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Qin T, Li X, Qiao K, Bai X, Gu M, Wang Y. Utilizing Group Model Building to Identify Barriers and Facilitators of Hypertension Management in Primary Health Care, China. Risk Manag Healthc Policy 2024; 17:1227-1237. [PMID: 38765783 PMCID: PMC11100508 DOI: 10.2147/rmhp.s454748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/12/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose Group Model Building (GMB) is a qualitative method that refers to a participatory process. This project aims to identify barriers and facilitators of hypertension management in primary health care in China, through which, the leverage point for intervention may be found. Methods The GMB was used to identify the factors influencing hypertension management. Graphs over time and causal loop diagram (CLD) were main tools of GMB. To propose the influencing factors, key stakeholders were invited to participate in a workshop. During the workshop, stakeholders were encouraged to plot the graphs over time of the variables about research issues and give a descriptive explanation. And based on this, a CLD was initially developed to establish a model of the interaction of factors. After the workshop, the research group further improved the CLD through repeated mutual discussions, and gave feedback to the participants. The Vensim PLE 9.0 software package was used to build CLD. Results A total of 14 key stakeholders were invited to participate in the workshop. Finally, 26 influencing factors were identified, which were divided into three dimensions, including the institutional, the community health workers (CHWs), and the patient level. And 5 reinforcing loops and 4 balancing loops were formed in the CLD. Promoting the building of the Medical Community/Regional Medical Association, implementing the family doctor contract service (FDCS), and enhancing the motivation of CHWs may be potential leverage points for hypertension management in China. Conclusion By using GMB, we have identified key factors in the management of hypertension in primary health care and provided comprehensive suggestions to overcome the obstacles.
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Affiliation(s)
- Tingting Qin
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
| | - Xingming Li
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
| | - Kun Qiao
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
| | - Xinyuan Bai
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
| | - Mingyu Gu
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
| | - Yao Wang
- School of Public Health, Capital Medical University, Beijing, People’s Republic of China
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Al Asfoor D, Tabche C, Al-Zadjali M, Mataria A, Saikat S, Rawaf S. Concept analysis of health system resilience. Health Res Policy Syst 2024; 22:43. [PMID: 38576011 PMCID: PMC10996206 DOI: 10.1186/s12961-024-01114-w] [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: 02/20/2023] [Accepted: 01/29/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND There are several definitions of resilience in health systems, many of which share some characteristics, but no agreed-upon framework is universally accepted. Here, we review the concept of resilience, identifying its definitions, attributes, antecedents and consequences, and present the findings of a concept analysis of health system resilience. METHODS We follow Schwarz-Barcott and Kim's hybrid model, which consists of three phases: theoretical, fieldwork and final analysis. We identified the concept definitions, attributes, antecedents and consequences of health system resilience and constructed an evidence-informed framework on the basis of the findings of this review. We searched PubMed, PsycINFO, CINAHL Complete, EBSCOhost-Academic Search and Premier databases and downloaded identified titles and abstracts on Covidence. We screened 3357 titles and removed duplicate and ineligible records; two reviewers then screened each title, and disagreements were resolved by discussion with the third reviewer. From the 130 eligible manuscripts, we identified the definitions, attributes, antecedents and consequences using a pre-defined data extraction form. RESULTS Resilience antecedents are decentralization, available funds, investments and resources, staff environment and motivation, integration and networking and finally, diversification of staff. The attributes are the availability of resources and funds, adaptive capacity, transformative capacity, learning and advocacy and progressive leadership. The consequences of health system resilience are improved health system performance, a balanced governance structure, improved expenditure and financial management of health and maintenance of health services that support universal health coverage (UHC) throughout crises. CONCLUSION A resilient health system maintains quality healthcare through times of crisis. During the coronavirus disease 2019 (COVID-19) epidemic, several seemingly robust health systems were strained under the increased demand, and services were disrupted. As such, elements of resilience should be integrated into the functions of a health system to ensure standardized and consistent service quality and delivery. We offer a systematic, evidence-informed method for identifying the attributes of health system resilience, intending to eventually be used to develop a measuring tool to evaluate a country's health system resilience performance.
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Affiliation(s)
| | - Celine Tabche
- WHOCC Imperial College London, London, United Kingdom
| | | | | | | | - Salman Rawaf
- WHOCC Imperial College London, London, United Kingdom
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Debie A, Nigusie A, Gedle D, Khatri RB, Assefa Y. Building a resilient health system for universal health coverage and health security: a systematic review. Glob Health Res Policy 2024; 9:2. [PMID: 38173020 PMCID: PMC10765832 DOI: 10.1186/s41256-023-00340-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 12/05/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Resilient health system (RHS) is crucial to achieving universal health coverage (UHC) and health security. However, little is known about strategies towards RHS to improve UHC and health security. This systematic review aims to synthesise the literature to understand approaches to build RHS toward UHC and health security. METHODS A systematic search was conducted including studies published from 01 January 2000 to 31 December 2021. Studies were searched in three databases (PubMed, Embase, and Scopus) using search terms under four domains: resilience, health system, universal health coverage, and health security. We critically appraised articles using Rees and colleagues' quality appraisal checklist to assess the quality of papers. A systematic narrative synthesis was conducted to analyse and synthesise the data using the World Health Organization's health systems building block framework. RESULTS A total of 57 articles were included in the final review. Context-based redistribution of health workers, task-shifting policy, and results-based health financing policy helped to build RHS. High political commitment, community-based response planning, and multi-sectorial collaboration were critical to realising UHC and health security. On the contrary, lack of access, non-responsive, inequitable healthcare services, poor surveillance, weak leadership, and income inequalities were the constraints to achieving UHC and health security. In addition, the lack of basic healthcare infrastructures, inadequately skilled health workforces, absence of clear government policy, lack of clarity of stakeholder roles, and uneven distribution of health facilities and health workers were the challenges to achieving UHC and health security. CONCLUSIONS Advanced healthcare infrastructures and adequate number of healthcare workers are essential to achieving UHC and health security. However, they are not alone adequate to protect the health system from potential failure. Context-specific redistribution of health workers, task-shifting, result-based health financing policies, and integrated and multi-sectoral approaches, based on the principles of primary health care, are necessary for building RHS toward UHC and health security.
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Affiliation(s)
- Ayal Debie
- Departement of Health Systems and Policy, Institute of Public Health, University of Gondar, Gondar, Ethiopia.
- College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Adane Nigusie
- Departement of Health Education and Behavioral Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Dereje Gedle
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Resham B Khatri
- School of Public Health, The University of Queensland, Brisbane, Australia
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, Australia
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Truppa C, Yaacoub S, Valente M, Celentano G, Ragazzoni L, Saulnier D. Health systems resilience in fragile and conflict-affected settings: a systematic scoping review. Confl Health 2024; 18:2. [PMID: 38172918 PMCID: PMC10763433 DOI: 10.1186/s13031-023-00560-7] [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: 05/29/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Health systems resilience (HSR) research is a rapidly expanding field, in which key concepts are discussed and theoretical frameworks are emerging with vibrant debate. Fragile and conflict-affected settings (FCAS) are contexts exposed to compounding stressors, for which resilience is an important characteristic. However, only limited evidence has been generated in such settings. We conducted a scoping review to: (a) identify the conceptual frameworks of HSR used in the analysis of shocks and stressors in FCAS; (b) describe the representation of different actors involved in health care governance and service provision in these settings; and (c) identify health systems operations as they relate to absorption, adaptation, and transformation in FCAS. METHODS We used standard, extensive search methods. The search captured studies published between 2006 and January 2022. We included all peer reviewed and grey literature that adopted a HSR lens in the analysis of health responses to crises. Thematic analysis using both inductive and deductive approaches was conducted, adopting frameworks related to resilience characteristics identified by Kruk et al., and the resilience capacities described by Blanchet et al. RESULTS: Thirty-seven studies met our inclusion criteria. The governance-centred, capacity-oriented framework for HSR emerged as the most frequently used lens of analysis to describe the health responses to conflict and chronic violence specifically. Most studies focused on public health systems' resilience analysis, while the private health sector is only examined in complementarity with the former. Communities are minimally represented, despite their widely acknowledged role in supporting HSR. The documentation of operations enacting HSR in FCAS is focused on absorption and adaptation, while transformation is seldom described. Absorptive, adaptive, and transformative interventions are described across seven different domains: safety and security, society, health system governance, stocks and supplies, built environment, health care workforce, and health care services. CONCLUSIONS Our review findings suggest that the governance-centred framework can be useful to better understand HSR in FCAS. Future HSR research should document adaptive and transformative strategies that advance HSR, particularly in relation to actions intended to promote the safety and security of health systems, the built environment for health, and the adoption of a social justice lens.
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Affiliation(s)
- Claudia Truppa
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy.
- International Committee of the Red Cross, Geneva, Switzerland.
| | - Sally Yaacoub
- Center for Research in Epidemiology and StatisticS (CRESS), Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, 75004, Paris, France
| | - Martina Valente
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, 13100, Vercelli, Italy
| | - Giulia Celentano
- ETH Zürich, Institut Für Bau- Und Infrastrukturmanagement, Chair of Sustainable Construction, Zurich, Schweiz
| | - Luca Ragazzoni
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department for Sustainable Development and Ecological Transition, Università del Piemonte Orientale, 13100, Vercelli, Italy
| | - Dell Saulnier
- Division of Social Medicine and Global Health/Department of Clinical Sciences, Lund University, Malmö, Sweden
- Geneva Centre of Humanitarian Studies, Université de Genève, Geneva, Switzerland
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Ismail SA, Tomoaia-Cotisel A, Noubani A, Fouad FM, Bell S, Borghi J, Blanchet K. Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon. BMJ Glob Health 2023; 8:e012399. [PMID: 37931939 PMCID: PMC10632819 DOI: 10.1136/bmjgh-2023-012399] [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: 03/24/2023] [Accepted: 09/09/2023] [Indexed: 11/08/2023] Open
Abstract
INTRODUCTION Despite rapidly growing academic and policy interest in health system resilience, the empirical literature on this topic remains small and focused on macrolevel effects arising from single shocks. To better understand health system responses to multiple shocks, we conducted an in-depth case study using qualitative system dynamics. We focused on routine childhood vaccination delivery in Lebanon in the context of at least three shocks overlapping to varying degrees in space and time: large-scale refugee arrivals from neighbouring Syria; COVID-19; and an economic crisis. METHODS Semistructured interviews were performed with 38 stakeholders working at different levels in the system. Interview transcripts were analysed using purposive text analysis to generate individual stakeholder causal loop diagrams (CLDs) mapping out relationships between system variables contributing to changes in coverage for routine antigens over time. These were then combined using a stepwise process to produce an aggregated CLD. The aggregated CLD was validated using a reserve set of interview transcripts. RESULTS Various system responses to shocks were identified, including demand promotion measures such as scaling-up community engagement activities and policy changes to reduce the cost of vaccination to service users, and supply side responses including donor funding mobilisation, diversification of service delivery models and cold chain strengthening. Some systemic changes were introduced-particularly in response to refugee arrivals-including task-shifting to nurse-led vaccine administration. Potentially transformative change was seen in the integration of private sector clinics to support vaccination delivery and depended on both demand side and supply side changes. Some resilience-promoting measures introduced following earlier shocks paradoxically increased vulnerability to later ones. CONCLUSION Flexibility in financing and human resource allocation appear key for system resilience regardless of the shock. System dynamics offers a promising method for ex ante modelling of ostensibly resilience-strengthening interventions under different shock scenarios, to identify-and safeguard against-unintended consequences.
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Affiliation(s)
- Sharif A Ismail
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Aya Noubani
- Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sadie Bell
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Karl Blanchet
- Geneva Center of Humanitarian Studies, University of Geneva, Geneva, Switzerland
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Decker H, Wendel M. Applications of Participatory System Dynamics Methods to Public Health: A Systematic Review. FAMILY & COMMUNITY HEALTH 2023; 46:S6-S21. [PMID: 37696012 DOI: 10.1097/fch.0000000000000369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
System dynamics, and specifically qualitative participatory applications of system dynamics, have potential to benefit public health research, scholarship, and practice. A systematic review was conducted to examine the existing applications of participatory system dynamics (PSD) to public health research. Three databases were searched using unique search terms related to PSD and methodological applications in public health research. A total of 57 unique articles met inclusion criteria and were included for review. The studies included for review were conducted globally and represent a wide breadth of public health issues. The review identified several advantages to adopting PSD methods in public health scholarship and practice. The PSD methods provide innovative frameworks for conceptualizing complex and nuanced public health problems. The participatory nature of PSD allows for increased community engagement and empowerment to address public health problems, as well as to mitigate existing power dynamics between research institutions and marginalized communities that are disproportionately impacted by social and health inequities. Finally, causal loop diagrams developed using PSD methods have unique potential to convey complex concepts to policy makers and interventionists. This systematic review reports evidence for PSD's potential to advance equity in public health research and practice.
