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Michielsen J, Criel B. Can community health insurance really live up to the expectations of providingequitable healthcare of sound quality? Soc Sci Med 2024; 345:115741. [PMID: 36764867 DOI: 10.1016/j.socscimed.2023.115741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
| | - Bart Criel
- Institute of Tropical Medicine, Antwerp, Belgium.
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Bosongo S, Belrhiti Z, Chenge F, Criel B, Coppieters Y, Marchal B. The role of provincial health administration in supporting district health management teams in the Democratic Republic of Congo: eliciting an initial programme theory of a realist evaluation. Health Res Policy Syst 2024; 22:29. [PMID: 38378688 PMCID: PMC10880215 DOI: 10.1186/s12961-024-01115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/31/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND In 2006, the Ministry of Health in the Democratic Republic of Congo designed a strategy to strengthen the health system by developing health districts. This strategy included a reform of the provincial health administration to provide effective technical support to district health management teams in terms of leadership and management. The provincial health teams were set up in 2014, but few studies have been done on how, for whom, and under what circumstances their support to the districts works. We report on the development of an initial programme theory that is the first step of a realist evaluation seeking to address this knowledge gap. METHODS To inform the initial programme theory, we collected data through a scoping review of primary studies on leadership or management capacity building of district health managers in sub-Saharan Africa, a review of policy documents and interviews with the programme designers. We then conducted a two-step data analysis: first, identification of intervention features, context, actors, mechanisms and outcomes through thematic content analysis, and second, formulation of intervention-context-actor-mechanism-outcome (ICAMO) configurations using a retroductive approach. RESULTS We identified six ICAMO configurations explaining how effective technical support (i.e. personalised, problem-solving centred and reflection-stimulating) may improve the competencies of the members of district health management teams by activating a series of mechanisms (including positive perceived relevance of the support, positive perceived credibility of provincial health administration staff, trust in provincial health administration staff, psychological safety, reflexivity, self-efficacy and perceived autonomy) under specific contextual conditions (including enabling learning environment, integration of vertical programmes, competent public health administration staff, optimal decision space, supportive work conditions, availability of resources and absence of negative political influences). CONCLUSIONS We identified initial ICAMO configurations that explain how provincial health administration technical support for district health management teams is expected to work, for whom and under what conditions. These ICAMO configurations will be tested in subsequent empirical studies.
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Affiliation(s)
- Samuel Bosongo
- Faculté de Médecine et Pharmacie, Université de Kisangani, Kisangani, Democratic Republic of Congo.
- École de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium.
- Institute of Tropical Medicine, Antwerp, Belgium.
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Democratic Republic of Congo.
| | - Zakaria Belrhiti
- Mohammed VI University of Sciences and Health (UM6SS), Casablanca, Morocco
- Centre Mohammed VI de la Recherche et Innovation (CM6), Rabat, Morocco
| | - Faustin Chenge
- Faculté de Médecine et Pharmacie, Université de Kisangani, Kisangani, Democratic Republic of Congo
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Democratic Republic of Congo
- Ecole de Santé Publique, Faculté de Médecine, Université de Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Bart Criel
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Yves Coppieters
- École de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
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Accoe K, Criel B, Ag Ahmed MA, Buitrago VT, Marchal B. Conditions for health system resilience in the response to the COVID-19 pandemic in Mauritania. BMJ Glob Health 2023; 8:e013943. [PMID: 38050409 PMCID: PMC10693853 DOI: 10.1136/bmjgh-2023-013943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/15/2023] [Indexed: 12/06/2023] Open
Abstract
INTRODUCTION A country's ability to manage a crisis depends on its level of resilience. Efforts are made to clarify the concept of health system resilience, but its operationalisation remains little studied. In the present research, we described the capacity of the local healthcare system in the Islamic Republic of Mauritania, in West Africa, to cope with the COVID-19 pandemic. METHODS We used a single case study with two health districts as units of analysis. A context analysis, a literature review and 33 semi-structured interviews were conducted. The data were analysed using a resilience conceptual framework. RESULTS The analysis indicates a certain capacity to manage the crisis, but significant gaps and challenges remain. The management of many uncertainties is largely dependent on the quality of the alignment of decision-makers at district level with the national level. Local management of COVID-19 in the context of Mauritania's fragile healthcare system has been skewed to awareness-raising and a surveillance system. Three other elements appear to be particularly important in building a resilient healthcare system: leadership capacity, community dynamics and the existence of a learning culture. CONCLUSION The COVID-19 pandemic has put a great deal of pressure on healthcare systems. Our study has shown the relevance of an in-depth contextual analysis to better identify the enabling environment and the capacities required to develop a certain level of resilience. The translation into practice of the skills required to build a resilient healthcare system remains to be further developed.
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Affiliation(s)
- Kirsten Accoe
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | | | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Mukala Mayoyo E, Criel B, Sow A, Coppieters Y, Chenge F. Understanding the mix of services for mental health care in urban DR Congo: a qualitative descriptive study. BMC Health Serv Res 2023; 23:1206. [PMID: 37925407 PMCID: PMC10625694 DOI: 10.1186/s12913-023-10219-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/26/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Mental health workers (MHWs) are exposed to conflicts of competence daily when performing tasks related to the provision of mental health services. This may be linked to a lack of understanding of their tasks as caregivers and providers. Furthermore, in most low-income settings, it is unclear how the available services are organized and coordinated to provide mental health care. To understand the above, this study aimed to identify the current mix of services for mental health care in the urban Democratic Republic of the Congo (DRC). METHODS A qualitative descriptive study was carried out in Lubumbashi from February to April 2021. We conducted 7 focus group discussions (FGDs) with 74 key informants (family members, primary care physicians, etc.) and 13 in-depth interviews (IDIs) with key informants (traditional healers, psychiatrists, etc.). We performed a qualitative content analysis, guided by an analytical framework, that led to the development of a comprehensive inventory of MHWs from the household level to specialized facilities, exploring their tasks in care delivery, identifying existing services, and defining their current organization. RESULTS Analysis of transcripts from the FGDs and IDIs showed that traditional healers and family caregivers are the leading providers in Lubumbashi. The exploration of the tasks performed by MHWs revealed that lifestyle, traditional therapies, psychotherapy, and medication are the main types of care offered/advised to patients. Active informal caregivers do not currently provide care corresponding to their competencies. The rare mental health specialists available do not presently recognize the tasks of primary care providers and informal caregivers in care delivery, and their contribution is considered marginal. We identified five types of services: informal services, traditional therapy services, social services, primary care services, and psychiatric services. Analyses pointed out an inversion of the ideal mix of these services. CONCLUSIONS Our findings show a suboptimal mix of services for mental health and point to a clear lack of collaboration between MHWs. There is an urgent need to clearly define the tasks of MHWs, build the capacity of nonspecialists, shift mental health-related tasks to them, and raise awareness about collaborative care approaches.
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Affiliation(s)
- Erick Mukala Mayoyo
- School of Public Health, University of Lubumbashi, Lubumbashi, DR, Congo.
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium.
- Department of Community Health, Institut Supérieur des Techniques Médicales de Kananga, Kananga, DR, Congo.
- National Mental Health Program, Ministry of Public Health, Hygiene and Prevention, Kinshasa, DR, Congo.
- Centre de Connaissances en Santé en RD Congo, Kinshasa, DR, Congo.
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Abdoulaye Sow
- Faculty of Health Sciences and Techniques, Gamal Abdel Nasser University of Conakry, Conakry, Guinea
| | - Yves Coppieters
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Faustin Chenge
- School of Public Health, University of Lubumbashi, Lubumbashi, DR, Congo
- Centre de Connaissances en Santé en RD Congo, Kinshasa, DR, Congo
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Ngo Bebe D, Kwilu FN, Mavila A, Mafuta EM, Mangalu JM, Jessani NS, Criel B. Making health insurance responsive to citizens: the management of members' complaints by mutual health organisations in Kinshasa, Democratic Republic of Congo. BMJ Glob Health 2023; 7:e011438. [PMID: 37666577 PMCID: PMC10514665 DOI: 10.1136/bmjgh-2022-011438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 08/06/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION In moving towards universal health coverage, a number of low-income and middle-income countries have adopted community-based health insurance (CBHI) as a means to reduce both the inequity in healthcare access and the burden of catastrophic health expenditures linked to user fees. However, organisations managing CBHIs face many challenges, including a poor relationship with their members. In the Democratic Republic of the Congo, CBHI schemes are managed by mutual health organisations (MHOs) and are in the process of enhancing their accountability and responsiveness to members' needs and expectations. This study assessed how MHOs have managed member complaints and their performance in grievance redressal. METHODS Using a sequential mixed-methods approach, we drew insights from four types of sources: review of approximately 50 relevant documents, 25 in-depth interviews (IDIs) with CBHI managers, 9 IDIs with health facility managers, 1063 surveys of MHO members and 15 focus group discussions (FGDs) comprising an additional 153 MHO members. MHO members in this study belonged to three different MHOs (Lisanga, La Borne and Mutuelle de santé des Enseignants de l'Enseignement Primaire, Secondaire et Professionnel) in the capital, Kinshasa. RESULTS The document review showed that there were no clear administrative processes for the implementation of the grievance redressal arrangement measures resulting in low member awareness of these measures. These results were confirmed by the IDIs. Of 1044 members surveyed, only 240 (23%) were aware of the complaint measures, and 201 (84%) of these declared they had used the measures at some point in time, 181/201 (90%) users who had used the measures declared being satisfied with the response provided. The FGDs confirmed that most members lack knowledge on the grievance redressal procedures, but those who were aware had made use of them and were often satisfied with the response provided. CONCLUSION MHOs should urgently improve communication with their members on the range of redressal measures put in place to address grievances. Attention should be given to properly monitor existing arrangements, and possibly adapt them with well-documented and communicated standard operating procedures.
