their trust in the health care system had declined due to COVID-19 (52.7%, n = 591). Declined trust was associated with higher likelihood of reporting barriers accessing antenatal care (aOR 1.59 [95% CI 1.24, 2.05]), avoiding care for oneself (aOR 2.26 [95% CI 1.59, 3.22]) and for one's infant (aOR 1.77 [95% CI 1.11, 2.83]), and of feeling unsafe accessing care (aOR 1.52 [95% CI 1.19, 1.93]). Since March 2020, emergency services, routine care and immunizations were avoided most often. Primary reported reasons for avoiding care and challenges accessing care were financial barriers and problems accessing the facility. Declined trust in the health care system due to COVID-19 may have affected health care-seeking for women and their children in Kenya, which could have important implications for their health and well-being. Programs and policies should consider targeted special "catch-up" strategies that include trust-building messages and actions for women who deliver during emergencies like the COVID-19 pandemic.