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Affiliation(s)
- Hallie Decker
- Health Equity Innovation Hub, University of Louisville, Louisville, Kentucky (Ms Decker); and Health Promotion & Behavioral Sciences, School of Public Health and Information Sciences, and Health Equity Innovation Hub, University of Louisville, Louisville, Kentucky (Dr Wendel)
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Li B, He Z, Peters R, Allender S, Zou Y, Zhou W, Lao J, Poh BK, Swinburn B. Cultural adaptations and methodological innovations to group model building for the systems actions to reduce malnutrition in all its forms in Southeast Asian countries and China (SYSTAM CHINA-SEACS International Consortium) project. Int J Behav Nutr Phys Act 2023; 20:111. [PMID: 37723534 PMCID: PMC10506199 DOI: 10.1186/s12966-023-01510-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/02/2023] [Indexed: 09/20/2023] Open
Abstract
BACKGROUND Group Model Building (GMB) is a participatory system dynamics method increasingly used to address complex public health issues like obesity. GMB represents a set of well-defined steps to engage key stakeholders to identify shared drivers and solutions of a given problem. However, GMB has not yet been applied specifically to develop multi-duty interventions that address multiple inter-related issues such as malnutrition in all its forms (MIAIF). Moreover, a recent systematic review of empirical applications of a systems approach to developing obesity interventions found no published work from non-western, low- and middle-income countries (LMICs). In this paper we describe adaptations and innovations to a common GMB process to co-develop systemic MIAIF interventions with Chinese decision-makers. METHODS We developed, piloted and implemented multiple cultural adaptations and two methodological innovations to the commonly used GMB process in Fang Cheng Gang city, China. We included formal, ceremonial and policy maker engagement events before and between GMB workshops, and incorporated culturally tailored arrangements during participant recruitment (officials of the same seniority level joined the same workshop) and workshop activities (e.g., use of individual scoring activities and hand boards). We made changes to the commonly used GMB activities which enabled mapping of shared drivers of multiple health issues (in our case MIAIF) in a single causal loop diagram. We developed and used a 'hybrid' GMB format combining online and in person facilitation to reduce travel and associated climate impact. RESULTS Our innovative GMB process led to high engagement and support from decision-makers representing diverse governmental departments across the whole food systems. We co-identified and prioritised systemic drivers and intervention themes of MIAIF. The city government established an official Local Action Group for long-term, inter-departmental implementation, monitoring and evaluation of the co-developed interventions. The 'hybrid' GMB format enabled great interactions while reducing international travel and mitigating limitations of fully online GMB process. CONCLUSIONS Cultural and methodological adaptations to the common GMB process for an Asian LMIC setting were successful. The 'hybrid' GMB format is feasible, cost-effective, and more environmentally friendly. These cultural adaptations could be considered for other Asian settings and beyond to address inter-related, complex issues such as MIAIF.
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Affiliation(s)
- Bai Li
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK.
- School of Public Health, Guangxi Medical University, Nanning, Guangxi, China.
| | - Zouyan He
- School of Public Health, Guangxi Medical University, Nanning, Guangxi, China
| | - Remco Peters
- Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, Bristol, UK
| | - Steven Allender
- Global Centre for Preventive Health and Nutrition (GLOBE), Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Yunfeng Zou
- School of Public Health, Guangxi Medical University, Nanning, Guangxi, China.
| | - Weiwen Zhou
- Institute of Nutrition and School Health, Guangxi Zhuang Autonomous Region Center for Disease Control and Prevention, Nanning, Guangxi, China
| | - Jianfeng Lao
- Fang Cheng Gang Health Commission, Fangchenggang, Guangxi, China
| | - Bee Koon Poh
- Centre for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Boyd Swinburn
- School of Population Health, University of Auckland, Auckland, New Zealand
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Witter S, Thomas S, Topp SM, Barasa E, Chopra M, Cobos D, Blanchet K, Teddy G, Atun R, Ager A. Health system resilience: a critical review and reconceptualisation. Lancet Glob Health 2023; 11:e1454-e1458. [PMID: 37591591 DOI: 10.1016/s2214-109x(23)00279-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 08/19/2023]
Abstract
This Viewpoint brings together insights from health system experts working in a range of settings. Our focus is on examining the state of the resilience field, including current thinking on definitions, conceptualisation, critiques, measurement, and capabilities. We highlight the analytical value of resilience, but also its risks, which include neglect of equity and of who is bearing the costs of resilience strategies. Resilience depends crucially on relationships between system actors and components, and-as amply shown during the COVID-19 pandemic-relationships with wider systems (eg, economic, political, and global governance structures). Resilience is therefore connected to power imbalances, which need to be addressed to enact the transformative strategies that are important in dealing with more persistent shocks and stressors, such as climate change. We discourage the framing of resilience as an outcome that can be measured; instead, we see it emerge from systemic resources and interactions, which have effects that can be measured. We propose a more complex categorisation of shocks than the common binary one of acute versus chronic, and outline some of the implications of this for resilience strategies. We encourage a shift in thinking from capacities towards capabilities-what actors could do in future with the necessary transformative strategies, which will need to encompass global, national, and local change. Finally, we highlight lessons emerging in relation to preparing for the next crisis, particularly in clarifying roles and avoiding fragmented governance.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK; ReBUILD for Resilience, Queen Margaret University, Edinburgh, UK.
| | - Steve Thomas
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Stephanie M Topp
- Centre for Health Policy & Management, James Cook University, Townsville, QLD, Australia
| | - Edwine Barasa
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | - Daniel Cobos
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, Geneva, Switzerland
| | - Gina Teddy
- Ghana Institute of Management and Public Affairs, Accra, Ghana
| | - Rifat Atun
- Harvard School of Public Health, Boston, MA, USA
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Estrada-Magbanua WM, Huang TTK, Lounsbury DW, Zito P, Iftikhar P, El-Bassel N, Gilbert L, Wu E, Lee BY, Mateu-Gelabert P, S. Sabounchi N. Application of group model building in implementation research: A systematic review of the public health and healthcare literature. PLoS One 2023; 18:e0284765. [PMID: 37590193 PMCID: PMC10434911 DOI: 10.1371/journal.pone.0284765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 04/09/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Group model building is a process of engaging stakeholders in a participatory modeling process to elicit their perceptions of a problem and explore concepts regarding the origin, contributing factors, and potential solutions or interventions to a complex issue. Recently, it has emerged as a novel method for tackling complex, long-standing public health issues that traditional intervention models and frameworks cannot fully address. However, the extent to which group model building has resulted in the adoption of evidence-based practices, interventions, and policies for public health remains largely unstudied. The goal of this systematic review was to examine the public health and healthcare applications of GMB in the literature and outline how it has been used to foster implementation and dissemination of evidence-based interventions. METHODS We searched PubMed, Web of Science, and other databases through August 2022 for studies related to public health or health care where GMB was cited as a main methodology. We did not eliminate studies based on language, location, or date of publication. Three reviewers independently extracted data on GMB session characteristics, model attributes, and dissemination formats and content. RESULTS Seventy-two studies were included in the final review. Majority of GMB activities were in the fields of nutrition (n = 19, 26.4%), health care administration (n = 15, 20.8%), and environmental health (n = 12, 16.7%), and were conducted in the United States (n = 29, 40.3%) and Australia (n = 7, 9.7%). Twenty-three (31.9%) studies reported that GMB influenced implementation through policy change, intervention development, and community action plans; less than a third reported dissemination of the model outside journal publication. GMB was reported to have increased insight, facilitated consensus, and fostered communication among stakeholders. CONCLUSIONS GMB is associated with tangible benefits to participants, including increased community engagement and development of systems solutions. Transdisciplinary stakeholder involvement and more rigorous evaluation and dissemination of GMB activities are recommended.
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Affiliation(s)
- Weanne Myrrh Estrada-Magbanua
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Terry T.-K. Huang
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - David W. Lounsbury
- Division of Health Behavior Research and Implementation Science, Albert Einstein College of Medicine, New York, NY, United States of America
| | - Priscila Zito
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Pulwasha Iftikhar
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Nabila El-Bassel
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, United States of America
| | - Louisa Gilbert
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, United States of America
| | - Elwin Wu
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, United States of America
| | - Bruce Y. Lee
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Pedro Mateu-Gelabert
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
| | - Nasim S. Sabounchi
- Center for Systems and Community Design and NYU-CUNY Prevention Research Center, CUNY Graduate School of Public Health and Health Policy, New York, NY, United States of America
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Forbi JC, Musa MS, Salawu M, Idris JM, Ba’aba AI, Higgins J, Musa AI, Bashir B, Shettima A, Njeakor N, Uzoma I, Mshelia H, Nganda GW, Mohammed KI, Bomoi IM, Chiroma U, Kovacs SD, Biya O, Waziri NE, Aina M, Adamu US, Shuaib F, Bolu O, Franka R, Wiesen E. Historical reconstruction of inaccessibility status in Local Government Areas (LGAs) of Borno and Yobe States, Nigeria, 2010-2020. Pan Afr Med J 2023; 45:7. [PMID: 38370102 PMCID: PMC10874094 DOI: 10.11604/pamj.supp.2023.45.2.39332] [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: 02/28/2023] [Accepted: 06/09/2023] [Indexed: 02/20/2024] Open
Abstract
Introduction ultimately detected in 2016, wild poliovirus (WPV) transmission continued undetected after 2011 in Northeast Nigeria Borno and Yobe States in security-compromised areas, inaccessible due to armed insurgency. Varying inaccessibility prevented children aged <5 years in these areas from polio vaccination interventions and surveillance, while massive population displacements occurred. We examined progress in access over time to provide data supporting a very low probability of undetected WPV circulation within remaining trapped populations after 2016. Methods to assess the extent of inaccessibility in security-compromised areas, we obtained empirical historical data in 2020 on a quarterly and annual basis from relevant polio eradication staff for the period 2010-2020. The extent of access to areas for immunization by recall was compared to geospatial data from vaccinator tracking. Population estimates over time in security-compromised areas were extracted from satellite imagery. We compared the historical access data from staff with tracking and population esimates. Results access varied during 2010-2020, with inaccessibility peaking during 2014-2016. We observed concurrent patterns between historical recalled data on inaccessibility and contemporaneous satellite imagery on population displacements, which increased confidence in the quality of recalled data. Conclusion staff-recalled access was consistent with vaccinator tracking and satellite imagery of population displacments. Despite variability in inaccessibility over time, innovative immunization initiatives were implemented as access allowed and surveillance initiatives were initiated to search for poliovirus transmission. Along with escape and liberation of residents by the military in some geographic areas, these initiatives resulted in a massive reduction in the size of the unvaccinated population remaining resident.
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Affiliation(s)
- Joseph Che Forbi
- Polio Elimination Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Musa Salawu
- Bill and Melinda Gates Foundation, Abuja, Nigeria
| | | | | | - Jeff Higgins
- Geospatial Research, Analysis and Services Program, Agency for Toxic Substances and Disease Registry, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | | | | | | | - Hyeni Mshelia
- Primary Health Care Development Agency, Abuja, Nigeria
| | - Gatei wa Nganda
- Polio Elimination Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | | | - Umar Chiroma
- Primary Health Care Development Agency, Abuja, Nigeria
| | - Stephanie Diane Kovacs
- Polio Elimination Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Oladayo Biya
- Polio Elimination Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | | | - Muyi Aina
- Solina Center for International Development and Research, Abuja, Nigeria
| | | | - Faisal Shuaib
- Primary Health Care Development Agency, Abuja, Nigeria
| | - Omotayo Bolu
- Polio Elimination Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Richard Franka
- Polio Elimination Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Eric Wiesen
- Polio Elimination Branch, US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Procureur F, Estifanos AS, Keraga DW, Kiflie Alemayehu AK, Hailemariam NW, Schellenberg J, Magge H, Hill Z. "Quality teaches you how to use water. It doesn't provide a water pump": a qualitative study of context and mechanisms of action in an Ethiopian quality improvement program. BMC Health Serv Res 2023; 23:381. [PMID: 37076845 PMCID: PMC10116784 DOI: 10.1186/s12913-023-09341-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 03/25/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Quality improvement collaboratives are a common approach to bridging the quality-of-care gap, but little is known about implementation in low-income settings. Implementers rarely consider mechanisms of change or the role of context, which may explain collaboratives' varied impacts. METHODS To understand mechanisms and contextual influences we conducted 55 in-depth interviews with staff from four health centres and two hospitals involved in quality improvement collaboratives in Ethiopia. We also generated control charts for selected indicators to explore any impacts of the collaboratives. RESULTS The cross facility learning sessions increased the prominence and focus on quality, allowed learning from experts and peers and were motivational through public recognition of success or a desire to emulate peers. Within facilities, new structures and processes were created. These were fragile and sometimes alienating to those outside the improvement team. The trusted and respected mentors were important for support, motivation and accountability. Where mentor visits were infrequent or mentors less skilled, team function was impacted. These mechanisms were more prominent, and quality improvement more functional, in facilities with strong leadership and pre-existing good teamwork; as staff had shared goals, an active approach to problems and were more willing and able to be flexible to implement change ideas. Quality improvement structures and processes were more likely to be internally driven and knowledge transferred to other staff in these facilities, which reduced the impact of staff turnover and increased buy-in. In facilities which lacked essential inputs, staff struggled to see how the collaborative could meaningfully improve quality and were less likely to have functioning quality improvement. The unexpected civil unrest in one region strongly disrupted the health system and the collaborative. These contextual issues were fluid, with multiple interactions and linkages. CONCLUSIONS The study confirms the need to carefully consider context in the implementation of quality improvement collaboratives. Facilities that implement quality improvement successfully may be those that already have characteristics that foster quality. Quality improvement may be alienating to those outside of the improvement team and implementers should not assume the organic spread or transfer of quality improvement knowledge.
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Affiliation(s)
- F Procureur
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK
| | - A S Estifanos
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - D W Keraga
- Department of Reproductive, Family and Population Health, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | - J Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - H Magge
- Institute for Healthcare Improvement, Addis Ababa, Ethiopia
- Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis Street, Boston, MA, 02115, USA
| | - Z Hill
- Institute for Global Health, University College London, Guilford St, London, WC1N 1EH, UK.