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Affiliation(s)
- Dosithee Ngo Bebe
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Fulbert Nappa Kwilu
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Arlette Mavila
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Eric Musalu Mafuta
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - José Mobhe Mangalu
- Department of Population Sciences and Development, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Nasreen S Jessani
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of GlobalHealth, Stellenbosch University, Stellenbosch, South Africa
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Bosongo S, Belrhiti Z, Ekofo J, Kabanga C, Chenge F, Criel B, Marchal B. How capacity building of district health managers has been designed, delivered and evaluated in sub-Saharan Africa: a scoping review and best fit framework analysis. BMJ Open 2023; 13:e071344. [PMID: 37532484 PMCID: PMC10401232 DOI: 10.1136/bmjopen-2022-071344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES We aimed to understand how capacity building programmes (CBPs) of district health managers (DHMs) have been designed, delivered and evaluated in sub-Saharan Africa. We focused on identifying the underlying assumptions behind leadership and management CBPs at the district level. DESIGN Scoping review. DATA SOURCES We searched five electronic databases (MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library and Google Scholar) on 6 April 2021 and 13 October 2022. We also searched for grey literature and used citation tracking. ELIGIBILITY CRITERIA We included all primary studies (1) reporting leadership or management capacity building of DHMs, (2) in sub-Saharan Africa, (3) written in English or French and (4) published between 1 January 1987 and 13 October 2022. DATA EXTRACTION AND SYNTHESIS Three independent reviewers extracted data from included articles. We used the best fit framework synthesis approach to identify an a priori framework that guided data coding, analysis and synthesis. We also conducted an inductive analysis of data that could not be coded against the a priori framework. RESULTS We identified 2523 papers and ultimately included 44 papers after screening and assessment for eligibility. Key findings included (1) a scarcity of explicit theories underlying CBPs, (2) a diversity of learning approaches with increasing use of the action learning approach, (3) a diversity of content with a focus on management rather than leadership functions and (4) a diversity of evaluation methods with limited use of theory-driven designs to evaluate leadership and management capacity building interventions. CONCLUSION This review highlights the need for explicit and well-articulated programme theories for leadership and management development interventions and the need for strengthening their evaluation using theory-driven designs that fit the complexity of health systems.
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Affiliation(s)
- Samuel Bosongo
- Faculté de Médecine et Pharmacie, Département de Santé Publique, Université de Kisangani, Kisangani, Congo (the Democratic Republic of the)
- Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
| | - Zakaria Belrhiti
- Département santé publique and management, Ecole Internationale de Santé Publique, Université Mohammed VI des Sciences de la Santé, Casablanca, Morocco
- Centre Mohammed VI de la recherche et Innovation (CM6), Rabat, Morocco
| | - Joël Ekofo
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
| | - Chrispin Kabanga
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
| | - Faustin Chenge
- Faculté de Médecine et Pharmacie, Département de Santé Publique, Université de Kisangani, Kisangani, Congo (the Democratic Republic of the)
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, Congo (the Democratic Republic of the)
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Bosongo S, Belrhiti Z, Chenge F, Criel B, Marchal B. Capacity building of district health management teams in the era of provincial health administration reform in the Democratic Republic of Congo: a realist evaluation protocol. BMJ Open 2023; 13:e073508. [PMID: 37463816 PMCID: PMC10357782 DOI: 10.1136/bmjopen-2023-073508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION In 2006, the Congolese Ministry of Health developed a health system strengthening strategy focusing on health district development. This strategy called for reforming the provincial health administration in order to better support the health district development through leadership and management capacity building of district health management teams. The implementation is currently underway, yet, more evidence on how, for whom and under what conditions this capacity building works is needed. The proposed research aims to address this gap using a realist evaluation approach. METHODS AND ANALYSIS We will follow the cycle of the realist evaluation. First, we will elicit the initial programme theory through a scoping review (completed in December 2022, using MEDLINE, Health Systems Evidence, Wiley Online Library, Cochrane Library, Google Scholar and grey literature), a review of health policy documents (completed in March 2023), and interviews with key stakeholders (by June 2023). Second, we will empirically test the initial programme theory using a multiple-embedded case study design in two provincial health administrations and four health districts (by March 2024). Data will be collected through document reviews, in-depth interviews, non-participant observations, a questionnaire, routine data from the health information management system and a context mapping tool. We will analyse data using the Intervention-Context-Actor-Mechanism-Outcome configuration heuristic. Last, we will refine the initial programme theory based on the results of the empirical studies and develop recommendations for policymakers (by June 2024). ETHICS AND DISSEMINATION The Institutional Review Board of the Institute of Tropical Medicine and the Medical Ethics Committee of the University of Lubumbashi approved this study. We will also seek approvals from provincial-level and district-level health authorities before data collection in their jurisdictions. We will disseminate the study findings through the publication of articles in peer-reviewed academic journals, policy briefs for national policymakers and presentations at national and international conferences.
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Affiliation(s)
- Samuel Bosongo
- Faculté de Médecine et Pharmacie, Département de Santé Publique, Université de Kisangani, Kisangani, Congo (the Democratic Republic of the)
- Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgium
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
| | - Zakaria Belrhiti
- Ecole Internationale de Santé Publique, Université Mohammed VI des sciences de la santé (UM6SS), Casablanca, Morocco
- Centre Mohammed VI de la recherche et innovation (CM6), Rabat, Morocco
| | - Faustin Chenge
- Faculté de Médecine et Pharmacie, Département de Santé Publique, Université de Kisangani, Kisangani, Congo (the Democratic Republic of the)
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Congo (the Democratic Republic of the)
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, Congo (the Democratic Republic of the)
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Mukala Mayoyo E, Criel B, Michielsen J, Chuy D, Coppieters Y, Chenge F. Mental health care in the city of Lubumbashi, Democratic Republic of the Congo: Analysis of demand, supply and operational response capacity of the health district of Tshamilemba. PLoS One 2023; 18:e0280089. [PMID: 37018318 PMCID: PMC10075459 DOI: 10.1371/journal.pone.0280089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/16/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Integrating mental health care into the primary care system is an important policy option in the Democratic Republic of the Congo (DRC). From the perspective of the integration of mental health care in district health services, this study analyzed the existing demand and supply of mental health care in the health district of Tshamilemba, which is located in Lubumbashi, the second largest city of the DRC. We critically examined the district's operational response capacity to address mental health. METHODS A multimethod cross-sectional exploratory study was carried out. We conducted a documentary review (including an analysis of the routine health information system) from the health district of Tshamilemba. We further organized a household survey to which 591 residents responded and conducted 5 focus group discussions (FGDs) with 50 key stakeholders (doctors, nurses, managers, community health workers and leaders, health care users). The demand for mental health care was analyzed through the assessment of the burden of mental health problems and care-seeking behaviors. The burden of mental disorders was assessed by calculating a morbidity indicator (proportion of mental health cases) and through a qualitative analysis of the psychosocial consequences as perceived by the participants. Care-seeking behavior was analyzed by calculating health service utilization indicators and more specifically the relative frequency of mental health complaints in primary health care centers, and by analyzing FGDs participants' reports. The mental health care supply available was described by using the qualitative analysis of the declarations of the participants (providers and users of care) to the FGDs and by analyzing the package of care available in the primary health care centers. Finally, the district's operational response capacity was assessed by making an inventory of all available resources and by analyzing qualitative data provided by health providers and managers regarding the district' capacity to address mental health conditions. RESULTS Analysis of technical documents indicated that the burden of mental health problems is a major public problem in Lubumbashi. However, the proportion of mental health cases among the general patient population seen in the outpatient curative consultations in the Tshamilemba district remains very low, at an estimated 5.3%. The interviews not only pointed to a clear demand for mental health care but also indicated that there is currently hardly any offer of care available in the district. There are no dedicated psychiatric beds, nor is there a psychiatrist or psychologist available. Participants in the FGDs stated that in this context, the main source of care for people remains traditional medicine. CONCLUSION Our findings show a clear demand for mental health care and a lack of formal mental health care supply in the Tshamilemba district. Moreover, this district lacks adequate operational capacity to meet the mental health needs of the population. Traditional African medicine is currently the main source of mental health care in this health district. Identifying concrete priority mental health actions to address this gap, by making evidence-based mental care available, is therefore of great relevance.