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12
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Ezzati F, Mosadeghrad AM, Jaafaripooyan E. Resiliency of the Iranian healthcare facilities against the Covid-19 pandemic: challenges and solutions. BMC Health Serv Res 2023; 23:207. [PMID: 36859284 PMCID: PMC9975873 DOI: 10.1186/s12913-023-09180-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/14/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Health care facilities are responsible for preventing and controlling diseases and must be resilient enough to deal with crises. The Iranian health care facilities have faced challenges in managing COVID-19 pandemic. The purpose of this study was to identify the challenges faced by the Iranian health care facilities during the Covid-19 epidemic and to provide solutions. METHODS This qualitative study was conducted with a phenomenological approach and using semi-structured interviews with 59 healthcare policy makers, managers, and employees, and medical university faculty members. The participants were selected through purposive and snowball sampling. Thematic analysis was used to analyze the data. RESULTS Overall, 43 challenges to the resilience of health care facilities during the Covid-19 pandemic were identified and grouped into 8 themes (i.e., leadership and management, planning, organizational culture, organizational learning, employee management, customer management, resource management, and process management. The most important resilience challenges were: fragmented management system; poor leadership; incompatible health network structure; lack of a national holistic plan; poor case detection; insufficient resources; inefficient information system; negative attitude of managers and employee; organizational inertia; failure to build on lessons learned from crises; low workforce preparedness; lack of community-based management; and improper monitoring and evaluation. Managers should use community-based, evidence-based, and integrated management to build health system resilience against COVID-19, have sufficient knowledge and experience to organize operations, use appropriate and effective coordination models, develop a creative and participatory culture, reengineer processes, and provide necessary resources. CONCLUSION The Iranian health care facilities face challenges that prevent them from becoming resilient, responsive, and efficient in managing COVID-19. Policy makers and managers should increase the resilience of health care facilities to shocks and crises by using the suggested measures.
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Affiliation(s)
- Farahnaz Ezzati
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Mohammad Mosadeghrad
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Ebrahim Jaafaripooyan
- grid.411705.60000 0001 0166 0922Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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13
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Elimian K, King C, Dewa O, Pembi E, Gandi B, Yennan S, Myles P, Pritchard C, Forsberg BC, Alfvén T. Healthcare workers knowledge of cholera multi-stranded interventions and its determining factors in North-East Nigeria: planning and policy implications. HUMAN RESOURCES FOR HEALTH 2023; 21:6. [PMID: 36726147 PMCID: PMC9891191 DOI: 10.1186/s12960-023-00796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/20/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Healthcare workers' (HCWs) knowledge of multi-stranded cholera interventions (including case management, water, sanitation, and hygiene (WASH), surveillance/laboratory methods, coordination, and vaccination) is crucial to the implementation of these interventions in healthcare facilities, especially in conflict-affected settings where cholera burden is particularly high. We aimed to assess Nigerian HCWs' knowledge of cholera interventions and identify the associated factors. METHODS We conducted a cross-sectional study using a structured interviewer-administered questionnaire with HCWs from 120 healthcare facilities in Adamawa and Bauchi States, North-East Nigeria. A knowledge score was created by assigning a point for each correct response. HCWs' knowledge of cholera interventions, calculated as a score, was recoded for ease of interpretation as follows: 0-50 (low); 51-70 (moderate); ≥ 71 (high). Additionally, we defined the inadequacy of HCWs' knowledge of cholera interventions based on a policy-relevant threshold of equal or lesser than 75 scores for an intervention. Multivariable logistic regression was used to identify the factors associated with the adequacy of knowledge score. RESULTS Overall, 490 HCWs participated in the study (254 in Adamawa and 236 in Bauchi), with a mean age of 35.5 years. HCWs' knowledge score was high for surveillance/laboratory methods, moderate for case management, WASH, and vaccination, and low for coordination. HCWs' knowledge of coordination improved with higher cadre, working in urban- or peri-urban-based healthcare facilities, and secondary education; cholera case management and vaccination knowledge improved with post-secondary education, working in Bauchi State and urban areas, previous training in cholera case management and response to a cholera outbreak-working in peri-urban areas had a negative effect. HCWs' knowledge of surveillance/laboratory methods improved with a higher cadre, 1-year duration in current position, secondary or post-secondary education, previous training in cholera case management and response to a cholera outbreak. However, HCWs' current position had both positive and negative impacts on their WASH knowledge. CONCLUSIONS HCWs in both study locations recorded a considerable knowledge of multi-stranded cholera interventions. While HCWs' demographic characteristics appeared irrelevant in determining their knowledge of cholera interventions, geographic location and experiences from the current position, training and involvement in cholera outbreak response played a significant role.
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Affiliation(s)
- Kelly Elimian
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
- Exhale Health Foundation, Abuja, Nigeria.
| | - Carina King
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Ozius Dewa
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
| | - Emmanuel Pembi
- Adamawa State Ministry of Health, Yola, Adamawa State, Nigeria
| | - Benjamin Gandi
- Bauchi State Ministry of Health, Yola, Bauchi State, Nigeria
| | | | - Puja Myles
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | | | | | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm, Sweden
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14
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Shawar YR, Neill R, Kunnuji M, Manoj M, Shiffman J. Understanding resilience, self-reliance and increasing country voice: a clash of ideologies in global health. BMJ Glob Health 2023; 8:bmjgh-2022-010895. [PMID: 36634980 PMCID: PMC9843176 DOI: 10.1136/bmjgh-2022-010895] [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: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND 'Resilience', 'self-reliance' and 'increasing country voice' are widely used terms in global health. However, the terms are understood in diverse ways by various global health actors. We analyse how these terms are understood and why differences in understanding exist. METHODS Drawing on scholarship concerning ideology, framing and power, we employ a case study of a USAID-sponsored suite of awards called MOMENTUM. Applying a meta-ethnographic approach, we triangulate data from peer-reviewed and grey literature, as well as 27 key informant interviews with actors at the forefront of shaping these discourses and those associated with MOMENTUM, working in development agencies, implementing organisations, low-income and middle-income country governments, and academia. RESULTS The lack of common understanding of these three terms is in part a result of differences in two perspectives in global health-reformist and transformational-which are animated by fundamentally different ideologies. Reformists, reflecting neoliberal and liberal democratic ideologies, largely take a technocratic approach to understanding health problems and advance incremental solutions, working within existing global and local health systems to effect change. Transformationalists, reflecting threads of neo-Marxist ideology, see the problems as inherently political and seek to overhaul national and global systems and power relations. These ideologies shape differences in how actors define the problem, its solutions and attribute responsibility, resulting in nuanced differences among global health actors in their understanding of resilience, self-reliance and increasing country voice. CONCLUSIONS Differences in how these terms are employed and framed are not just linguistic; the language that is used is reflective of underlying ideological differences among global health actors, with implications for the way programmes are designed and implemented, the knowledge that is produced and engagement with stakeholders. Laying these distinct ideologies bare may be crucial for managing actor differences and advancing more productive discussions and actions towards achieving global health equity.
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Affiliation(s)
- Yusra Ribhi Shawar
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA .,Johns Hopkins University Paul H. Nitze School of Advanced International Studies, Washington, DC, USA
| | - Rachel Neill
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michael Kunnuji
- Department of Sociology, University of Lagos, Akoka, Lagos, Nigeria
| | - Malvikha Manoj
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jeremy Shiffman
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA,Johns Hopkins University Paul H. Nitze School of Advanced International Studies, Washington, DC, USA
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15
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Durrance-Bagale A, Marzouk M, Tung LS, Agarwal S, Aribou ZM, Ibrahim NBM, Mkhallalati H, Newaz S, Omar M, Ung M, Zaseela A, Nagashima-Hayashi M, Howard N. Community engagement in health systems interventions and research in conflict-affected countries: a scoping review of approaches. Glob Health Action 2022; 15:2074131. [PMID: 35762841 PMCID: PMC9246261 DOI: 10.1080/16549716.2022.2074131] [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] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Healthcare research, planning, and delivery with minimal community engagement can result in financial wastage, failure to meet objectives, and frustration in the communities that programmes are designed to help. Engaging communities - individual service-users and user groups - in the planning, delivery, and assessment of healthcare initiatives from inception promotes transparency, accountability, and 'ownership'. Health systems affected by conflict must try to ensure that interventions engage communities and do not exacerbate existing problems. Engaging communities in interventions and research on conflict-affected health systems is essential to begin addressing effects on service delivery and access. OBJECTIVE This review aimed to identify and interrogate the literature on community engagement in health system interventions and research in conflict-affected settings. METHODS We conducted a scoping review using Arksey & O'Malley's framework, synthesising the data descriptively. RESULTS We included 19 of 2,355 potential sources identified. Each discussed at least one aspect of community engagement, predominantly participatory methods, in 12 conflict-affected countries. Major lessons included the importance of engaging community and religious leaders, as well as people of lower socioeconomic status, in both designing and delivering culturally acceptable healthcare; mobilising community members and involving them in programme delivery to increase acceptability; mediating between governments, armed groups and other organisations to increase the ability of healthcare providers to remain in post; giving community members spaces for feedback on healthcare provision, to provide communities with evidence that programmes and initiatives are working. CONCLUSION Community engagement in identifying and setting priorities, decision-making, implementing, and evaluating potential solutions helps people share their views and encourages a sense of ownership and increases the likely success of healthcare interventions. However, engaging communities can be particularly difficult in conflict-affected settings, where priorities may not be easy to identify, and many other factors, such as safety, power relations, and entrenched inequalities, must be considered.
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Affiliation(s)
- Anna Durrance-Bagale
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Manar Marzouk
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Lam Sze Tung
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Sunanda Agarwal
- Stanford Distinguished Careers Institute, Campus Drive, Stanford, CA, USA
| | - Zeenathnisa Mougammadou Aribou
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Nafeesah Bte Mohamed Ibrahim
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Hala Mkhallalati
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Sanjida Newaz
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Maryam Omar
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Mengieng Ung
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Ayshath Zaseela
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Michiko Nagashima-Hayashi
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Natasha Howard
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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16
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Grimm PY, Oliver S, Merten S, Han WW, Wyss K. Enhancing the Understanding of Resilience in Health Systems of Low- and Middle-Income Countries: A Qualitative Evidence Synthesis. Int J Health Policy Manag 2022; 11:899-911. [PMID: 33619924 PMCID: PMC9808204 DOI: 10.34172/ijhpm.2020.261] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/19/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND A country's health system faces pressure when hit by an unexpected shock, such as what we observe in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The concept of resilience is highly relevant in this context and is a prerequisite for a health system capable of withstanding future shocks. By exploring how the key dimensions of the resilient health system framework are applied, the present systematic review synthesizes the vital features of resilient health systems in low- and middle-income countries. The aim of this review is to ascertain the relevance of health system resilience in the context of a major shock, through better understanding its dimensions, uses and implications. METHODS The review uses the best-fit framework synthesis approach. An a priori conceptual framework was selected and a coding framework created. A systematic search identified 4284 unique citations from electronic databases and reports by non-governmental organisations, 12 of which met the inclusion criteria. Data were extracted and coded against the pre-existing themes. Themes outside of the a priori framework were collated to form a refined list of themes. Then, all twelve studies were revisited using the new list of themes in the context of each study. RESULTS Ten themes were generated from the analysis. Five confirmed the a priori conceptual framework that capture the dynamic attributes of a resilient system. Five new themes were identified as foundational for achieving resilience: realigned relationships, foresight and motivation as drivers, and emergency preparedness and change management as organisational mechanisms. CONCLUSION The refined conceptual model shows how the themes inter-connect. The foundations of resilience appear to be critical especially in resource-constrained settings to unlock the dynamic attributes of resilience. This review prompts countries to consider building the foundations of resilience described here as a priority to better prepare for future shocks.
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Affiliation(s)
- Pauline Yongeun Grimm
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Sandy Oliver
- Social Science Research Unit, University College London, London, UK
- Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
| | - Sonja Merten
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Wai Wai Han
- Department of Medical Research, Ministry of Health and Sports, Yangon, Myanmar
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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17
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Ismail SA, Bell S, Chalabi Z, Fouad FM, Mechler R, Tomoaia-Cotisel A, Blanchet K, Borghi J. Conceptualising and assessing health system resilience to shocks: a cross-disciplinary view. Wellcome Open Res 2022; 7:151. [PMID: 38826487 PMCID: PMC11140310 DOI: 10.12688/wellcomeopenres.17834.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2022] [Indexed: 06/04/2024] Open
Abstract
Health systems worldwide face major challenges in anticipating, planning for and responding to shocks from infectious disease epidemics, armed conflict, climatic and other crises. Although the literature on health system resilience has grown substantially in recent years, major uncertainties remain concerning approaches to resilience conceptualisation and measurement. This narrative review revisits literatures from a range of fields outside health to identify lessons relevant to health systems. Four key insights emerge. Firstly, shocks can only be understood by clarifying how, where and over what timescale they interact with a system of interest, and the dynamic effects they produce within it. Shock effects are contingent on historical path-dependencies, and on the presence of factors or system pathways (e.g. financing models, health workforce capabilities or supply chain designs) that may amplify or dampen impact in unexpected ways. Secondly, shocks often produce cascading effects across multiple scales, whereas the focus of much of the health resilience literature has been on macro-level, national systems. In reality, health systems bring together interconnected sub-systems across sectors and geographies, with different components, behaviours and sometimes even objectives - all influencing how a system responds to a shock. Thirdly, transformability is an integral feature of resilient social systems: cross-scale interactions help explain how systems can show both resilience and transformational capability at the same time. We illustrate these first three findings by extending the socioecological concept of adaptive cycles in social systems to health, using the example of maternal and child health service delivery. Finally, we argue that dynamic modelling approaches, under-utilised in research on health system resilience to date, have significant promise for identification of shock-moderating or shock-amplifying pathways, for understanding effects at multiple levels and ultimately for building resilience.
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Affiliation(s)
- Sharif A. Ismail
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Sadie Bell
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Zaid Chalabi
- Institute for Environmental Design and Engineering, University College London, London, WC1E 6BT, UK
| | - Fouad M. Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Reinhard Mechler
- Advanced Systems Analysis Program, International Institute for Applied Systems Analysis, Laxenburg, A-2361, Austria
| | - Andrada Tomoaia-Cotisel
- RAND Corporation, Santa Monica, 90401-3208, USA
- Department of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, University of Geneva, Geneva, 1211, Switzerland
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
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18
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Ekezie W, Siebert P, Timmons S, Murray RL, Bains M. Exploring the influence of health management processes on health outcomes among internally displaced persons (IDPs). J Migr Health 2022; 6:100124. [PMID: 35795078 PMCID: PMC9251554 DOI: 10.1016/j.jmh.2022.100124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 06/01/2022] [Accepted: 06/19/2022] [Indexed: 11/20/2022] Open
Abstract
Background Despite global action and policy initiatives, internally displaced persons (IDPs) experience poor living conditions and lack healthcare access compared to refugees. This study sought to understand the relationship between health management processes and health outcomes among camp-dwelling IDPs in northern Nigeria. Method 73 individuals participated in either a focus group (n = 49) or one-to-one interview (n = 24), comprising IDPs (n = 49), camp managers (n = 9), health workers (n = 7) and government administrative authorities (n = 8). Interviews explored IDP health management processes, partners and perceptions around camp management. Data were analysed using an inductive thematic approach. Results Four main themes were identified: opinions about healthcare organisation and management, service availability, interventions and information management, and IDP health outcomes. Though many stakeholders, partnerships, and national and international government agencies were involved in the provision of healthcare services, respondents described efforts as disjointed. Reports suggested that the coordination and management of health services and resources were not tailored to the needs of those living in all camps. And because so many national and international agencies were involved, but under weak coordination, access to services was less than optimal and adequate management of critical public health interventions was lacking. Varied allocation of resources such as funding, medication and medically trained staff were viewed as key factors in the availability and the ability to access what was considered as essential healthcare services. Conclusion The health of IDPs in camp-like settings was compromised by uncoordinated management, treatment, and control of communicable and non-communicable diseases. Government authorities need to be aware and consider the complexity of the multiagency involvement in the management and provision of IDP healthcare services. Introducing systems to streamline, monitor and support IDP healthcare management could be cost-effective strategies for achieving optimal health care.
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Affiliation(s)
- Winifred Ekezie
- Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom
- Health and Internal Displacement Network (HIDN)
- Corresponding author at: Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, United Kingdom.
| | - Penelope Siebert
- School of Health and Social Care, Nottingham Trent University, Nottingham, United Kingdom
| | - Stephen Timmons
- Nottingham University Business School, University of Nottingham, Nottingham, United Kingdom
| | - Rachael L. Murray
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Manpreet Bains
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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19
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Altare C, Castelgrande V, Tosha M, Malembaka EB, Spiegel P. From Insecurity to Health Service Delivery: Pathways and System Response Strategies in the Eastern Democratic Republic of the Congo. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:915-927. [PMID: 34933986 PMCID: PMC8691875 DOI: 10.9745/ghsp-d-21-00107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 10/15/2021] [Indexed: 11/25/2022]
Abstract
The provinces of North and South Kivu in eastern Democratic Republic of the Congo (DRC) have experienced insecurity since the 1990s. Without any solution to the conflict in sight, health actors have adapted their interventions to maintain some level of health service provision. We reflect on the health system resilience in the Kivu provinces in response to chronic levels of insecurity. Using qualitative interviews of health care providers from local government, United Nations agencies, and international nongovernmental organizations, we identify the mediating factors through which insecurity affects both service quality and delivery and investigate the strategies adopted to sustain service provision.Three main drivers linking insecurity and health service quality and delivery emerged: via violence, mobility restrictions, and resources availability. The effect of these drivers is mediated by several system or individual-level factors. Two factors were reported in each pathway: health care workforce availability and drug/equipment accessibility. Human resources were affected differently by each driver: in terms of willingness to be stationed in a certain area (violence), capacity to access the health facility (mobility), and sustainability and motivation of conducting duties (resources). Similarly, the presence of drugs/equipment varied in case of looting or damages (violence), delays in delivery (mobility), or delays in procurement (resources). While these mediators are not surprising, their identification allows the design of appropriate response strategies. The majority of the reported solutions attempt to address the lack of human resources and reflect absorptive capacity. Adaptive capacity characterizes the attempts to address lack of access (contingency plan, mobile clinics, maternity waiting homes, and security drugs). Finally, interventions to address insecurity can be classified as transformative. Health actors in eastern DRC have shown some capacity to adapt, adjust, and transform due to insecurity. Further research is needed to measure the effectiveness of such strategies to provide guidance to increasingly vulnerable health systems.
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Affiliation(s)
- Chiara Altare
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Vito Castelgrande
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Maphie Tosha
- Foundation RamaLevina, Bukavu, Democratic Republic of the Congo
| | - Espoir Bwenge Malembaka
- Center for Tropical Diseases and Global Health, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Paul Spiegel
- Center for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Ibrahim S, Al-Dahir S, Al Mulla T, Lami F, Hossain SMM, Baqui A, Burnham G. Resilience of health systems in conflict affected governorates of Iraq, 2014-2018. Confl Health 2021; 15:76. [PMID: 34663395 PMCID: PMC8521490 DOI: 10.1186/s13031-021-00412-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 10/05/2021] [Indexed: 11/10/2022] Open
Abstract
Objectives The objective of this study was to assess the resilience of health systems in four governorates affected by conflict from 2014 to 2018, and to convey recommendations.
Methods Health managers from Al Anbar, Ninawa, Salah al-Din, and Kirkuk governorates discussed resilience factors of Primary Health Care services affected by the 2014–2017 ISIS insurgency in focus groups, and general discussions. Additional information was gathered from key informants and a UNICEF health facility survey. Three specific aspects were examined: (1) meeting health needs in the immediate crisis response, (2) adaptation of services, (3) restructuring and recovery measures. Data from a MoH/UNICEF national health facility survey in 2017 were analyzed for functionality.
Results There were many common themes across the four governorates, with local variations. (1) Absorption The shock to the public sector health services by the ISIS invasion caught health services in the four governorates unprepared, with limited abilities to continue to provide services. Private pharmacies and private clinics in some places withstood the initial shock better than the public sector. (2) Adaptation After the initial shock, many health facilities adapted by focusing on urgent needs for injury and communicable disease care. In most locations, maternal, neonatal, and child health (MNCH) preventive and promotive PHC services stopped. Ill persons would sometimes consult health workers in their houses at night for security reasons. (3) Restructuring or transformative activities In most areas, health services recovery was continuing in 2020. Some heavily damaged facilities are still functioning, but below pre-crisis level. Rebuilding lost community trust in the public sector is proving difficult. Conclusion Health services generally had little preparation for and limited resilience to the ISIS influx. Governorates are still restructuring services after the liberation from ISIS in 2017. Disaster planning was identified by all participants as a missing component, as everyone anticipated future similar emergencies.
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Affiliation(s)
- Shaimaa Ibrahim
- UNICEF Iraq Country Office, UN Compound, Baghdad, 10011, Iraq
| | - Sara Al-Dahir
- Xavier University of Louisiana, 1 Drexel Dr, New Orleans, LA, 70125, USA
| | - Taha Al Mulla
- UNICEF Iraq Country Office, UN Compound, Baghdad, 10011, Iraq
| | - Faris Lami
- University of Baghdad, Medical City, Baghdad, 00964, Iraq
| | | | - Abdullah Baqui
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21210, USA
| | - Gilbert Burnham
- Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Baltimore, MD, 21210, USA.
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21
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Miller NP, Ardestani FB, Dini HS, Shafique F, Zunong N. Community health workers in humanitarian settings: Scoping review. J Glob Health 2021; 10:020602. [PMID: 33312508 PMCID: PMC7719274 DOI: 10.7189/jogh.10.020602] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background There is a need for greater understanding of experiences implementing community-based primary health care in humanitarian settings and of the adjustments needed to ensure continuation of essential services and utilization of services by the population, and to contribute to effective emergency response. We reviewed the evidence base on community health workers (CHWs) in humanitarian settings, with the goal of improving delivery of essential services to the most vulnerable populations. Methods We conducted a scoping review of published and grey literature related to health and nutrition services provided by CHWs in humanitarian settings. Extracted data from retained documents were analyzed inductively for key themes. Results Of 3709 documents screened, 219 were included in the review. Key findings from the literature include: 1) CHWs were often able to continue providing services during acute and protracted crises, including prolonged periods of conflict and insecurity and during population displacement. 2) CHWs carried out critical emergency response activities during acute crises. 3) Flexible funding facilitated transitions between development and humanitarian programming. 4) Communities that did not have a locally-resident CHW experienced reduced access to services when travel was limited. 5) Community selection of CHWs and engagement of respected local leaders were crucial for community trust and acceptance and high utilization of services. 6) Selection of local supervisors and use of mobile phones facilitated continued supervision. 7) Actions taken to maintain supplies included creating parallel supply chains, providing buffer stocks to CHWs, and storing commodities in decentralized locations. 8) When travel was restricted, reporting and data collection were continued using mobile phones and use of local data collectors. 9) CHWs and supervisors faced security threats and psychological trauma as a result of their work. Conclusions To achieve impact, policy makers and program implementers will have to address the bottlenecks to CHW service delivery common in stable low-income settings as well as the additional challenges unique to humanitarian settings. Future interventions should take into account the lessons learned from years of experience with implementation of community-based primary health care in humanitarian settings. There is also a need for rigorous assessments of community-based primary health care interventions in humanitarian settings.
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Affiliation(s)
- Nathan P Miller
- UNICEF, New York, USA.,Columbia University Mailman School of Public Health, New York, USA
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22
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Biddle L, Wahedi K, Bozorgmehr K. Health system resilience: a literature review of empirical research. Health Policy Plan 2021; 35:1084-1109. [PMID: 32529253 PMCID: PMC7553761 DOI: 10.1093/heapol/czaa032] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2020] [Indexed: 11/25/2022] Open
Abstract
The concept of health system resilience has gained popularity in the global health discourse, featuring in UN policies, academic articles and conferences. While substantial effort has gone into the conceptualization of health system resilience, there has been no review of how the concept has been operationalized in empirical studies. We conducted an empirical review in three databases using systematic methods. Findings were synthesized using descriptive quantitative analysis and by mapping aims, findings, underlying concepts and measurement approaches according to the resilience definition by Blanchet et al. We identified 71 empirical studies on health system resilience from 2008 to 2019, with an increase in literature in recent years (62% of studies published since 2017). Most studies addressed a specific crisis or challenge (82%), most notably infectious disease outbreaks (20%), natural disasters (15%) and climate change (11%). A large proportion of studies focused on service delivery (48%), while other health system building blocks were side-lined. The studies differed in terms of their disciplinary tradition and conceptual background, which was reflected in the variety of concepts and measurement approaches used. Despite extensive theoretical work on the domains which constitute health system resilience, we found that most of the empirical literature only addressed particular aspects related to absorptive and adaptive capacities, with legitimacy of institutions and transformative resilience seldom addressed. Qualitative and mixed methods research captured a broader range of resilience domains than quantitative research. The review shows that the way in which resilience is currently applied in the empirical literature does not match its theoretical foundations. In order to do justice to the complexities of the resilience concept, knowledge from both quantitative and qualitative research traditions should be integrated in a comprehensive assessment framework. Only then will the theoretical ‘resilience idea’ be able to prove its usefulness for the research community.
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Affiliation(s)
- Louise Biddle
- Social Determinants, Equity and Migration Working Group, Department of General Practice & Health Services Research, University Hospital Heidelberg, Marsilius Arkaden, Turm West, Heidelberg 69120, Germany
| | - Katharina Wahedi
- Social Determinants, Equity and Migration Working Group, Department of General Practice & Health Services Research, University Hospital Heidelberg, Marsilius Arkaden, Turm West, Heidelberg 69120, Germany
| | - Kayvan Bozorgmehr
- Social Determinants, Equity and Migration Working Group, Department of General Practice & Health Services Research, University Hospital Heidelberg, Marsilius Arkaden, Turm West, Heidelberg 69120, Germany.,Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany
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23
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Hill Z, Scheelbeek P, Schellenberg J, Hamza Y. "Everything is from God but it is always better to get to the hospital on time": A qualitative study with community members to identify factors that influence facility delivery in Gombe State, Nigeria. Glob Health Action 2021; 13:1785735. [PMID: 32666908 PMCID: PMC7480450 DOI: 10.1080/16549716.2020.1785735] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background Nigeria has one of the highest maternal mortality rates in the world, but facility delivery levels are relatively low and stagnant. Few qualitative studies have explored this issue and most have focused on barriers to utilization, much can be learnt from women who already deliver in facilities. Objectives We aimed to identify facilitators and barriers to facility delivery in Gombe State in North East Nigeria with a focus on women who have had a facility delivery. Methods We conducted 24 narrative and in-depth interviews with mothers, and 16 focus-group-discussions with mothers, fathers, grandmothers and community health workers. Data were collected in Hausa, and transcribed and translated into English. Preliminary data analysis was conducted through team workshops, followed by systematic coding of the transcripts. Initial themes were identified a priori from the research questions and others emerged during coding. Results A safe delivery was the main motivator for facility delivery, with facilities considered safe because of the presence of a trained health worker, the detection and management of problems, the availability of medicines and good hygiene. Those who delivered in a facility had a desire to be modern and rejected traditional practices. Decision-making power, social norms, accessibility, cost and perceived poor quality of care were reported as barriers. Community health workers, when they reached households, provided information on the benefits of facility delivery, stressed that times were changing, provided practical help such as arranging transport and, by accompanying families to the facility, brokered better quality of care and provided social support. Conclusion This study highlights both the facilitators and barriers to facility delivery, and demonstrates the need for interventions to address a wide range of issues at multiple levels.