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Affiliation(s)
- Erick Mukala Mayoyo
- Centre de Recherche en Épidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
- School of Public Health, University of Lubumbashi, Lubumbashi, Haut-Katanga, DR Congo
- Section de Santé Communautaire, Institut Supérieur des Techniques Médicales de Kananga, Kananga, Kasaï Central, DR Congo
- Centre de Connaissances en Santé au Congo, Kinshasa, DR Congo
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine in Antwerp, Antwerp, Belgium
| | - Joris Michielsen
- Department of Public Health, Institute of Tropical Medicine in Antwerp, Antwerp, Belgium
| | - Didier Chuy
- School of Public Health, University of Lubumbashi, Lubumbashi, Haut-Katanga, DR Congo
- Centre de Connaissances en Santé au Congo, Kinshasa, DR Congo
- Section de Santé Communautaire, Institut Supérieur des Techniques Médicales de Lubumbashi, Lubumbashi, Haut-Katanga, DR Congo
| | - Yves Coppieters
- Centre de Recherche en Épidémiologie, Biostatistique et Recherche Clinique, Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
| | - Faustin Chenge
- School of Public Health, University of Lubumbashi, Lubumbashi, Haut-Katanga, DR Congo
- Centre de Connaissances en Santé au Congo, Kinshasa, DR Congo
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Mulenga-Cilundika P, Ekofo J, Kabanga C, Criel B, Van Damme W, Chenge F. Indirect Effects of Ebola Virus Disease Epidemics on Health Systems in the Democratic Republic of the Congo, Guinea, Sierra Leone and Liberia: A Scoping Review Supplemented with Expert Interviews. Int J Environ Res Public Health 2022; 19:13113. [PMID: 36293703 PMCID: PMC9602680 DOI: 10.3390/ijerph192013113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
Ebola Virus Disease (EVD) epidemics have been extensively documented and have received large scientific and public attention since 1976. Until July 2022, 16 countries worldwide had reported at least one case of EVD, resulting in 43 epidemics. Most of the epidemics occurred in the Democratic Republic of Congo (DRC) but the largest epidemic occurred from 2014-2016 in Guinea, Sierra Leone and Liberia in West Africa. The indirect effects of EVD epidemics on these countries' health systems, i.e., the consequences beyond infected patients and deaths immediately related to EVD, can be significant. The objective of this review was to map and measure the indirect effects of the EVD epidemics on the health systems of DRC, Guinea, Sierra Leone and Liberia and, from thereon, draw lessons for strengthening their resilience vis-à-vis future EVD outbreaks and other similar health emergencies. A scoping review of published articles from the PubMed database and gray literature was conducted. It was supplemented by interviews with experts. Eighty-six articles were included in this review. The results were structured based on WHO's six building blocks of a health system. During the EVD outbreaks, several healthcare services and activities were disrupted. A significant decline in indicators of curative care utilization, immunization levels and disease control activities was noticeable. Shortages of health personnel, poor health data management, insufficient funding and shortages of essential drugs characterized the epidemics that occurred in the above-mentioned countries. The public health authorities had virtually lost their leadership in the management of an EVD response. Governance was characterized by the development of a range of new initiatives to ensure adequate response. The results of this review highlight the need for countries to invest in and strengthen their health systems, through the continuous reinforcement of the building blocks, even if there is no imminent risk of an epidemic.
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Affiliation(s)
- Philippe Mulenga-Cilundika
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
- School of Public Health, Faculty of Medicine, University of Lubumbashi, Lubumbashi 1825, Democratic Republic of the Congo
| | - Joel Ekofo
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
| | - Chrispin Kabanga
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
| | - Bart Criel
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
- Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Wim Van Damme
- Institute of Tropical Medicine, 2000 Antwerp, Belgium
| | - Faustin Chenge
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa 3088, Democratic Republic of the Congo
- School of Public Health, Faculty of Medicine, University of Lubumbashi, Lubumbashi 1825, Democratic Republic of the Congo
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Ssennyonjo A, Van Belle S, Ssengooba F, Titeca K, Bakubi R, Criel B. Not for us, without us: examining horizontal coordination between the Ministry of Health and other sectors to advance health goals in Uganda. Health Policy Plan 2022; 37:1221-1235. [DOI: 10.1093/heapol/czac079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 07/26/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
The Ministry or Department of Health (M/DoH) is the mandated government agency for health in all countries. However, achieving good health and wellbeing requires the health sector to coordinate with other sectors such as the environment, agriculture, and education. Little is known about the coordination relationship between MOH and other sectors to advance health and development goals in low- and middle-income countries (LMICs). Our study examined the coordination relationship between MOH and other government ministries, departments, and agencies (MDAs) at the national level in Uganda. This was an embedded case study nested in a study on intragovernmental coordination at the central government in Uganda. A qualitative approach used document review and key informant interviews with government officials and non-state actors. Data were analysed thematically using a multitheoretical framework. The coordination relationship was characterized by interdependences generally framed lopsidedly in terms of health sector goals and not vice versa. Actor opportunism and asymmetrical interests interacted with structural-institutional factors contributing to variable influence on internal and external coordination within and beyond MOH. Supportive mechanisms include a) diverse health sector legal-institutional frameworks, b) their alignment to broader government efforts, and c) the MOH’s agency to leverage government-wide efforts. Constraints arose from gaps in the legal-institutional framework, b) demands on resources due to the ‘broad’ MOH mandate, and c) the norms of the MOH’s professional bureaucracy and the predominance of medical professionals. This study underlies critical actions to improve coordination between the health and non-health sectors. Introspection within the MOH is vital to inform efforts to modify MOH’s internal functioning and positioning within the broader government to strategically advance MOH’s (development) aspirations. The nature of MoH’s role in multisectoral efforts should be contingent. Considerations of mutual sectoral interdependencies and interactions with and within broader government systems are critical.
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Affiliation(s)
- Aloysius Ssennyonjo
- Department of Health Policy Planning and Management, Makerere University School of Public Health , Kampala, Uganda
- Department of Public Health, Institute of Tropical Medicine , Antwerp, Belgium
- Institute of Development Policy (IOB), University of Antwerp , Antwerp, Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine , Antwerp, Belgium
| | - Freddie Ssengooba
- Department of Health Policy Planning and Management, Makerere University School of Public Health , Kampala, Uganda
| | - Kristof Titeca
- Institute of Development Policy (IOB), University of Antwerp , Antwerp, Belgium
| | - Rachael Bakubi
- Department of Health Policy Planning and Management, Makerere University School of Public Health , Kampala, Uganda
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine , Antwerp, Belgium
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Ssennyonjo A, Criel B, Van Belle S, Ssengooba F, Titeca K. What are the Tools Available for the Job? Coordination Instruments at Uganda's Central Government Level and Their Implications for Multisectoral Action for Health. Health Policy Plan 2022; 37:1025-1041. [PMID: 35711138 DOI: 10.1093/heapol/czac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/26/2022] [Accepted: 06/14/2022] [Indexed: 11/14/2022] Open
Abstract
Managing sectoral interdependences requires functional tools that facilitate coordinated multisectoral efforts. The pursuit of multisectoral action (MSA) for health is intrinsically linked to broader efforts in many governments to achieve greater internal coordination. This research explores the nature of coordination instruments for MSA at the national level in Uganda and the complexities of how these tools play out in implementation. Data was collected through 26 purposive in-depth interviews with national-level stakeholders, including government officials and non-state actors, and a review of selected government strategic documents. An adapted framework by Bouckaert and colleagues (2010) was used to establish a typology of coordination instruments (CIs) and break them down into structural and management tools, and infer their underlying coordination mechanisms based on their design and operational features. A multitheoretical framework guided the analysis of the factors influencing the implementation dynamics and functioning of the tools. The study found that the government of Uganda uses a range of structural and management instrument mixes mutually influencing each other and mainly based on hierarchy and network mechanisms. These instruments constitute and generate the resources that structure interorganisational relationships across vertical and horizontal boundaries. The instrument mixes also create hybrid institutional configurations that generate complementary but at times conflicting influences. This study demonstrated that a contextualized examination of specific coordination tools can be enhanced by delineating the underlying institutional forms of ideal type mechanisms. Such an approach can inspire more complex analysis and comparisons of CIs within and across government levels, policy domains or issues over time. Health policy and systems research needs to pay attention to the instrument mixes in government systems and their dynamic interaction across policy issues and over time.
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Affiliation(s)
- Aloysius Ssennyonjo
- Department of Health Policy Planning and Management, Makerere University School of Public Health Kampala, Uganda.,Department of Public Health, Institute of Tropical Medicine, Antwerp Belgium.,Institute of Development Policy (IOB), University of Antwerp, Antwerp, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp Belgium
| | - Freddie Ssengooba
- Department of Health Policy Planning and Management, Makerere University School of Public Health Kampala, Uganda
| | - Kristof Titeca
- Institute of Development Policy (IOB), University of Antwerp, Antwerp, Belgium
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Putturaj M, Krumeich A, Nuggehalli Srinivas P, Engel N, Criel B, Van Belle S. Crying baby gets the milk? The governmentality of grievance redressal for patient rights violations in Karnataka, India. BMJ Glob Health 2022; 7:bmjgh-2022-008626. [PMID: 35623644 PMCID: PMC9150157 DOI: 10.1136/bmjgh-2022-008626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Patient rights aim to protect the dignity of healthcare-seeking individuals. Realisation of these rights is predicated on effective grievance redressal for the victims of patient rights violations. Methods We used a critical case (that yields the most information) of patient rights violations reported in Karnataka state (South India) to explore the power dynamics involved in resolving grievances raised by healthcare-seeking individuals. Using interviews, media reports and other documents pertaining to the case, we explored the ‘governmentality’ of grievance redressal for patient rights violations, that is, the interaction of micropractices and techniques of power employed by actors to govern the processes and outcomes. We also examined whether existing governmentality ensured procedural and substantive justice to care-seeking individuals. Results Collective action was necessary by the aggrieved women in terms of protests, media engagement, petitions and follow-up to ensure that the State accepted a complaint against a medical professional. Each institution, and especially the medical professional council, exercised its power by problematising the grievance in its own way which was distinct from the problematisation of the grievance by the collective. The State bureaucracy enacted its power by creating a maze of organisational units and by fragmenting the grievance redressal across various bureaucratic units. Conclusion There is a need for measures guaranteeing accountability, transparency, promptness, fairness, credibility and trustworthiness in the patient grievance redressal system. Governmentality as a framework enabled to study how subjects (care-seeking individuals) are rendered governable and resist dominant forces in the grievance redressal system for patient rights violations.