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Affiliation(s)
- Zelee Hill
- Institute for Global Health, University College London , London, UK
| | - Pauline Scheelbeek
- Department of Population Health, London School of Hygiene and Tropical Medicine , London, UK
| | | | - Yashua Hamza
- Department of Disease Control, London School of Hygiene and Tropical Medicine , London, UK
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24
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Jordan K, Lewis TP, Roberts B. Quality in crisis: a systematic review of the quality of health systems in humanitarian settings. Confl Health 2021; 15:7. [PMID: 33531065 PMCID: PMC7851932 DOI: 10.1186/s13031-021-00342-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background There is a growing concern that the quality of health systems in humanitarian crises and the care they provide has received little attention. To help better understand current practice and research on health system quality, this paper aimed to examine the evidence on the quality of health systems in humanitarian settings. Methods This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The context of interest was populations affected by humanitarian crisis in low- and middle- income countries (LMICs). We included studies where the intervention of interest, health services for populations affected by crisis, was provided by the formal health system. Our outcome of interest was the quality of the health system. We included primary research studies, from a combination of information sources, published in English between January 2000 and January 2019 using quantitative and qualitative methods. We used the High Quality Health Systems Framework to analyze the included studies by quality domain and sub-domain. Results We identified 2285 articles through our search, of which 163 were eligible for full-text review, and 55 articles were eligible for inclusion in our systematic review. Poor diagnosis, inadequate patient referrals, and inappropriate treatment of illness were commonly cited barriers to quality care. There was a strong focus placed on the foundations of a health system with emphasis on the workforce and tools, but a limited focus on the health impacts of health systems. The review also suggests some barriers to high quality health systems that are specific to humanitarian settings such as language barriers for refugees in their host country, discontinued care for migrant populations with chronic conditions, and fears around provider safety. Conclusion The review highlights a large gap in the measurement of quality both at the point of care and at the health system level. There is a need for further work particularly on health system measurement strategies, accountability mechanisms, and patient-centered approaches in humanitarian settings. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-021-00342-z.
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Affiliation(s)
- Keely Jordan
- Department of Health Policy, New York University School of Global Public Health, 665 Broadway, New York, NY, 10012, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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25
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Zablith N, Diaconu K, Naja F, El Koussa M, Loffreda G, Bou-Orm I, Saleh S. Dynamics of non-communicable disease prevention, diagnosis and control in Lebanon, a fragile setting. Confl Health 2021; 15:4. [PMID: 33430916 PMCID: PMC7802297 DOI: 10.1186/s13031-020-00337-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 12/22/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Non-communicable diseases (NCD) present an increasing global health challenge, particularly for settings affected by fragility where access to care may be disrupted, and where high-quality continuous care delivery is difficult to achieve. This study documents the complex dynamics of NCD prevention and management in the fragile setting of rural Beqaa, Lebanon. METHODS Participatory system dynamics methods were used, including 30 semi-structured interviews and three Group Model Building (GMB) workshops. Participants included health care providers offering NCD care, and Lebanese host- and Syrian refugees community members affected by NCDs. RESULTS Participants across all groups articulated a shared complex understanding of both the structural and direct determinants behind NCD onset. Lebanese and Syrian community members further identified several barriers to health seeking, including restrictions in health coverage, limited availability of services in the Beqaa and perceptions of poor-quality care. Health providers and community members described a health system overtly focused on disease control and overwhelmed by delivery of care to people living with NCD across both communities. CONCLUSION Participants across all groups agreed on the need for health promotion and primary prevention activities and identified priority interventions in these areas.
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Affiliation(s)
- Nadine Zablith
- NIHR Global Health Research Unit on Health in Situations of Fragility, Musselburgh, UK
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Karin Diaconu
- NIHR Global Health Research Unit on Health in Situations of Fragility, Musselburgh, UK.
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.
| | - Farah Naja
- Nutrition and Food Sciences Department, Faculty of Agriculture and Food Sciences, American University of Beirut, Beirut, Lebanon
| | - Maria El Koussa
- NIHR Global Health Research Unit on Health in Situations of Fragility, Musselburgh, UK
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Giulia Loffreda
- NIHR Global Health Research Unit on Health in Situations of Fragility, Musselburgh, UK
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Ibrahim Bou-Orm
- NIHR Global Health Research Unit on Health in Situations of Fragility, Musselburgh, UK
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Shadi Saleh
- NIHR Global Health Research Unit on Health in Situations of Fragility, Musselburgh, UK
- Global Health Institute, American University of Beirut, Beirut, Lebanon
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26
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Elimian KO, Musah A, Ochu CL, Onwah SS, Oyebanji O, Yennan S, Fall IS, Yao M, Chukwuji M, Ekeng E, Abok P, Omar LH, Balde T, Kankia A, Williams N, Mutbam K, Dhamari N, Okudo I, Alemu W, Peter C, Ihekweazu C. Identifying and quantifying the factors associated with cholera-related death during the 2018 outbreak in Nigeria. Pan Afr Med J 2020; 37:368. [PMID: 33796181 PMCID: PMC7992435 DOI: 10.11604/pamj.2020.37.368.20981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/19/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction cholera outbreaks in Nigeria are often associated with high case fatality rates; however, there is a dearth of evidence on context-specific factors associated with the trend. This study therefore aimed to identify and quantify the factors associated with cholera-related deaths in Nigeria. Methods using a cross-sectional design, we analysed surveillance data from all the States that reported cholera cases during the 2018 outbreak, and defined cholera-related death as death of an individual classified as having cholera according to the Nigeria Centre for Disease Control case definition. Factors associated with cholera-related death were assessed using multivariable logistic regression and findings presented as adjusted odds ratios (ORs) with 95% Confidence Intervals (95% CIs). Results between January 1 and November 19, 2018, 41,394 cholera cases were reported across 20 States, including 815 cholera-related deaths. In the adjusted multivariable model, older age, male gender, living in peri-urban areas or in flooded states, infection during the rainy season, and delay in seeking health care by >2 days were positively associated with cholera-related death; whereas living in urban areas, hospitalisation in the course of illness, and presentation to a secondary hospital were negatively associated with cholera-related death. Conclusion cholera-related deaths during the 2018 outbreak in Nigeria appeared to be driven by multiple factors, which further reemphasises the importance of adopting a multisectoral approach to the design and implementation of context-specific interventions in Nigeria.
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Affiliation(s)
- Kelly Osezele Elimian
- Nigeria Centre for Disease Control, Abuja, Nigeria.,University of Benin, Edo State, Nigeria
| | - Anwar Musah
- University College London, London, United Kingdom
| | | | | | | | | | - Ibrahima Soce Fall
- World Health Organization/ Regional Office for Africa, Democratic Republic of Congo
| | - Michel Yao
- World Health Organization/ Regional Office for Africa, Democratic Republic of Congo
| | | | - Eme Ekeng
- Nigeria Centre for Disease Control, Abuja, Nigeria
| | - Patrick Abok
- World Health Organization/ Regional Office for Africa, Democratic Republic of Congo
| | - Linda Haj Omar
- World Health Organization/ Regional Office for Africa, Democratic Republic of Congo
| | - Thieno Balde
- World Health Organization/ Regional Office for Africa, Democratic Republic of Congo
| | - Adamu Kankia
- World Health Organization/ Regional Office for Africa, Democratic Republic of Congo
| | | | | | | | - Ifeanyi Okudo
- World Health Organization/ Regional Office for Africa, Democratic Republic of Congo
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27
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Bang HN, Mbah MF, Ndi HN, Ndzo JA. Gauging Cameroon’s resilience to the COVID-19 pandemic: implications for enduring a novel health crisis. TRANSFORMING GOVERNMENT- PEOPLE PROCESS AND POLICY 2020. [DOI: 10.1108/tg-08-2020-0196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Purpose
This paper aims to examine Cameroon’s health service resilience in the first five months (March–July 2020) of the coronavirus (COVID-19) outbreak. The motive is to diagnose sub-optimal performance in sustaining health-care services during the pandemic to identify areas for improvement and draw lessons for the future.
Design/methodology/approach
This is principally qualitative, exploratory, analytical and descriptive research that involves the collation of empirical, primary and secondary data. A conceptual framework [health systems resilience for emerging infectious diseases (HSREID)] provides structure to the study and an anchor for interpreting the findings. The research validity has been established by analysing the aims/objectives from multiple perspectives in the research tradition of triangulation.
Findings
Cameroon has exerted much effort to combat the COVID-19 pandemic. Yet, several constraints and gaps exist. The findings reveal limitations in Cameroon’s response to the COVID-19 pandemic in the provision of fundamental health-care services under contextual themes of health infrastructure/medical supplies, human capital, communication/sensitisation/health education, governance and trust/confidence. Analysis of the identified impediments demonstrates that Cameroon’s health-care system is not resilient enough to cope with the COVID-19 pandemic and provides several insights for an enhanced response as the pandemic accelerates in the country.
Originality/value
This is one of the first scholarly articles to examine how Cameroon’s health-care system is faring in COVID-19 combat. Underscored by the novel HSREID model, this study provides initial insights into Cameroon’s resilience to COVID-19 with a view to enhancing the health system’s response as the pandemic unfolds and strengthens readiness for subsequent health crises.
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28
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Jamal Z, Alameddine M, Diaconu K, Lough G, Witter S, Ager A, Fouad FM. Health system resilience in the face of crisis: analysing the challenges, strategies and capacities for UNRWA in Syria. Health Policy Plan 2020; 35:26-35. [PMID: 31625558 DOI: 10.1093/heapol/czz129] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2019] [Indexed: 11/13/2022] Open
Abstract
Health system resilience reflects the ability to continue service delivery in the face of extraordinary shocks. We examined the case of the United Nations Relief and Works Agency (UNRWA) and its delivery of services to Palestine refugees in Syria during the ongoing crisis to identify factors enabling system resilience. The study is a retrospective qualitative case study utilizing diverse methods. We conducted 35 semi-structured interviews with UNRWA clinical and administrative professionals engaged in health service delivery over the period of the Syria conflict. Through a group model building session with a sub-group of eight of these participants, we then elicited a causal loop diagram of health system functioning over the course of the war, identifying pathways of threat and mitigating resilience strategies. We triangulated analysis with data from UNRWA annual reports and routine health management information. The UNRWA health system generally sustained service provision despite individual, community and system challenges that arose during the conflict. We distinguish absorptive, adaptive and transformative capacities of the system facilitating this resilience. Absorptive capacities enabled immediate crisis response, drawing on available human and organizational resources. Adaptive capacities sustained service delivery through revised logistical arrangements, enhanced collaborative mechanisms and organizational flexibility. Transformative capacity was evidenced by the creation of new services in response to changing community needs. Analysis suggests factors such as staff commitment, organizational flexibility and availability of collaboration mechanisms were important assets in maintaining service continuity and quality. This evidence regarding alternative strategies adopted to sustain service delivery in Syria is of clear relevance to other actors seeking organizational resilience in crisis contexts.
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Affiliation(s)
- Zeina Jamal
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Mohamad Alameddine
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, P.O. Box 11-0236, Riad El-Solh/Beirut 1107 2020, Lebanon
| | - Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Graham Lough
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Alastair Ager
- Institute for Global Health and Development, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Fouad M Fouad
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, P.O. Box 11-0236, Riad El-Solh/Beirut 1107 2020, Lebanon
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29
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Odhiambo J, Jeffery C, Lako R, Devkota B, Valadez JJ. Measuring health system resilience in a highly fragile nation during protracted conflict: South Sudan 2011-15. Health Policy Plan 2020; 35:313-322. [PMID: 31876921 PMCID: PMC7152724 DOI: 10.1093/heapol/czz160] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2019] [Indexed: 12/31/2022] Open
Abstract
Health systems resilience (HSR) is defined as the ability of a health system to continue providing normal services in response to a crisis, making it a critical concept for analysis of health systems in fragile and conflict-affected settings (FCAS). However, no consensus for this definition exists and even less about how to measure HSR. We examine three current HSR definitions (maintaining function, improving function and achieving health system targets) using real-time data from South Sudan to develop a data-driven understanding of resilience. We used 14 maternal, newborn and child health (MNCH) coverage indicators from household surveys in South Sudan collected at independence (2011) and following 2 years of protracted conflict (2015), to construct a resilience index (RI) for 9 of the former 10 states and nationally. We also assessed health system stress using conflict-related indicators and developed a stress index. We cross tabulated the two indices to assess the relationship of resilience and stress. For maintaining function for 80% of MNCH indicators, seven state health systems were resilient, compared with improving function for 50% of the indicators (two states were resilient). Achieving the health system national target of 50% coverage in half of the MNCH indicators displayed no resilience. MNCH coverage levels were low, with state averages ranging between 15% and 44%. Central Equatoria State displayed high resilience and high system stress. Lakes and Northern Bahr el Ghazal displayed high resilience and low stress. Jonglei and Upper Nile States had low resilience and high stress. This study is the first to investigate HSR definitions using a resilience metric and to simultaneously measure health system stress in FCAS. Improving function is the HSR definition detecting the greatest variation in the RI. HSR and health system stress are not consistently negatively associated. HSR is highly complex warranting more in-depth analyses in FCAS.
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Affiliation(s)
- Jackline Odhiambo
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Caroline Jeffery
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Richard Lako
- Directorate of Policy, Planning, Budgeting and Research, Ministry of Health, Juba, South Sudan
| | - Baburam Devkota
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
| | - Joseph J Valadez
- Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK
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30
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Wong KLM, Brady OJ, Campbell OMR, Banke-Thomas A, Benova L. Too poor or too far? Partitioning the variability of hospital-based childbirth by poverty and travel time in Kenya, Malawi, Nigeria and Tanzania. Int J Equity Health 2020; 19:15. [PMID: 31992319 PMCID: PMC6988213 DOI: 10.1186/s12939-020-1123-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 01/09/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, women are most likely to receive skilled and adequate childbirth care in hospital settings, yet the use of hospital for childbirth is low and inequitable. The poorest and those living furthest away from a hospital are most affected. But the relative contribution of poverty and travel time is convoluted, since hospitals are often located in wealthier urban places and are scarcer in poorer remote area. This study aims to partition the variability in hospital-based childbirth by poverty and travel time in four sub-Saharan African countries. METHODS We used data from the most recent Demographic and Health Survey in Kenya, Malawi, Nigeria and Tanzania. For each country, geographic coordinates of survey clusters, the master list of hospital locations and a high-resolution map of land surface friction were used to estimate travel time from each DHS cluster to the nearest hospital with a shortest-path algorithm. We quantified and compared the predicted probabilities of hospital-based childbirth resulting from one standard deviation (SD) change around the mean for different model predictors. RESULTS The mean travel time to the nearest hospital, in minutes, was 27 (Kenya), 31 (Malawi), 25 (Nigeria) and 62 (Tanzania). In Kenya, a change of 1SD in wealth led to a 33.2 percentage points change in the probability of hospital birth, whereas a 1SD change in travel time led to a change of 16.6 percentage points. The marginal effect of 1SD change in wealth was weaker than that of travel time in Malawi (13.1 vs. 34.0 percentage points) and Tanzania (20.4 vs. 33.7 percentage points). In Nigeria, the two were similar (22.3 vs. 24.8 percentage points) but their additive effect was twice stronger (44.6 percentage points) than the separate effects. Random effects from survey clusters also explained substantial variability in hospital-based childbirth in all countries, indicating other unobserved local factors at play. CONCLUSIONS Both poverty and long travel time are important determinants of hospital birth, although they vary in the extent to which they influence whether women give birth in a hospital within and across countries. This suggests that different strategies are needed to effectively enable poor women and women living in remote areas to gain access to skilled and adequate care for childbirth.
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Affiliation(s)
- Kerry L M Wong
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Oliver J Brady
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Centre for Mathematical Modelling for Infectious Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Aduragbemi Banke-Thomas
- Department of Health Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Lenka Benova
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Department of Public Health, Institute of Tropical Medicine, Kronenburgstraat 43, 2000, Antwerp, Belgium
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31
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Ager A, Saleh S, Wurie H, Witter S. Health systems research in fragile settings. Bull World Health Organ 2020; 97:378-378A. [PMID: 31210671 PMCID: PMC6560370 DOI: 10.2471/blt.19.233965] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Alastair Ager
- NIHR Research Unit on Health in Situations of Fragility, Queen Margaret University, Queen Margaret Drive, Edinburgh, EH21 6UU, Scotland
| | - Shadi Saleh
- NIHR Research Unit on Health in Situations of Fragility, Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Haja Wurie
- NIHR Research Unit on Health in Situations of Fragility, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Sophie Witter
- NIHR Research Unit on Health in Situations of Fragility, Queen Margaret University, Queen Margaret Drive, Edinburgh, EH21 6UU, Scotland
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Malakoane B, Heunis JC, Chikobvu P, Kigozi NG, Kruger WH. Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening. BMC Health Serv Res 2020; 20:58. [PMID: 31973740 PMCID: PMC6979387 DOI: 10.1186/s12913-019-4862-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022] Open
Abstract
Background Since the advent of democracy, the South African government has been putting charters, policies, strategies and plans in place in an effort to strengthen public health system performance and enhance service delivery. However, public health programme performance and outcomes remained poor while the burden of disease increased. This was also the case in the Free State Province, where major public health system challenges occurred around 2012. Assessment was necessary in order to inform health system strengthening. Methods The study entailed a multi-method situation appraisal utilising information collated in 44 reports generated in 2013 through presentations by unit managers, subdistrict assessments by district clinical specialist teams, and group discussions with district managers, clinic supervisors, primary health care managers and chief executive and clinical officers of hospitals. These data were validated through community and provincial health indabas including non-governmental organisations, councils and academics, as well as unannounced facility visits involving discussions with a wide range of functionaries and patients. The reports were reviewed using the World Health Organization health system building blocks as a priori themes with subsequent identification of emerging subthemes. Data from the different methods employed were triangulated in a causal loop diagram showing the complex interactions between the components of an (in) effective health system. Results The major subthemes or challenges that emerged under each a priori theme included: firstly, under the ‘service delivery’ a priori theme, ‘fragmentation of health services’ (42 reports); secondly, under the ‘health workforce’ a priori theme, ‘staff shortages’ (39 reports); thirdly, under the ‘health financing’ a priori theme, ‘financial/cash-flow problems’ (39 reports); fourthly, under the ‘leadership and governance’ a priori theme, ‘risk to patient care’ (38 reports); fifthly, under the ‘medical products/technologies’ a priori theme, ‘dysfunctional communication technology’ (27 reports); and, sixthly, under the ‘information’ a priori theme, ‘poor information management’ (26 reports). Conclusion The major overall public health system challenges reported by stakeholders involved fragmentation of services, staff shortages and financial/cash-flow problems. In order to effect health systems strengthening there was particularly a need to improve integration and address human and financial deficiencies in this setting.
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Affiliation(s)
- B Malakoane
- Department of Community Health, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
| | - J C Heunis
- Centre for Health Systems Research & Development, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa.
| | - P Chikobvu
- Department of Community Health, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa.,Free State Department of Health, P.O. Box 277, Bloemfontein, 9300, South Africa
| | - N G Kigozi
- Centre for Health Systems Research & Development, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa
| | - W H Kruger
- Department of Community Health, University of the Free State, P.O. Box 339, Bloemfontein, 9300, South Africa.,Free State Department of Health, P.O. Box 277, Bloemfontein, 9300, South Africa
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33
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Dayyab FM, Iliyasu G, Ahmad BG, Bako AT, Ngamariju SS, Habib AG. Hepatitis B vaccine knowledge and self-reported vaccination status among healthcare workers in a conflict region in northeastern Nigeria. Ther Adv Vaccines Immunother 2020; 8:2515135519900743. [PMID: 32002499 PMCID: PMC6966246 DOI: 10.1177/2515135519900743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/19/2019] [Indexed: 11/15/2022] Open
Abstract
Background Hepatitis B virus (HBV) infection is highly endemic in Nigeria. The primary objective of this study is to describe the knowledge, self-reported vaccination status, and intention of healthcare workers to receive hepatitis B vaccine at a tertiary referral center in conflict-ravaged northeastern Nigeria. Methods This was cross-sectional analytical study among medical practitioners, nurses, laboratory workers, health attendants, pharmacists, and radiographers working at Federal Medical Center Nguru, Yobe State. Written informed consent was obtained from all study participants. Data were obtained using questionnaires and entered into a Microsoft Excel spreadsheet, cleaned and analyzed using JMP Pro software. Results Of the 182 participants, we found that 151 (82.97%), 81 (44.51%), 85 (46.70%), and 33 (18.13%) had good knowledge of HBV, good knowledge of hepatitis B vaccine, were vaccinated against HBV by the least dose, and had a complete hepatitis B vaccination status, respectively. The lack of availability of the vaccine was the main reason for not receiving the vaccine among the unvaccinated 36/91 (39.56%), followed by not knowing where to access the vaccine 19/91 (20.88%). Conclusion The study highlights the need for strategies to ensure the availability of hepatitis B vaccine in conflict settings and need for vaccinology training given the suboptimal level of awareness and uptake of the hepatitis B vaccine among the healthcare workers.
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Affiliation(s)
| | - Garba Iliyasu
- Department of Medicine, Bayero University Kano, Kano, Nigeria
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Meh C, Thind A, Ryan B, Terry A. Levels and determinants of maternal mortality in northern and southern Nigeria. BMC Pregnancy Childbirth 2019; 19:417. [PMID: 31718572 PMCID: PMC6852989 DOI: 10.1186/s12884-019-2471-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/22/2019] [Indexed: 11/25/2022] Open
Abstract
Background Maternal mortality is still a major risk for women of childbearing age in Nigeria. In 2008, Nigeria bore 14% of the global burden of maternal mortality. The national maternal mortality ratio has remained elevated despite efforts to reduce maternal deaths. Though health disparities exist between the North and South of Nigeria, there is a dearth of evidence on the estimates and determinants of maternal mortality for these regions. Methods This study aimed to assess differences in the levels and determinants of maternal mortality in women of childbearing age (15–49 years) in the North and South of Nigeria. The Nigeria Demographic and Health Surveys (2008 and 2013) were used. The association between maternal mortality (outcome) and relevant sociocultural, economic and health factors was tested using multivariable logistic regression in a sample of 51,492 living or deceased women who had given birth. Results There were variations in the levels of maternal mortality between the two regions. Maternal mortality was more pronounced in the North and increased in 2013 compared to 2008. For the South, the levels slightly decreased. Media exposure and education were associated with maternal mortality in the North while contraceptive method, residence type and wealth index were associated with maternal death in the South. In both regions, age and community wealth were significantly associated with maternal mortality. Conclusions Differences in the levels and determinants of maternal mortality between the North and South of Nigeria stress the need for efforts to cut maternal deaths through new strategies that are relevant for each region. These should improve education of girls in the North and access to health information and services in the South. Overall, new policies to improve women’s socioeconomic status should be adopted.
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Affiliation(s)
- Catherine Meh
- Department of Epidemiology and Biostatistics, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada.
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada.,Department of Family Medicine, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada.,Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada
| | - Bridget Ryan
- Department of Epidemiology and Biostatistics, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada.,Department of Family Medicine, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada
| | - Amanda Terry
- Department of Epidemiology and Biostatistics, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada.,Department of Family Medicine, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada.,Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, ON, N6A 5C1, Canada
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35
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Solanke BL, Oyinlola FF, Oyeleye OJ, Ilesanmi BB. Maternal and community factors associated with unmet contraceptive need among childbearing women in Northern Nigeria. Contracept Reprod Med 2019; 4:11. [PMID: 31497311 PMCID: PMC6717978 DOI: 10.1186/s40834-019-0093-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/19/2019] [Indexed: 12/20/2022] Open
Abstract
Background Unmet need for modern contraceptive remains a critical reproductive health challenge in Nigeria. Numerous studies in Nigeria and other countries have investigated the patterns, prevalence and associated factors of unmet contraceptive need. In spite of these, the associated factors of unmet contraceptive need in Northern Nigeria have remained insufficiently explored. The few studies that focused on Northern Nigeria have mainly examined maternal individual factors leaving out higher level factors such as community-level factors that may be associated with unmet contraceptive need. This study examines the extent to which maternal and community factors are associated with unmet contraceptive need in Northern Nigeria. Method Data was pooled from 2008 to 2013 Nigeria Demographic and Health Surveys. A weighted sample size of 26,730 women was analysed. The outcome variable was unmet contraceptive need, dichotomised into no unmet need and unmet need. The explanatory variables were individual maternal characteristics such as age, education, number of living children, age at marriage, pregnancy termination experience, and death of a child, and selected community characteristics such as community socioeconomic status, community literacy level, community knowledge of modern contraceptive and geo-political zone. The Multilevel Logistic Regression Model (MLRM) was applied. Result Results showed a prevalence of 18% unmet contraceptive need among Northern women in Nigeria. Maternal age of 35 years or older (AOR = 0.873; p < 0.05, CI: 0.780–0.976), having five or more living children (AOR = 1.813; p < 0.001, CI: 1.663–1.977), higher maternal education (AOR = 0.787; p < 0.05, CI: 0.625–0.993), and never experience death of a child (AOR = 0.866; p < 0.001, CI: 0.805–0.933) are the maternal factors significantly associated with unmet contraceptive need, while high community literacy level (AOR = 1.230; p < 0.05, CI: 1.041–1.454), moderate (AOR = 0.862; p < 0.05, CI: 0.767–0.968) or high (AOR = 0.821; p < 0.05, CI: 0.726–0.929) community knowledge of modern contraceptive, and geo-political zone of residence are the community-level characteristics significantly associated with unmet contraceptive need among women in Northern Nigeria. Conclusion Maternal and community factors are significantly associated with unmet contraceptive need, but based on the ICC maternal factors have more significance in Northern Nigeria. The expansion of existing family planning delivery points to cover all communities including rural and remote areas in the region is imperative.