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Affiliation(s)
- Meena Putturaj
- Department of Health Ethics and Society, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands .,Health Equity Cluster, Institute of Public Health Bangalore, Bangalore, Karnataka, India.,Centre for Local Health Traditions and Policy, The University of Trans-Disciplinary Health Sciences and Technology, Bengaluru, Karnataka, India.,Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Anja Krumeich
- Department of Health Ethics and Society, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Nora Engel
- Department of Health Ethics and Society, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Ssennyonjo A, Ssengooba F, Criel B, Titeca K, Van Belle S. 'Writing budgets for meetings and teas?': a multitheoretical analysis of intragovernmental coordination for multisectoral action for health in Uganda. BMJ Glob Health 2022; 7:bmjgh-2021-007990. [PMID: 35197251 PMCID: PMC8867254 DOI: 10.1136/bmjgh-2021-007990] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/27/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction Coordination across policy domains and among government agencies is considered critical for addressing complex challenges such as inequities, urbanisation and climate change. However, the factors influencing coordination among government entities in low-income and middle-income countries are not well known. Although theory building is well suited to explain complex social phenomena, theory-based health policy and systems studies are limited. This paper examined the factors influencing coordination among government entities at the central government level in Uganda. Methods This theory-based case study used a qualitative approach. Primary data were collected through 26 national-level key informant interviews supplemented with a review of 6 national strategic and policy documents. Data were analysed abductively using a multitheoretical framework combining the transaction cost economics theory, principal–agent theory, resource dependence theory and political economy perspective. Results Complex and dynamic interactions among different factors, both internal and external to the government, were found. Interdependencies, coordination costs, non-aligned interests, and institutional and ideational aspects were crucial factors. The power dynamics within the bureaucratic structures and the agency of the coordinated entities influence the effectiveness of coordination efforts. New public management principles promoted in the 1990s by donor institutional strengthening projects (characterised by agencification and setting up of independent agencies to circumvent ineffective big line ministries) created further fragmentation within the government. The donors and international agendas were occasionally supportive but sometimes counterintuitive to national coordination efforts. Conclusion The multitheoretical framework derives a deep analysis of the factors that influence organisational decision-making to coordinate with others or not. Achieving intragovernmental coordination requires more time and resources to guide the software aspects of institutional change—articulating a shared vision on coordination across government. Shaping incentives to align interests, managing coordination costs and navigating historical-institutional contexts are critical. Countervailing political actions and power dynamics should be judiciously navigated.
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Affiliation(s)
- Aloysius Ssennyonjo
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda .,Institute of Development Policy, University of Antwerp, Antwerp, Belgium.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Freddie Ssengooba
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kristof Titeca
- Institute of Development Policy, University of Antwerp, Antwerp, Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Bello K, De Lepeleire J, Agossou C, Apers L, Zannou DM, Criel B. Lessons Learnt From the Experiences of Primary Care Physicians Facing COVID-19 in Benin: A Mixed-Methods Study. Front Health Serv 2022; 2:843058. [PMID: 36925823 PMCID: PMC10012796 DOI: 10.3389/frhs.2022.843058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/08/2022] [Indexed: 11/13/2022]
Abstract
Introduction In sub-Saharan Africa, there is a need to better understand and guide the practice of primary care physicians (PCPs), especially in a crisis context like the COVID-19 pandemic. This study analyses the experiences of PCPs facing COVID-19 in Benin and draws policy lessons. Methods The study followed a fully mixed sequential dominant status design. Data were collected between April and August 2020 from a sample of PCPs in Benin. We performed descriptive analyses on the quantitative data. We also performed bivariate analyses for testing associations between various outcomes and the public/private status of the PCPs, their localization within or outside the cordon sanitaire put in place at the beginning of COVID-19, and their practice' category. A thematic content analysis was done on qualitative data. Results from both analyses were triangulated. Results Ninety PCPs participated in the quantitative strand, and 14 in the qualitative. The median percentage of the COVID-19 control measures implemented in the health facilities, as reported by the PCPs, was 77.8% (interquartile range = 16.7%), with no difference between the various groups. While 29.4% of the PCPs reported being poorly/not capable of helping the communities to deal with COVID-19, 45.3% felt poorly/not confident in dealing with an actual case. These percentages were bigger in the private sector. The PCP's experiences were marked by anxiety and fear, with 80.2% reporting stress. Many PCPs (74.1%) reported not receiving support from local health authorities, and 75.3% felt their concerns were not adequately addressed. Both percentages were higher in the private sector. The PCPs especially complained of insufficient training, insufficient coordination, and less support to private providers than the public ones. For 72.4 and 79.3% of the PCPs, respectively, the pandemic impacted services utilization and daily work. There were negative impacts (like a decrease in the services utilization or the quality of care), but also positive ones (like improved compliance to hygiene measures and new opportunities). Conclusion Our study highlighted the need for more structured support to PCPs for optimizing their contribution to epidemics control and good primary healthcare in Benin. Efforts in this direction can build on several good practices and opportunities.
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Affiliation(s)
- Kéfilath Bello
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin.,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Public Health and Primary Care, General Practice, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, General Practice, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Christian Agossou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Ludwig Apers
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Bello K, De Lepeleire J, Kabinda M. J, Bosongo S, Dossou JP, Waweru E, Apers L, Zannou M, Criel B. The expanding movement of primary care physicians operating at the first line of healthcare delivery systems in sub-Saharan Africa: A scoping review. PLoS One 2021; 16:e0258955. [PMID: 34679111 PMCID: PMC8535187 DOI: 10.1371/journal.pone.0258955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In sub-Saharan Africa (SSA), the physicians' ratio is increasing. There are clear indications that many of them have opted to work at the first-line of healthcare delivery systems, i.e. providing primary care. This constitutes an important change in African healthcare systems where the first line has been under the responsibility of nurse-practitioners for decades. Previous reviews on primary care physicians (PCPs) in SSA focused on the specific case of family physicians in English-speaking countries. This scoping review provides a broader mapping of the PCPs' practices in SSA, beyond family physicians and including francophone Africa. For this study, we defined PCPs as medical doctors who work at the first-line of healthcare delivery and provide generalist healthcare. METHODS We searched five databases and identified additional sources through purposively selected websites, expert recommendations, and citation tracking. Two reviewers independently selected studies and extracted and coded the data. The findings were presented to a range of stakeholders. FINDINGS We included 81 papers, mostly related to the Republic of South Africa. Three categories of PCPs are proposed: family physicians, "médecins généralistes communautaires", and general practitioners. We analysed the functioning of each along four dimensions that emerged from the data analysis: professional identity, governance, roles and activities, and output/outcome. Our analysis highlighted several challenges about the PCPs' governance that could threaten their effective contribution to primary care. More research is needed to investigate better the precise nature and performance of the PCPs' activities. Evidence is particularly needed for PCPs classified in the category of GPs and, more generally, PCPs in African countries other than the Republic of South Africa. CONCLUSIONS This review sheds more light on the institutional, organisational and operational realities of PCPs in SSA. It also highlighted persisting gaps that remain in our understanding of the functioning and the potential of African PCPs.
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Affiliation(s)
- Kéfilath Bello
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, General Practice, KU Leuven—University of Leuven, Leuven, Belgium
| | - Jeff Kabinda M.
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Democratic Republic of Congo
| | - Samuel Bosongo
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Democratic Republic of Congo
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Evelyn Waweru
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Ludwig Apers
- Department Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marcel Zannou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Faculty of Health Sciences, University of Abomey-Calavi, Abomey-Calavi, Benin
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Bosongo SI, Mukalenge FC, Tambwe AM, Criel B. [Les médecins prestataires à la première ligne des soins dans la ville de Kisangani en République Démocratique du Congo : vers une typologie]. Afr J Prim Health Care Fam Med 2021; 13:e1-e8. [PMID: 34636602 PMCID: PMC8517732 DOI: 10.4102/phcfm.v13i1.2617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 01/11/2021] [Accepted: 01/09/2021] [Indexed: 11/23/2022] Open
Abstract
The first-line physicians' practice in Kisangani city in Democratic Republic of Congo: Towards a typology. BACKGROUND In the Democratic Republic of the Congo (DRC), for a number of years, there has been a spontaneous and growing phenomenon of physicians operating at the front line of the health system, while this role is traditionally devolved to nurse-practitioners. This phenomenon does not align with the current health policy. AIM The aim of this paper is to develop and discuss the main types of frontline physicians in the city of Kisangani. SETTING We conducted a descriptive cross-sectional study in two urban districts in the city of Kisangani. METHODS The study population consisted of all first-line health facilities that employed at least one physician. The construction of a typology of first-line physicians consisted of three stages: identification and definition of relevant dimensions of analysis; grouping cases based on empirical data; and analysis of significant relationships and establishment of the typology itself. RESULTS An involvement of physicians in healthcare delivery at the first line was observed in 60% of all first line facilities in the two urban districts. Two main types of first-line physicians were identified: firstly, and by large the most prevalent one (96% of cases), the 'hospital-like physician', and secondly, the much less frequent type of the 'supervision physician'. CONCLUSION The involvement of physicians in first line healthcare is today a growing phenomenon in the DRC, especially in urban areas. The most dominant expression of this phenomenon is a transposition of the hospital-based physician model to the first line healthcare services, which thereby jeopardizing the specificity of first line healthcare.
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Affiliation(s)
- Samuel I Bosongo
- Department of Public Health, Faculty of Medicine and Pharmacy, University of Kisangani, Kisangani, Democratic Republic of the Congo.