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Affiliation(s)
- Bola Lukman Solanke
- 1Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Olaoye James Oyeleye
- 1Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife, Nigeria.,Action Against Hunger, ACF-International, Damaturu, Yobe State Nigeria
| | - Benjamin Bukky Ilesanmi
- 1Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife, Nigeria
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36
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Mui Y, Ballard E, Lopatin E, Thornton RLJ, Pollack Porter KM, Gittelsohn J. A community-based system dynamics approach suggests solutions for improving healthy food access in a low-income urban environment. PLoS One 2019; 14:e0216985. [PMID: 31086409 PMCID: PMC6516673 DOI: 10.1371/journal.pone.0216985] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/02/2019] [Indexed: 11/19/2022] Open
Abstract
Little is known about the mechanisms through which neighborhood-level factors (e.g., social support, economic opportunity) relate to suboptimal availability of healthy foods in low-income urban communities. We engaged a diverse group of chain and local food outlet owners, residents, neighborhood organizations, and city agencies based in Baltimore, MD. Eighteen participants completed a series of exercises based on a set of pre-defined scripts through an interactive, iterative group model building process over a two-day community-based workshop. This process culminated in the development of causal loop diagrams, based on participants' perspectives, illustrating the dynamic factors in an urban neighborhood food system. Synthesis of diagrams yielded 21 factors and their embedded feedback loops. Crime played a prominent role in several feedback loops within the neighborhood food system: contributing to healthy food being "risky food," supporting unhealthy food stores, and severing social ties important for learning about healthy food. Findings shed light on a new framework for thinking about barriers related to healthy food access and pointed to potential new avenues for intervention, such as reducing neighborhood crime.
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Affiliation(s)
- Yeeli Mui
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Ellis Ballard
- Social System Design Lab, Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States of America
| | - Eli Lopatin
- Reservoir Hill Improvement Council; Baltimore, MD, United States of America
| | - Rachel L. J. Thornton
- Center for Child and Community Health Research, Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Keshia M. Pollack Porter
- Department of Health Policy and Management, Institute for Health and Social Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Joel Gittelsohn
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Global Obesity Prevention Center (GOPC) at Johns Hopkins University, Baltimore, MD, United States of America
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37
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Chamberland-Rowe C, Chiocchio F, Bourgeault IL. Harnessing instability as an opportunity for health system strengthening: A review of health system resilience. Healthc Manage Forum 2019; 32:128-135. [PMID: 30971130 DOI: 10.1177/0840470419830105] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In recent years, resilience has emerged as a prominent topic in global health systems discourse as a result of the increasing variety and volume of sources of instability inflicting strain on systems. In line with this study's intent to bring together existing literature on health system resilience as a means to understand the process through which systems achieve resilience, a review of academic literature related to health system resilience was conducted. Emerging from this review is an operational model of resilience that builds on existing health systems frameworks. The model highlights health system resilience as a process through which leaders in all sectors need to be mobilized in order to harness instability as an opportunity for health system strengthening rather than a threat to the system's sustainability and integrity.
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Affiliation(s)
| | - François Chiocchio
- 1 Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Ivy Lynn Bourgeault
- 1 Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
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38
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Turenne CP, Gautier L, Degroote S, Guillard E, Chabrol F, Ridde V. Conceptual analysis of health systems resilience: A scoping review. Soc Sci Med 2019; 232:168-180. [PMID: 31100697 DOI: 10.1016/j.socscimed.2019.04.020] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 04/02/2019] [Accepted: 04/14/2019] [Indexed: 10/26/2022]
Abstract
System resilience has long been an area of study, and the term has become increasingly used across different sectors. Studies on resilience in health systems are more recent, multiplying particularly since the 2014 Ebola epidemic in West Africa. The World Health Organization (WHO) is calling for national governments to increase the resilience of their health systems. Concepts help define research objects and guide the analysis. Yet, to be useful, concepts need to be clear and precise. We aimed to improve the conceptual understanding of health systems resilience by conducting a scoping review to describe the state of knowledge in this area. We searched for literature in 10 databases, and analyzed data using a list of themes. We evaluated the clarity and the precision of the concept of health systems resilience using Daigneault & Jacob's three dimensions of a concept: term, sense, and referent. Of the 1091 documents initially identified, 45 met the inclusion criteria. Term: multiple terms are used, switching from one to the other to speak about the same subject. Sense: there is no consensus yet on a unique definition. Referent: the magnitude and nature of events that resilient health systems face differ with context, covering a broad range of situations from sudden crisis to everyday challenges. The lack of clarity in this conceptualization hinders the expansion of knowledge, the creation of reliable analytical tools, and the effectiveness of communication. The current conceptualization of health systems resilience is too scattered to enable the enhancement of this concept with great potential, opening a large avenue for future research.
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Affiliation(s)
- Charlotte Pailliard Turenne
- Institute for Research on Sustainable Development, CEPED (IRD-Université de Paris), Université de Paris, ERL INSERM SAGESUD, 45 Rue des Saints-Pères, 75006, Paris, France.
| | - Lara Gautier
- Department of Social and Preventive Medicine, University of Montreal, Montreal, Canada; Public Health Research Institute, University of Montreal, 2900, Boulevard Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada; CESSMA (IRD-Paris-Diderot University), Université Sorbonne Paris Cité, Bâtiment Olympe de Gouges (8ème étage - secrétariat bureau 817) rue Albert Einstein, 75013, PARIS, France.
| | - Stéphanie Degroote
- Institute for Research on Sustainable Development, CEPED (IRD-Université de Paris), Université de Paris, ERL INSERM SAGESUD, 45 Rue des Saints-Pères, 75006, Paris, France.
| | | | - Fanny Chabrol
- Institute for Research on Sustainable Development, CEPED (IRD-Université de Paris), Université de Paris, ERL INSERM SAGESUD, 45 Rue des Saints-Pères, 75006, Paris, France.
| | - Valéry Ridde
- Institute for Research on Sustainable Development, CEPED (IRD-Université de Paris), Université de Paris, ERL INSERM SAGESUD, 45 Rue des Saints-Pères, 75006, Paris, France; Fellow de l'Institut Français des Migrations, Paris, France.
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39
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Nkwogu L, Shuaib F, Braka F, Mkanda P, Banda R, Korir C, Bawa S, Mele S, Saidu M, Mshelia H, Shettima A, Tegegne SG, Yehualashet YG, Adamu U, Nsubuga P, Vaz RG, Wondimagegnehu A. Impact of engaging security personnel on access and polio immunization outcomes in security-inaccessible areas in Borno state, Nigeria. BMC Public Health 2018; 18:1311. [PMID: 30541498 PMCID: PMC6292175 DOI: 10.1186/s12889-018-6188-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nigeria was polio free for almost 2 years but, with the recent liberation of areas under the captivity of insurgents, there has been a resurgence of polio cases. For several years, these inaccessible areas did not have access to vaccination due to activities of Bokoharam, resulting in a concentration of a cohort of unvaccinated children that served as a polio sanctuary. This article describes the processes of engagement of security personnel to access security-compromised areas and the impact on immunization outcomes. METHODS We assessed routine program data from January 2016 to July 2016 in security-inaccessible areas and we evaluated the effectiveness of engaging security personnel to improve access to settlements in security-compromised Local Government Areas (LGAs) of Borno state. We thereafter evaluated the effects of this engagement on postcampaign evaluation indicators. RESULTS From 15 LGAs accessible to vaccination teams in January 2016, there was a 47% increase in July 2016. The number of wards increased from 131 in January to 162 in July 2016, while the settlement numbers increased from 6050 in January to 6548 in July 2016. The average percentage of missed children decreased from 8% in January to 3% in July 2016, while the number of LGAs with ≥ 80% coverage increased from 85% in January to 100% in July 2016. CONCLUSION The engagement of security personnel in immunization activities led to an improved access and improvement in postcampaign evaluation indicators in security-compromised areas of a Nigerian state. This approach promises to be an impactful innovation in reaching settlements in security-compromised areas.
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Affiliation(s)
- Loveday Nkwogu
- World Health Organization Country Representative's Office, Abuja, Nigeria.
| | - Faisal Shuaib
- National Primary Health Care Development Agency, Abuja, Nigeria
| | - Fiona Braka
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | - Pascal Mkanda
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | - Richard Banda
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | - Charles Korir
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | - Samuel Bawa
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | - Sule Mele
- Borno State Primary Health Care Development Agency, Maiduguri, Nigeria
| | - Mahmud Saidu
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | - Hyelni Mshelia
- Borno State Primary Health Care Development Agency, Maiduguri, Nigeria
| | - Aliyu Shettima
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | - Sisay G Tegegne
- World Health Organization Country Representative's Office, Abuja, Nigeria
| | | | - Usman Adamu
- National Primary Health Care Development Agency, Abuja, Nigeria
| | - Peter Nsubuga
- Global Public Health Care Solutions, Atlanta, GA, USA
| | - Rui G Vaz
- World Health Organization, Geneva, Switzerland
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40
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Lembani M, de Pinho H, Delobelle P, Zarowsky C, Mathole T, Ager A. Understanding key drivers of performance in the provision of maternal health services in eastern cape, South Africa: a systems analysis using group model building. BMC Health Serv Res 2018; 18:912. [PMID: 30497460 PMCID: PMC6267091 DOI: 10.1186/s12913-018-3726-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/16/2018] [Indexed: 11/19/2022] Open
Abstract
Background The Eastern Cape Province reports among the poorest health service indicators in South Africa with some of its districts standing out as worst performing as regards maternal health indicators. To understand key drivers and outcomes of this underperformance and to explore whether a participatory analysis could deepen action-oriented understanding among stakeholders, a study was conducted in one of the chronically poorly performing districts. Methods The study used a systems analysis approach to understand the drivers and outcomes affecting maternal health in the district in order to identify key leverage points for addressing the situation. The approach included semi-structured interviews with a total of 24 individuals consisting health system managers at various levels, health facility staff and patients. This was followed by a participatory group model building exercise with 23 key stakeholders to analyze system factors and their interrelationships affecting maternal health in the district using rich pictures and interrelationship diagraphs (IRDs) and finally the development of causal loop diagrams (CLDs). Results The stakeholders were able to unpack the complex ways in which factors were interrelated in contributing to poor maternal health performance and identified the feedback loops which resulted in the situation being intractable, suggesting strategies for sustainable improvement. Quality of leadership was shown to have a pervasive influence on overall system performance by linking to numerous factors and feedback loops, including staff motivation and capacity building. Staff motivation was linked to quality of care in turn influencing patient attendance and feeding back into staff motivation through its impact on workload. Without attention to workload, patient waiting times and satisfaction, the impact of improved leadership and staff support on staff competence and attitudes would be diminished. Conclusion Understanding the complex interrelationships of factors in the health system is key to identifying workable solutions especially in the context of chronic health systems challenges. Systems modelling using group model building methods can be an efficient means of supporting stakeholders to recognize valuable resources within the context of a dysfunctional system to strengthen systems performance.
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Affiliation(s)
- Martina Lembani
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, Cape Town, 7535, South Africa.
| | - Helen de Pinho
- Mailman School of Public Health, Columbia University, New York, USA
| | - Peter Delobelle
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, Cape Town, 7535, South Africa
| | - Christina Zarowsky
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, Cape Town, 7535, South Africa.,University of Montreal Hospital Research Centre and School of Public Health, University of Montreal, Montreal, Canada
| | - Thubelihle Mathole
- School of Public Health, University of the Western Cape, Private Bag X17, Bellville, Cape Town, 7535, South Africa
| | - Alastair Ager
- Mailman School of Public Health, Columbia University, New York, USA.,Institute for Global Health and Development, Queen Margaret University, Edinburgh, Scotland, UK
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41
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Solanke BL. Factors associated with use of maternal healthcare services during the Boko Haram insurgency in North-East Nigeria. Med Confl Surviv 2018; 34:158-184. [PMID: 30156121 DOI: 10.1080/13623699.2018.1511358] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Studies have focused on both individual and community factors affecting the use of maternal healthcare services. However, studies in Nigeria have rarely examined whether the influence of individual and community factors in explaining the use of maternal healthcare has changed in the context of the Boko Haram insurgency in North-East Nigeria. This study investigates factors associated with the use of maternal healthcare services during the Boko Haram insurgency in North-East Nigeria. The study analysed data from the 2013 Nigeria Demographic and Health Survey. Results showed that some individual characteristics are no longer associated with the use of maternal healthcare services, compared to community characteristics which are. Humanitarian assistance to the region should take this into account when considering interventions to encourage better uptake of maternal healthcare services.
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Affiliation(s)
- Bola Lukman Solanke
- a Department of Demography and Social Statistics , Obafemi Awolowo University , Ile-Ife , Nigeria
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42
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Adamu PI, Oguntunde PE, Okagbue HI, Agboola OO. On the Epidemiology and Statistical Analysis of HIV/AIDS Patients in the Insurgency Affected States of Nigeria. Open Access Maced J Med Sci 2018; 6:1315-1321. [PMID: 30087744 PMCID: PMC6062286 DOI: 10.3889/oamjms.2018.229] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/09/2018] [Accepted: 06/25/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND: The effect of insurgencies on a nation regarding the economy, education, health and infrastructure cannot be overemphasised. AIM: This research is therefore focused on analysing the incidence of HIV/AIDS disease in states affected by the activities of the Boko Haram insurgency in Nigeria. MATERIAL AND METHODS: The data collected refer to the period from 2004 to 2017, reporting information on 16,102 patients and including the age, gender, year of diagnosing and status of the patients. Descriptive, Chi-square test of independence and Correlation analyses were performed using Statistical Package for Social Sciences (SPSS) version 20. RESULTS: It was discovered that the majority of those living with HIV/AIDS in these Boko Haram ravaged areas are females between the age group of 30 years to 39 years. Reported cases of HIV/AIDS started increasing significantly from age 20, and the highest number of reported cases of HIV/AIDS was recorded in the year 2017. CONCLUSION: The status of the patient was found to be dependent on both the gender and age of the patients’ treatment, though the strength of the linear relationship between status and age is not significantly different from zero.
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Sani R, Adamou H, Daddy H, Amodou MI, Adoulaye MB, James LD, Garba I, Idé K, Hama Y, Sanoussi S. INJURIES OF BOKO HARAM INSURGENCY IN SOUTH-EAST NIGER REPUBLIC. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2018; 8:22-44. [PMID: 32754455 PMCID: PMC7368572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Currently, wounds of wars, terrorism and criminality are increasing and constitute major public health problem worldwide. AIM To present the epidemiological, clinical and therapeutic characteristics of the wounds observed during the Boko Haram (BH) insurgency in the South-east of the Republic of Niger. METHODOLOGY This was a cross-sectional study from December 2014 to December 2016 at Diffa Regional Hospital, Diffa, Niger of individuals whose injuries were as a result of Boko Haram insurgency. RESULTS In the period of this study, 573 injuries from Boko Haram insurgency were managed at the Regional Hospital at Diffa. The majority, 513(89.5%), were males while females constituted 60(10.5%) with a male/female ratio of 8.55. The mean age was 30,94(SD24,91) years (range 1 to 97 years). Civilian victims accounted for 379 (66.1%) while Nigerien soldiers accounted for 160(27.9%) and 34 (5.9%) were Boko Haram fighters. Firearms and explosives accounted for injuries in 489 (85.3%) and 7(1.2%) of patients respectively; 42 (7.3%) suffered injuries from a variety of traditional weapons. Injuries to limbs accounted for 361(63%) of cases and polytrauma in 65(11.34%). The main surgical management included wound debridement in 409 (71.4%), external bone fixation in 38 (6.6%), laparotomy in 30 (5.2%), thoracic drainage in 27 (4.7%), and major limb amputations in 13 (2.3%) cases.Postoperative follow-up was uneventful in 460 (80.28%) of cases; there were 29 deaths, giving a mortality rate of 5.1%. Predictors of death after injuries of Boko Haram terrorism in this study included: being civilian patients (OR = 3.38 [1.15-9.85], p=0.018), injuries to head, neck, trunk or spine (OR 3.45[1.58-7.58], p= 0.001) or the presence of polytrauma on admission (OR = 17.30 [7.72-38.80], p<0.0001). CONCLUSION This study has shown that injuries sustained in Boko Haram insurgency in Niger were mainly firearm injuries and injuries from the use of traditional weapons, affecting mostly young civilian males. The part of the body most commonly involved were the extremities, with mainly soft tissue injuries. Wound debridement was the commonest surgical procedure performed and the mortality rate was 5.1%. Predictors of mortality were being civilian patients, injuries of head, neck, trunk or spine and polytrauma. The ICRC has played a major role in strengthening our hospital for the task of caring for the victims, in terms of provision of material resources and in the further training of our personnel.
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Affiliation(s)
- R Sani
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - H Adamou
- Department of Surgery, Zinder National Hospital, Faculty of Health Sciences, University of Zinder, Niger
| | - H Daddy
- Department of Anesthesia and Critical Care, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - Magagi I Amodou
- Department of Surgery, Zinder National Hospital, Faculty of Health Sciences, University of Zinder, Niger
| | - M B Adoulaye
- Department of Surgery, Diffa regional Hospital, Niger
| | - L Didier James
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - I Garba
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - K Idé
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - Y Hama
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
| | - S Sanoussi
- Department of Surgery and Surgical specialties, Niamey National Hospital, Faculty of Health Sciences, Abdou Moumouni University of Niamey, Niger
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Barasa E, Mbau R, Gilson L. What Is Resilience and How Can It Be Nurtured? A Systematic Review of Empirical Literature on Organizational Resilience. Int J Health Policy Manag 2018; 7:491-503. [PMID: 29935126 PMCID: PMC6015506 DOI: 10.15171/ijhpm.2018.06] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 01/20/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Recent health system shocks such as the Ebola outbreak of 2014-2016 and the global financial crisis of 2008 have generated global health interest in the concept of resilience. The concept is however not new, and has been applied to other sectors for a longer period of time. We conducted a review of empirical literature from both the health and other sectors to synthesize evidence on organizational resilience. METHODS We systematically searched for literature in PubMed, Econlit, EBSCOHOST databases, google, and Google Scholar and manually searched the reference lists of selected papers. We identified 34 papers that met our inclusion criteria. We analysed data from the selected papers by thematic review. RESULTS Resilience was generally taken to mean a system's ability to continue to meet its objectives in the face of challenges. The concepts of resilience that were used in the selected papers emphasized not just a system's capacity to withstand shocks, but also to adapt and transform. The resilience of organizations was influenced by the following factors: Material resources, preparedness and planning, information management, collateral pathways and redundancy, governance processes, leadership practices, organizational culture, human capital, social networks and collaboration. CONCLUSION A common theme across the selected papers is the recognition of resilience as an emergent property of complex adaptive systems. Resilience is both a function of planning for and preparing for future crisis (planned resilience), and adapting to chronic stresses and acute shocks (adaptive resilience). Beyond resilience to acute shocks, the resilience of health systems to routine and chronic stress (everyday resilience) is also key. Health system software is as, if not more important, as its hardware in nurturing health system resilience.
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Affiliation(s)
- Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rahab Mbau
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Lucy Gilson
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Erim DO, Offiong HE, Kim C, Bello FA, Moulton J, Wheeler SB, Thirumurthy H. The spillover effect of midwife attrition from the Nigerian midwives service scheme. BMC Health Serv Res 2018; 18:295. [PMID: 29685178 PMCID: PMC5914034 DOI: 10.1186/s12913-018-3106-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/10/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Nigerian Midwives Service Scheme (MSS) increased use of antenatal services at rural public sector clinics. However, it is unclear if women who would not have otherwise sought care, or those who would have sought care in rural private sector clinics caused this change. Additionally, it is also unclear if the reported midwife attrition was associated with a spillover of the scheme's effect on urban areas. We sought to answer these two questions using data from two nationally representative surveys. METHODS We used an interrupted time series model to assess trends in the use of obstetric (i.e. antenatal and delivery) services among rural and urban respondents in the 2008 and 2013 Nigerian demographic and health surveys. RESULTS We found that the MSS led to a 5-percentage point increase in the use of antenatal services at rural public sector clinics, corroborating findings from a previous study. This change was driven by women who would not have sought care otherwise. We also found that there was a 4-percentage point increase in the use of delivery services at urban public sector clinics, and a concurrent 4-percentage point decrease in urban home deliveries. These changes are most likely explained by midwives' attrition and exemplify a spillover of the scheme's effect. CONCLUSION Midwife attrition from the Nigerian MSS was associated with a spillover of the scheme's effect on the use of delivery services, on urban areas.
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Affiliation(s)
- Daniel O. Erim
- Department of Health Policy and Management, the University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | | | - Christine Kim
- Department of Health Policy and Management, the University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Folasade A. Bello
- Department of Obstetrics and Gynecology, University of Ibadan, Ibadan, Nigeria
| | - Jeremy Moulton
- Department of Public Policy, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, the University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, USA
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Haruna-Ogun OA. Geographical differentials in uptake of antenatal care services in Nigeria. Health Care Women Int 2017; 39:34-49. [PMID: 29053408 DOI: 10.1080/07399332.2017.1388804] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Uptake of antenatal care (ANC) is poor in Nigeria; however, there are geographical variations. We investigated the relationship between place of residence, region and ANC utilization in Nigeria. Using data of the most recent demographic and health survey, the geographic predictors of ANC were modeled. Women in the rural areas were 79% less likely to have the recommended four ANC visits. The odds of a woman in southern Nigeria having four ANC visit are 4.347 times the odds of a woman in northern Nigeria having the recommended ANC visit. We recommend increased coverage of maternal health services.
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Martineau T, McPake B, Theobald S, Raven J, Ensor T, Fustukian S, Ssengooba F, Chirwa Y, Vong S, Wurie H, Hooton N, Witter S. Leaving no one behind: lessons on rebuilding health systems in conflict- and crisis-affected states. BMJ Glob Health 2017; 2:e000327. [PMID: 29082000 PMCID: PMC5656126 DOI: 10.1136/bmjgh-2017-000327] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/23/2017] [Accepted: 05/26/2017] [Indexed: 11/03/2022] Open
Abstract
Conflict and fragility are increasing in many areas of the world. This context has been referred to as the 'new normal' and affects a billion people. Fragile and conflict-affected states have the worst health indicators and the weakest health systems. This presents a major challenge to achieving universal health coverage. The evidence base for strengthening health systems in these contexts is very weak and hampered by limited research capacity, challenges relating to insecurity and apparent low prioritisation of this area of research by funders. This article reports on findings from a multicountry consortium examining health systems rebuilding post conflict/crisis in Sierra Leone, Zimbabwe, northern Uganda and Cambodia. Across the ReBUILD consortium's interdisciplinary research programme, three cross-cutting themes have emerged through our analytic process: communities, human resources for health and institutions. Understanding the impact of conflict/crisis on the intersecting inequalities faced by households and communities is essential for developing responsive health policies. Health workers demonstrate resilience in conflict/crisis, yet need to be supported post conflict/crisis with appropriate policies related to deployment and incentives that ensure a fair balance across sectors and geographical distribution. Postconflict/crisis contexts are characterised by an influx of multiple players and efforts to support coordination and build strong responsive national and local institutions are critical. The ReBUILD evidence base is starting to fill important knowledge gaps, but further research is needed to support policy makers and practitioners to develop sustainable health systems, without which disadvantaged communities in postconflict and postcrisis contexts will be left behind in efforts to promote universal health coverage.
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Affiliation(s)
- Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Barbara McPake
- Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Sally Theobald
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joanna Raven
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Tim Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Suzanne Fustukian
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management at the School of Public Health, Makerere University, Kampala, Uganda
| | - Yotamu Chirwa
- Centre for International Health Policy, Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Haja Wurie
- Department of Biochemistry, College of Medicine and Applied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Nick Hooton
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Gilson L, Barasa E, Nxumalo N, Cleary S, Goudge J, Molyneux S, Tsofa B, Lehmann U. Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa. BMJ Glob Health 2017; 2:e000224. [PMID: 29081995 PMCID: PMC5656138 DOI: 10.1136/bmjgh-2016-000224] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/25/2017] [Accepted: 03/28/2017] [Indexed: 11/05/2022] Open
Abstract
Recent global crises have brought into sharp relief the absolute necessity of resilient health systems that can recognise and react to societal crises. While such crises focus the global mind, the real work lies, however, in being resilient in the face of routine, multiple challenges. But what are these challenges and what is the work of nurturing everyday resilience in health systems? This paper considers these questions, drawing on long-term, primarily qualitative research conducted in three different district health system settings in Kenya and South Africa, and adopting principles from case study research methodology and meta-synthesis in its analytic approach. The paper presents evidence of the instability and daily disruptions managed at the front lines of the district health system. These include patient complaints, unpredictable staff, compliance demands, organisational instability linked to decentralisation processes and frequently changing, and sometimes unclear, policy imperatives. The paper also identifies managerial responses to these challenges and assesses whether or not they indicate everyday resilience, using two conceptual lenses. From this analysis, we suggest that such resilience seems to arise from the leadership offered by multiple managers, through a combination of strategies that become embedded in relationships and managerial routines, drawing on wider organisational capacities and resources. While stable governance structures and adequate resources do influence everyday resilience, they are not enough to sustain it. Instead, it appears important to nurture the power of leaders across every system to reframe challenges, strengthen their routine practices in ways that encourage mindful staff engagement, and develop social networks within and outside organisations. Further research can build on these insights to deepen understanding.
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Affiliation(s)
- Lucy Gilson
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Center for Geographical Medicine, KEMRI-Wellcome Trust Programme, Nairobi, Kenya
| | - Nonhlanhla Nxumalo
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Cleary
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Jane Goudge
- Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
| | - Sassy Molyneux
- Center for Geographical Medicine, KEMRI-Wellcome Trust Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Benjamin Tsofa
- Center for Geographical Medicine, KEMRI-Wellcome Trust Programme, Nairobi, Kenya
| | - Uta Lehmann
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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Patient Experiences of Decentralized HIV Treatment and Care in Plateau State, North Central Nigeria: A Qualitative Study. AIDS Res Treat 2017; 2017:2838059. [PMID: 28331636 PMCID: PMC5346378 DOI: 10.1155/2017/2838059] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/01/2016] [Accepted: 12/07/2016] [Indexed: 11/23/2022] Open
Abstract
Background. Decentralization of care and treatment for HIV infection in Africa makes services available in local health facilities. Decentralization has been associated with improved retention and comparable or superior treatment outcomes, but patient experiences are not well understood. Methods. We conducted a qualitative study of patient experiences in decentralized HIV care in Plateau State, north central Nigeria. Five decentralized care sites in the Plateau State Decentralization Initiative were purposefully selected. Ninety-three patients and 16 providers at these sites participated in individual interviews and focus groups. Data collection activities were audio-recorded and transcribed. Transcripts were inductively content analyzed to derive descriptive categories representing patient experiences of decentralized care. Results. Patient participants in this study experienced the transition to decentralized care as a series of “trade-offs.” Advantages cited included saving time and money on travel to clinic visits, avoiding dangers on the road, and the “family-like atmosphere” found in some decentralized clinics. Disadvantages were loss of access to ancillary services, reduced opportunities for interaction with providers, and increased risk of disclosure. Participants preferred decentralized services overall. Conclusion. Difficulty and cost of travel remain a fundamental barrier to accessing HIV care outside urban centers, suggesting increased availability of community-based services will be enthusiastically received.
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Awosusi AE. Aftermath of Boko Haram violence in the Lake Chad Basin: a neglected global health threat. BMJ Glob Health 2017; 2:e000193. [PMID: 28589004 PMCID: PMC5321389 DOI: 10.1136/bmjgh-2016-000193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 11/23/2016] [Accepted: 11/24/2016] [Indexed: 11/25/2022] Open
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