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Mukala Mayoyo E, van de Put W, Van Belle S, van Mierlo B, Criel B. Intégration de la santé mentale dans les services de soins de santé primaires en République démocratique du Congo. Sante Publique 2021; Vol. 33:77-87. [PMID: 34372645 DOI: 10.3917/spub.211.0077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The study aims to document the experience of integrating a mental health care package into the general health care system of Lubero district in the Democratic Republic of Congo (DRC) between 2011 and 2015, and more specifically, the effects of this integration on the access to and use of health services offering mental health care. METHOD This is a retrospective study using a case study design. Data collected from different project documents and an analytic review of the official reports of the Ministry of Public Health were used for an analysis of the results of the integration. RESULTS The results indicate that 3,941 patients with mental health problems used the care offered at the health centers and the district hospital between 2012 and 2015. In 2015, the average utilization rate of curative care in health centers for mental health problems was 7 new cases/1,000 inhabitants/year. The majority of these patients were treated on an outpatient basis, at primary health care level. DISCUSSION Our study shows that it is possible to integrate mental health into existing general health services in the DRC. Nevertheless, the major problems in terms of access and use of basic care in the Lubero district indicate that the success of such an integration depends on the quality of the health system in place and the involvement of a wide range of both health and non-health actors, including key people within communities.
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Belrhiti Z, Van Belle S, Criel B. How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco. BMJ Glob Health 2021; 6:bmjgh-2021-006140. [PMID: 34261759 PMCID: PMC8280911 DOI: 10.1136/bmjgh-2021-006140] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background In Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals. Methods We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of ‘negotiated order’ and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco. Results Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care. Conclusion The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.
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Affiliation(s)
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Lall D, Engel N, Devadasan N, Horstman K, Criel B. Team-based primary health care for non-communicable diseases: complexities in South India. Health Policy Plan 2021; 35:ii22-ii34. [PMID: 33156934 PMCID: PMC7646724 DOI: 10.1093/heapol/czaa121] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/26/2022] Open
Abstract
Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, have reached epidemic proportions worldwide. Health systems, especially those in low- and middle-income countries, such as India, struggle to deliver quality chronic care. A reorganization of healthcare service delivery is needed to strengthen care for chronic conditions. In this study, we evaluated the implementation of a package of tailored interventions to reorganize care, which were identified following a detailed analysis of gaps in delivering quality NCD care at the primary care level in India. Interventions included a redesign of the workflow at primary care clinics, a redistribution of tasks, the introduction of patient information records and the involvement of community health workers in the follow-up of patients with NCDs. An experimental case study design was chosen to study the implementation of the quality improvement measures. Three public primary care facilities in rural South India were selected. Qualitative methods were used to gain an in-depth understanding of the implementation process and outcomes of implementation. Observations, field notes and semi-structured interviews with staff at these facilities (n = 15) were thematically analysed to identify contextual factors that influenced implementation. Only one of the primary health centres implemented all components of the intervention by the end of 9 months. The main barriers to implementation were hierarchical arrangements that inhibited team-based care, the amount of time required for counselling and staff transfers. Team cohesion, additional staff and staff motivation seem to have facilitated implementation. This quality improvement research highlights the importance of building relational leadership to enable team-based care at primary care clinics in India. Redesigned organization of care and task redistribution is important solutions to deliver quality chronic care. However, implementing these will require capacity building of local primary care teams.
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Affiliation(s)
- Dorothy Lall
- Institute of Public Health, 3009, II-A Main, 17th Cross, KR Rd, Siddanna Layout, Banashankari Stage II, Banashankari, Bengaluru, Karnataka, 560070 India
| | - Nora Engel
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Narayanan Devadasan
- Institute of Public Health, 3009, II-A Main, 17th Cross, KR Rd, Siddanna Layout, Banashankari Stage II, Banashankari, Bengaluru, Karnataka, 560070 India
| | - Klasien Horstman
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - Bart Criel
- Institute of Tropical Medicine, Nationalestraat 155, Antwerpen 2000, Belgium
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Bosongo S, Chenge F, Mwembo A, Criel B. L’influence des prestations des médecins à la première ligne de soins sur le système intégré de district sanitaire à Kisangani, République Démocratique du Congo: une étude qualitative. Pan Afr Med J 2021; 39:215. [PMID: 34630827 PMCID: PMC8486932 DOI: 10.11604/pamj.2021.39.215.25737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 07/14/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION in the DRC, doctors, formerly absent, are increasingly being employed as primary care physicians, in particular but not exclusively in urban areas. This study describes and analyses the impact of primary care physician services on the integrated district health system in Kisangani, DRC. METHODS in the third quarter of 2018, we conducted 40 semi-structured interviews of health district stakeholders (population, nurses, doctors, managers) selected in a reasoned way. Questions focused on doctors' motivation, their package of activities and the perceptions of other district stakeholders on their front-line services. Data were analysed using the thematic content analysis. RESULTS the services of primary care physicians were a de facto but they were unplanned and unsupported. This derived largely from doctors' need for professional integration. This seemed to improve treatment acceptability but limited their financial accessibility. It was associated with an uncontrolled expansion of the activity packages and caused competition between first-line and second-line physicians. CONCLUSION physician services are a challenge and an opportunity to strengthen first-line care while preserving complementarity with second-line care. A (re)definition of first-line physicians' role and activity package is then required. Hence, the need to improve the dialogue between different health system actors in order to (re)define consensually a model of first-line care adapted to match physicians' needs.
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Affiliation(s)
- Samuel Bosongo
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Faculté de Médecine et Pharmacie, Université de Kisangani, Kisangani, République Démocratique du Congo
| | - Faustin Chenge
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, République Démocratique du Congo
| | - Albert Mwembo
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, République Démocratique du Congo
| | - Bart Criel
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Institut de Médecine Tropicale d´Anvers, Antwerpen, Belgique
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21
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Sarkar NDP, Bardaji A, Baingana FK, Rivera JM, Criel B, Bunders-Aelen J, Grietens KP. Intra-household Variation in Pathways to Care for Epilepsy and Mental Disorders in Eastern Uganda. Front Public Health 2021; 9:583667. [PMID: 34381746 PMCID: PMC8350049 DOI: 10.3389/fpubh.2021.583667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 06/14/2021] [Indexed: 11/22/2022] Open
Abstract
Integrating mental, neurological, and substance use (MNS) health care into the public health system has become a global priority, with mental health, and well-being now being part of the Sustainable Development Goals. In the aim to provide good quality care for MNS disorders, understanding patients' pathways to care is key. This qualitative study explores the pathways to care of patients attending an outpatient mental health clinic of a district hospital in eastern rural Uganda, from the perspectives of their caregivers. Twenty seven in-depth interviews were conducted with caregivers of MNS patients visiting the clinic, with a focus on four case-presentations. Data analysis consisted of thematic and emergent content analyses using NVivo 11. Results across all interviews highlight that chosen help-seeking itineraries were largely pluralistic, combining and alternating between traditional healing practices, and biomedical care, regardless of the specific MNS disorder. Intra-household differences in care seeking pathways—e.g., where one patient received traditional help or no care at all, while the other received biomedical care—depended on caregivers' perceived contextual illness narrative for each patient, in combination with a variety of other factors. If interpreted as a form of bewitchment, traditional medicine and healing was often the first form of care sought, while the mental health clinic was seen as a recourse to “free” care. Patients, especially younger children, who showed visible improvements once stabilized on psychotropic medication was a source of motivation for caregivers to continue with biomedical care at the mental health clinic. However, stock-outs of the free psychotropic medication at the clinic led to dissatisfaction with services due to out-of-pocket expenses and precipitated returning to alternative therapy choices. This article showcases the importance of understanding the complex and varied combinations of individual, cultural, socioeconomic and structural factors that may affect caregivers' choices of pathways to care for patients with MNS disorders in eastern rural Uganda. These cumulative complex processes and context-specific help-seeking behaviors, which ultimately impact patient treatment and MNS health outcomes, need to be first acknowledged, understood and taken into account if we are to promote more inclusive, effective and integrated public mental health systems globally.
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Affiliation(s)
- Nandini D P Sarkar
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands.,ISGlobal, Hospital Clinic - University of Barcelona, Barcelona, Spain
| | - Azucena Bardaji
- ISGlobal, Hospital Clinic - University of Barcelona, Barcelona, Spain
| | - Florence K Baingana
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Joan Muela Rivera
- PASS Suisse, Neuchatel, Switzerland.,Medical Anthropology Research Centre (MARC) at Departament d'Antropologia, Filosofia i Treball Social, Universidad Rovira i Virgili, Tarragona, Spain
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Joske Bunders-Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Sow A, Smekens T, De Man J, De Spigelaere M, Vanlerberghe V, Van Dormael M, Criel B. [Quality of health worker-patient communication: What are the benefits of integrating mental health into front-line services in Guinea?]. Rev Epidemiol Sante Publique 2021; 69:287-295. [PMID: 34272084 DOI: 10.1016/j.respe.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Patient-centred care presupposes communication based on empathy, active listening and dialogue. Our study examines the effects of integrating mental health in multi-purpose health centres on health workers' communication with patients who consult for problems unrelated to mental health. The objective is to compare the quality of communication in health centres where staff have received specific training in the management of mental disorders (SM+) compared to those without such training (SM-). METHODS The study was conducted among 18 health workers in charge of primary curative consultations in 12 non-governmental health centers in Guinea: 7 health workers in 4 SM+ health centers and 11 health workers in 8 SM- health centres. The study is based on mixed methods: observation, semi-structured and group interviews. The Global Consultation Rating Scale (GCRS) was applied to assess patient-centered communication. RESULTS The SM+ GCRS scores obtained by SM+s during observations are generally higher than the SM- scores. The odds of having a "good quality" consultation are almost 3 times higher in SM+ than in SM- for some steps in the consultation process. The SM+ discourse is more patient-centered, and differs from the more biomedical discourse of SM-. SM- health workers do not consider all of the stages of a patient-centred consultation to be applicable and recommend "leapfrogging". On the contrary, SM+ health workers consider all stages to be important and are convinced that the integration of mental health has improved their communication through the training they have received and the practice of caring for persons with mental disorders. CONCLUSION The integration of mental health into primary care provision represents an opportunity to improve the quality of care in its "patient-centred care" dimension. That said, optimal development of patient-centred care presupposes favorable structural conditions.
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Affiliation(s)
- A Sow
- École de santé publique, Université Libre de Bruxelles, Route de Lennik 808 CP 594- B-1070, Bruxelles, Belgique; Faculté des sciences et techniques de la santé, Chaire de santé publique, Université Gamal Abdel Nasser, Commune de Dixinn-1017 Conakry, Guinée.
| | - T Smekens
- Institut de médecine tropicale, Nationalestraat155, 2000Anvers, Belgique
| | - J De Man
- Centre for General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Doornstraat 331, 2610 Wilrijk, Antwerp, Belgium
| | - M De Spigelaere
- École de santé publique, Université Libre de Bruxelles, Route de Lennik 808 CP 594- B-1070, Bruxelles, Belgique
| | - V Vanlerberghe
- Institut de médecine tropicale, Nationalestraat155, 2000Anvers, Belgique
| | - M Van Dormael
- Institut de médecine tropicale, Nationalestraat155, 2000Anvers, Belgique
| | - B Criel
- Institut de médecine tropicale, Nationalestraat155, 2000Anvers, Belgique
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Ssennyonjo A, Van Belle S, Titeca K, Criel B, Ssengooba F. Multisectoral action for health in low-income and middle-income settings: how can insights from social science theories inform intragovernmental coordination efforts? BMJ Glob Health 2021; 6:bmjgh-2020-004064. [PMID: 34039586 PMCID: PMC8160194 DOI: 10.1136/bmjgh-2020-004064] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 12/21/2022] Open
Abstract
There is consensus in global health on the need for multisectoral action (MSA) to address many contemporary development challenges, but there is limited action. Examples of issues that require coordinated MSA include the determinants of health conditions such as nutrition (malnutrition and obesity) and chronic non-communicable diseases. Nutrition, tobacco control and such public health issues are regulated separately by health, trade and treasury ministries. Those issues need to be coordinated around the same ends to avoid conflicting policies. Despite the need for MSA, why do we see little progress? We investigate the obstacles to and opportunities for MSA by providing a government perspective. This paper draws on four theoretical perspectives, namely (1) the political economy perspective, (2) principal–agent theory, (3) resource dependence theory and (4) transaction cost economics theory. The theoretical framework provides complementary propositions to understand, anticipate and prepare for the emergence and structuring of coordination arrangements between government organisations at the same or different hierarchical levels. The research on MSA for health in low/middle-income countries needs to be interested in a multitheory approach that considers several theoretical perspectives and the contextual factors underlying coordination practices.
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Affiliation(s)
- Aloysius Ssennyonjo
- School of Public Health, Department of Health Policy Planning and Management, Makerere University College of Health Sciences, Kampala, Uganda .,Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Institute of Development Policy, University of Antwerp, Antwerp, Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Kristof Titeca
- Institute of Development Policy, University of Antwerp, Antwerp, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Freddie Ssengooba
- School of Public Health, Department of Health Policy Planning and Management, Makerere University College of Health Sciences, Kampala, Uganda
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Putturaj M, Van Belle S, Engel N, Criel B, Krumeich A, Nagendrappa PB, Srinivas PN. Multilevel governance framework on grievance redressal for patient rights violations in India. Health Policy Plan 2021; 36:1470-1482. [PMID: 34133734 DOI: 10.1093/heapol/czab066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 05/18/2021] [Accepted: 05/26/2021] [Indexed: 11/14/2022] Open
Abstract
The notion of patient rights encompasses the obligations of the state and healthcare providers to respect the dignity, autonomy and equality of care-seeking individuals in healthcare processes. Functional patient grievance redressal systems are key to ensuring that the rights of individuals seeking healthcare are protected. We critically examined the published literature from high-income and upper-middle-income countries to establish an analytical framework on grievance redressal for patient rights violations in health facilities. We then used lawsuits on patient rights violations from the Supreme Court of India to analyse the relevance of the developed framework to the Indian context. With market perspectives pervading the health sector, there is an increasing trend of adopting a consumerist approach to protecting patient rights. In this line, avenues for grievance redressal for patient rights violations are gaining traction. Some of the methods and instruments for patient rights implementation include charters, ombudsmen, tribunals, health professional councils, separating rules for redressal and professional liability in patient rights violations, blame-free reporting systems, direct community monitoring and the court system. The grievance redressal mechanisms for patient rights violations in health facilities showcase multilevel governance arrangements with overlapping decision-making units at the national and subnational levels. The privileged position of medical professionals in multilevel governance arrangements for grievance redressal puts care-seeking individuals at a disadvantaged position during dispute resolution processes. Inclusion of external structures in health services and the healthcare profession and laypersons in the grievance redressal processes is heavily contested. Normatively speaking, a patient grievance redressal system should be accessible, impartial and independent in its function, possess the required competence, have adequate authority, seek continuous quality improvement, offer feedback to the health system and be comprehensive and integrated within the larger healthcare regulatory architecture.
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Affiliation(s)
- Meena Putturaj
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium.,Department of Health Ethics and Society, Maastricht University, 6200MD, Maastricht, The Netherlands.,Centre for Local Health Traditions and Policy, The University of Trans-disciplinary Health Sciences and Technology, 74/2, Post Attur via Yelahanka, Jarakabande Kaval, Bengaluru, Karnataka-560064, India.,Health Equity Cluster, Institute of Public Health, 3009, II A Main, 17th Cross, KR road, Sidanna Layout, Banashankari stage II, Banashankari, Bengaluru, Karnataka-560070, India
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | - Nora Engel
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
| | - Bart Criel
- Department of Health Ethics and Society, Maastricht University, 6200MD, Maastricht, The Netherlands
| | - Anja Krumeich
- Department of Health Ethics and Society, Maastricht University, 6200MD, Maastricht, The Netherlands
| | - Prakash B Nagendrappa
- Centre for Local Health Traditions and Policy, The University of Trans-disciplinary Health Sciences and Technology, 74/2, Post Attur via Yelahanka, Jarakabande Kaval, Bengaluru, Karnataka-560064, India
| | - Prashanth N Srinivas
- Health Equity Cluster, Institute of Public Health, 3009, II A Main, 17th Cross, KR road, Sidanna Layout, Banashankari stage II, Banashankari, Bengaluru, Karnataka-560070, India
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Angwenyi V, Bunders‐Aelen J, Criel B, Lazarus JV, Aantjes C. An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: A 12-month follow-up study. Health Soc Care Community 2021; 29:353-368. [PMID: 32671938 PMCID: PMC7983972 DOI: 10.1111/hsc.13094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/02/2020] [Accepted: 06/12/2020] [Indexed: 05/08/2023]
Abstract
This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life SciencesFaculty of SciencesVrije Universiteit AmsterdamAmsterdamthe Netherlands
- Unit of Equity and HealthDepartment of Public HealthInstitute of Tropical MedicineAntwerpBelgium
- Barcelona Institute for Global Health (ISGlobal)Hospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Joske Bunders‐Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life SciencesFaculty of SciencesVrije Universiteit AmsterdamAmsterdamthe Netherlands
| | - Bart Criel
- Unit of Equity and HealthDepartment of Public HealthInstitute of Tropical MedicineAntwerpBelgium
| | - Jeffrey V. Lazarus
- Barcelona Institute for Global Health (ISGlobal)Hospital ClínicUniversity of BarcelonaBarcelonaSpain
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD)University of KwaZulu‐NatalDurbanSouth Africa
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Abstract
BACKGROUND Chronic conditions are a leading cause of death and disability worldwide. Low-income and middle-income countries such as India bear a significant proportion of this global burden. Redesigning primary care from an acute-care model to a model that facilitates chronic care is a challenge and requires interventions at multiple levels. OBJECTIVES In this intervention study, we aimed to strengthen primary care for diabetes and hypertension at publicly funded primary healthcare centres (PHCs) in rural South India. DESIGN AND METHODS The complexities of transforming the delivery of primary care motivated us to use a 'theory of change' approach to design, implement and evaluate the interventions. We used both quantitative and qualitative data collection methods. Data from patient records regarding processes of care, glycaemic and blood pressure control, interviews with patients, observations and field notes were used to analyse what changes occurred and why. INTERVENTIONS We implemented the interventions for 9 months at three PHCs: (1) rationalise workflow to include essential tasks like counselling and measurement of blood pressure/blood glucose at each visit; (2) distribute clinical tasks among staff; (3) retain clinical records at the health facility and (4) capacity building of staff. RESULTS We found that interventions were implemented at all three PHCs for the first 4 months but did not continue at two of the PHCs. This fadeout was most likely the result of staff transfers and a doctor's reluctance to share tasks. The availability of an additional staff member in the role of a coordinator most likely influenced the relative success of implementation at one PHC. CONCLUSION These findings draw attention to the need for building teams in primary care for managing chronic conditions. The role of a coordinator emerged as an important consideration, as did the need for a stable core of staff to provide continuity of care.
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Affiliation(s)
- Dorothy Lall
- Health Services, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
| | - Nora Engel
- CAPHRI Care and Public Health Research Institute, Faculty of Health and Medicine and Life Sciences, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Prashanth N Srinivasan
- Health Equity Research, Institute of Public Health Bengaluru, Bangalore, Karnataka, India
| | | | - Klasien Horstman
- CAPHRI Care and Public Health Research Institute, Faculty of Health and Medicine and Life Sciences, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Sarkar NDP, Baingana F, Criel B. Integration of perinatal mental health care into district health services in Uganda: Why is it not happening? The Four Domain Integrated Health (4DIH) explanatory framework. Soc Sci Med 2020; 296:113464. [PMID: 35114558 DOI: 10.1016/j.socscimed.2020.113464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/05/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
The Sustainable Development Goals recognise mental health and well-being as a target area, however, mobilizing funding and prioritisation of the same remains a challenge. Perinatal mental health care has the potential for incorporation and integration across the overall maternal health agenda, and can be especially relevant for low- and middle-income countries in their overall health systems strengthening strategies. This study aimed at qualitatively situating the extent to which integration of perinatal mental health care into maternal health care was considered desirable, possible and opportune within the existing policy and service-delivery environment in Uganda. A total of 81 in-depth interviews and nine focus group discussions (N = 64) were conducted with a variety of national, district, health system and community-level stakeholders. Data were analysed thematically using theory- and data-driven codebooks in NVivo 11. Analysis of the desirability, possibility and opportunity for integrating perinatal mental health care within the Ugandan district health system, highlights that concerned stakeholders perceive this as a worthwhile endeavour that would benefit the communities as well as the health system as a whole. Based on these current realities and ideal scenarios, a tentative explanatory framework that brings together various perspectives - that is, the perceived nature of the health problem, local and national health system issues, alternative systems of care and support, and international global perspectives - was constructed. The framework needs further validation but already hints at the need for global, national and local forces to concurrently rally behind the inclusion and integration of perinatal mental health care, especially at the primary care level in low- and middle-income contexts. If the global health community is poised to achieve high quality, women-centered care and people-centered health systems across the lifespan, then the sustainable integration of mental health care into general health care, is a commitment that can no longer be delayed.
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Affiliation(s)
- Nandini D P Sarkar
- Equity and Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium; Athena Institute, Faculty of Earth and Life Sciences, Vrije Universiteit Amsterdam, the Netherlands; ISGlobal, Hospital Clínic - Universitat de Barcelona, Spain.
| | | | - Bart Criel
- Equity and Health Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Putturaj M, Van Belle S, Criel B, Engel N, Krumeich A, B Nagendrappa P, Prashanth NS. Towards a multilevel governance framework on the implementation of patient rights in health facilities: a protocol for a systematic scoping review. BMJ Open 2020; 10:e038927. [PMID: 33060087 PMCID: PMC7566736 DOI: 10.1136/bmjopen-2020-038927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/24/2020] [Accepted: 09/06/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Patient rights are "those rights that are attributed to a person seeking healthcare". Patient rights have implications for quality of healthcare and acts as a key accountability tool. It can galvanise structural improvements in the health system and reinforces ethical healthcare. States are duty bound to respect, protect and promote patient rights. The rhetoric on patient rights is burgeoning across the globe. With changing modes of governance arrangements, a number of state and non-state actors and institutions at various levels play a role in the design and implementation of (patient rights) policies. However, there is limited understanding on the multilevel institutional mechanisms for patient rights implementation in health facilities. We attempt to fill this gap by analysing the available scholarship on patient rights through a critical interpretive synthesis approach in a systematic scoping review. METHODS The review question is 'how do the multilevel actors, institutional structures, processes interact and influence the patient rights implementation in healthcare facilities? How do they work at what level and in which contexts?" Three databases PubMed, LexisNexis and Web of Science will be systematically searched until 30 th April 2020, for empirical and non-empirical literature in English from both lower middle-income countries and high-income countries. Targeted search will be performed in grey literature and through citation and reference tracking of key records. Using the critical interpretive synthesis approach, a multilevel governance framework on the implementation of patient rights in health facilities which is grounded in the data will be developed. ETHICS AND DISSEMINATION The review uses published literature hence ethics approval is not required. The findings of the review will be published in a peer-reviewed journal. REGISTRATION NUMBER PROSPERO 2020 CRD42020176939.
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Affiliation(s)
- Meena Putturaj
- Centre for Local Health Traditions and Policy, The University of Trans-disciplinary Health Sciences and Technology, Bengaluru, India
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Health, Ethics and Society, Maastricht University, Maastricht, Netherlands
- Health Equity Cluster, Institute of Public Health, Bengaluru, India
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Nora Engel
- Department of Health, Ethics and Society, Maastricht University, Maastricht, Netherlands
| | - Anja Krumeich
- Department of Health, Ethics and Society, Maastricht University, Maastricht, Netherlands
| | - Prakash B Nagendrappa
- Centre for Local Health Traditions and Policy, The University of Trans-disciplinary Health Sciences and Technology, Bengaluru, India
| | - N S Prashanth
- Health Equity Cluster, Institute of Public Health, Bengaluru, India
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Renmans D, Holvoet N, Criel B. No Mechanism Without Context: Strengthening the Analysis of Context in Realist Evaluations Using Causal Loop Diagramming. ACTA ACUST UNITED AC 2020. [DOI: 10.1002/ev.20424] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine Antwerp
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Mulinganya G, Bwenge Malembaka E, Lukula Akonkwa M, Mpunga Mukendi D, Kajibwami Birindwa E, Maheshe Balemba G, Temmerman M, Tambwe AM, Criel B, Bisimwa Balaluka G. Applying the Robson classification to routine facility data to understand the Caesarean section practice in conflict settings of South Kivu, eastern DR Congo. PLoS One 2020; 15:e0237450. [PMID: 32898139 PMCID: PMC7478810 DOI: 10.1371/journal.pone.0237450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Sub-Saharan Africa has low Caesarean (CS) levels, despite a global increase in CS use. In conflict settings, the pattern of CS use is unclear because of scanty data. We aimed to examine the opportunity of using routine facility data to describe the CS use in conflict settings. METHODS We conducted a facility-based cross-sectional study in 8 health zones (HZ) of South Kivu province in eastern DR Congo. We reviewed patient hospital records, maternity registers and operative protocol books, from January to December 2018. Data on direct conflict fatalities were obtained from the Uppsala Conflict Data Program. Based on conflict intensity and chronicity (expressed as a 6-year cumulative conflict death rate), HZ were classified as unstable (higher conflict death rate), intermediate and stable (lower conflict death rate). To describe the Caesarean section practice, we used the Robson classification system. Based on parity, history of previous CS, onset of labour, foetal lie and presentation, number of neonates and gestational age, the Robson classification categorises deliveries into 10 mutually exclusive groups. We performed a descriptive analysis of the relative contribution of each Robson group to the overall CS rate in the conflict stratum. RESULTS Among the 29,600 deliveries reported by health facilities, 5,520 (18.6%) were by CS; 5,325 (96.5%) records were reviewed, of which 2,883 (54.1%) could be classified. The overall estimated population CS rate was 6.9%. The proportion of health facility deliveries that occurred in secondary hospitals was much smaller in unstable health zones (22.4%) than in intermediate (40.25) or stable health zones (43.0%). Robson groups 5 (previous CS, single cephalic, ≥ 37 weeks), 1 (nulliparous, single cephalic, ≥ 37 weeks, spontaneous labour) and 3 (multiparous, no previous CS, single cephalic, ≥ 37 weeks, spontaneous labour) were the leading contributors to the overall CS rate; and represented 75% of all CS deliveries. In unstable zones, previous CS (27.1%) and abnormal position of the fetus (breech, transverse lie, 3.3%) were much less frequent than in unstable and intermediate (44.3% and 6.0% respectively) and stable (46.7%and 6.2% respectively). Premature delivery and multiple pregnancy were more prominent Robson groups in unstable zones. CONCLUSION In South Kivu province, conflict exposure is linked with an uneven estimated CS rate at HZ level with at high-risks women in conflict affected settings likely to have lower access to CS compared to low-risk mothers in stable health zones.
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Affiliation(s)
- Guy Mulinganya
- Department of Gynecology and Obstetrics, Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
| | - Espoir Bwenge Malembaka
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Institute of Health and Society, IRSS, Ecole de Santé Publique, Université Catholique de Louvain, Brussels, Belgium
- * E-mail: ,
| | - Melissa Lukula Akonkwa
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Dieudonné Mpunga Mukendi
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Etienne Kajibwami Birindwa
- Department of Gynecology and Obstetrics, Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Ghislain Maheshe Balemba
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Department of Radiology, Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Marleen Temmerman
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Centre of Excellence in Women and Child Health, School of Medicine, Aga Khan University, Nairobi, Kenya
| | - Albert Mwembo Tambwe
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, Democratic Republic of Congo
| | - Bart Criel
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Ghislain Bisimwa Balaluka
- Renforcement Institutionnel Pour des Politiques de Santé Basées sur l’Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo
- Ecole Régionale de Santé Publique, ERSP, Faculté de Médecine, Univesité Catholique de Bukavu, Bukavu, Democratic Republic of Congo
- Université du Cinquantenaire de Lwiro, Lwiro, Democratic Republic of Congo
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Mwembo-Tambwe A, Chenge F, Criel B. Institutional strengthening for evidence-based health policies in the DR Congo (RIPSEC): Impact. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.1274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Issue
In the DRC, the need to strengthen the health system for a more equitable charge of the health of the population in a perspective of universal health coverage proves to be relevant. Develop a culture that promotes decision-making based on scientific evidence, essential to improve the overall performance of the health system from this perspective
Description of the Problem
The RIPSEC program aims to (i) develop the capacity to manage health knowledge in the DRC through the creation of a Health Knowledge Center in the DRC, (CCSC- Asbl); to strengthen the scientific capacity of the Public Health Schools and the National Institute of Biomedical Research in health systems research and education and to strengthen the training capacity of the Public Health Schools by Development of Learning and Research Health Districts (LRHD). We assess the level of achievement of the results of this program.
Results
The majority of objectives have been reached.The CCSC-Asbl, created is an autonomous institution with legal personality. It produces scientific evidence and support for decision-making. The Ministry of Health has been strengthened and diversified. Institutional capacities and visibility have been strengthened through continuing education and the publication of scientific articles. But, no doctorals theses has been completed yet. Establishment of a consultation framework for health science training institutes: online training, short-term joint training on health system research. The third component concerns the development of LHRD; Transformation processes in the district went through a strengthening of the capacity of the district health teams and via a process of action-research.
Lessons
The RIPSEC program is increasingly becoming part of the Congolese health system as a strong partner.
Key messages
This experience can be used elsewhere in different contexts This program could be continued to perpetuate these fragile achievements. It corresponds to the felt needs and the priority of the health education system in the DRC or elsewhere.
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Affiliation(s)
- A Mwembo-Tambwe
- Santé Publique, RIPSEC/CCSC/ ESP UNILU, Lubumbashi, Democratic Republic of the Congo
| | - F Chenge
- Santé Publique, RIPSEC/CCSC/ ESP UNILU, Lubumbashi, Democratic Republic of the Congo
| | - B Criel
- Santé Publique, IMT Antwerp, Antwerp, Belgium
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Ag Ahmed MA, Ly BA, Millimouno TM, Alami H, Faye CL, Boukary S, Accoe K, Van Damme W, Put WVD, Criel B, Doumbia S. Willingness to comply with physical distancing measures against COVID-19 in four African countries. BMJ Glob Health 2020; 5:e003632. [PMID: 32972967 PMCID: PMC7517213 DOI: 10.1136/bmjgh-2020-003632] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Mohamed Ali Ag Ahmed
- University of Sherbrooke, Sherbrooke, Quebec, Canada
- Faculty of Medicine, Pharmacy and Odonto-Stomatology of bamako, USTTB Mali, Bamako, Mali
| | - Birama Apho Ly
- Faculty of Pharmacy, Université des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Tamba Mina Millimouno
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Maferinyah, Guinea
| | | | - Christophe L Faye
- Migration Health Department, International Organization for Migration, Dakar, Senegal
| | - Sana Boukary
- Management Sciences for Health, Ouagadougou, Burkina Faso
| | - Kirsten Accoe
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Willem Van De Put
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Bart Criel
- Unit of Equity and Health - Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Mwembo -Tambwekoy A, Chenge F, Criel B. Development of Learning and Research Health Districts (LRHD) in the DR Congo: results. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.1276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Issue
There is great need in DRCongo for adequate training sites where national public health managers and workers can discover what is means to manage complex district healthcare delivery systems in a perspective of PHC and UHC. The development of such LRHD is coherent with the national policy in DRC advocating for demonstration districts.
Description of the Problem
The RIPSEC has launched three sites called LRHD, two of which are rural and one urban. A specialist in the organization and management of health services, from each of the three schools of public health, supervised the development and monitoring of those LRHDs. The Provincial Supervisor was also involved. Three approaches to solving priority problems have been defined: strengthening leadership at the HD level; transform health services into a learning and research framework. We analyze the transformation process obtained in these HD.
Results
Transformation processes in the district went through a strengthening of the capacity of the district health teams and via a process of action-research. The results of those LRHD after 4 years were mixed: the leadership of the management teams has improved. A reflexive attitude developed which contributes to more appropriate decision-making,monitoring and evaluation.At least one hospital service and 2 health centers have been transformed according to specific problems,improving the interaction between health structures, in order to quality of care has improved, the results of action research have made it possible to resolve local health problems. RIPSEC support to Provincial Supervisor to develop their working tools to better address their functions and responsibilities. However, the documentation of these changes induced by RIPSEC was not yet systematized. No residential internship could be carried out due to operational constraints.
Lessons
Mentoring, through its intellectual inputs, has contributed to a dynamic of change in the HD.
Key messages
The basis of the strategy is the improvement of the leadership of the HD management team,reinforced by mentoring and systematic documentation of complex decisions. This program could be continued to perpetuate these fragile achievements. This experience can be used elsewhere in different contexts. But,the residential internship requires other resources.
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Affiliation(s)
- A Mwembo -Tambwekoy
- Santé Publique, RIPSEC ESP UNILU, Lubumbashi, Congo, Democratic Republic of the
| | - F Chenge
- Santé Publique, RIPSEC ESP UNILU, Lubumbashi, Congo, Democratic Republic of the
| | - B Criel
- Santé Publique, IMT Antwerp, Antwerp, Belgium
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Angwenyi V, Aantjes C, Bunders-Aelen J, Criel B, Lazarus JV. Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district. BMC Fam Pract 2020; 21:101. [PMID: 32513112 PMCID: PMC7282183 DOI: 10.1186/s12875-020-01174-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 05/27/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. METHODS A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. RESULTS Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. CONCLUSION In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.
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Affiliation(s)
- Vibian Angwenyi
- Faculty of Sciences, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081, HV Amsterdam, the Netherlands.
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Nationalestraat, 155, B-2000, Antwerp, Belgium.
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036, Barcelona, Spain.
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban, 4000, South Africa
| | - Joske Bunders-Aelen
- Faculty of Sciences, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081, HV Amsterdam, the Netherlands
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Nationalestraat, 155, B-2000, Antwerp, Belgium
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036, Barcelona, Spain
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Criel B, Waelkens MP, Kwilu Nappa F, Coppieters Y, Laokri S. Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo. PLoS One 2020; 15:e0231660. [PMID: 32298341 PMCID: PMC7162613 DOI: 10.1371/journal.pone.0231660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/29/2020] [Indexed: 02/01/2023] Open
Abstract
Background In their mission to achieve better access to quality healthcare services, mutual health organisations (MHOs) are not limited to providing health insurance. As democratically controlled member organisations, MHOs aim to make people’s voices heard. At national level, they seek involvement in the design of social protection policies; at local level, they seek to improve responsiveness of healthcare services to members’ needs and expectations. Methods In this qualitative study, we investigated whether MHOs in the Democratic Republic of Congo (DRC) succeed in defending members’ rights by improving healthcare quality while minimising expenses. The data originate from an earlier in-depth investigation conducted in the DRC in 2016 of the performance of 13 MHOs. We re-analysed this existing dataset and more specifically investigated actions that the MHOs undertook to improve quality and affordability of healthcare provision for their members, using a framework for analysis based on Hirschman’s exit-voice theory. This framework distinguishes four mechanisms for MHO members to use in influencing providers: (1) ‘exit’ or ‘voting with the feet’; (2) ‘co-producing a long voice route’ or imposing rules through strategic purchasing; (3) ‘guarding over the long voice route of accountability’ or pressuring authorities to regulate and enforce regulations; and (4) ‘strengthening the short voice route’ by transforming the power imbalance at the provider–patient interface. Results All studied MHOs used these four mechanisms to improve healthcare provision. Most healthcare providers, however, did not recognise their authority to do so. In the DRC, controlling quality and affordability of healthcare is firmly seen as a role for the health authorities, but the authorities only marginally take up this role. Under current circumstances, the power of MHOs in the DRC to enhance quality and affordability of healthcare is weak. Conclusion On their own, mutual health organisations in the DRC do not have sufficient power to influence the practices of healthcare providers. Greater responsiveness of the health services to MHO members requires cooperation of all actors involved in healthcare delivery to create an enabling environment where voices defending people’s rights are heard.
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Affiliation(s)
- Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Maria-Pia Waelkens
- School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fulbert Kwilu Nappa
- Department of Health System Management, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Yves Coppieters
- School of Public Health, Health Policy and Systems–International Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Samia Laokri
- School of Public Health and Tropical Medicine, Global Community Health and Behavioral Sciences, Tulane University, New Orleans, LA, United States of America
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Accoe K, Marchal B, Gnokane Y, Abdellahi D, Bossyns P, Criel B. Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa. Health Res Policy Syst 2020; 18:25. [PMID: 32075648 PMCID: PMC7031916 DOI: 10.1186/s12961-020-0531-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 02/04/2020] [Indexed: 05/05/2023] Open
Abstract
Background Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country’s efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems. Methods We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process. Results An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change. Conclusion Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level.
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Affiliation(s)
- Kirsten Accoe
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium
| | - Yahya Gnokane
- AI-PASS Programme (Institutional Support for Health Sector Strengthening), Enabel - Belgian Development Agency, Nouakchott, Mauritania
| | - Dieng Abdellahi
- AI-PASS Programme (Institutional Support for Health Sector Strengthening), Enabel - Belgian Development Agency, Nouakchott, Mauritania
| | - Paul Bossyns
- Department of Health, Enabel - Belgian Development Agency, Rue Haute 147, 1000, Brussels, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium
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Sow A, De Man J, De Spiegelaere M, Vanlerberghe V, Criel B. Integration of mental health care in private not-for-profit health centres in Guinea, West Africa: a systemic entry point towards the delivery of more patient-centred care? BMC Health Serv Res 2020; 20:61. [PMID: 31992271 PMCID: PMC6986146 DOI: 10.1186/s12913-020-4914-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/16/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient-centred care is an essential component of quality of health care. We hypothesize that integration of a mental health care package into versatile first-line health care services can strengthen patient participation, an important dimension of patient-centred care. The objective of this study is to analyse whether consultations conducted by providers in facilities that integrated mental health care score higher in terms of patient participation. METHODS This study was conducted in Guinea in 12 not-for-profit health centres, 4 of which had integrated a mental health care package (MH+) and 8 had not (MH-). The study involved 450 general curative consultations (175 in MH+ and 275 in MH- centres), conducted by 18 care providers (7 in MH+ and 11 in MH- centres). Patients were interviewed after the consultation on how they perceived their involvement in the consultation, using the Patient Participation Scale (PPS). The providers completed a self-administered questionnaire on their perception of patient's involvement in the consultation. We compared scores of the PPS between MH+ and MH- facilities and between patients and providers. RESULTS The mean PPS score was 24.21 and 22.54 in MH+ and MH- health centres, respectively. Participation scores depended on both care providers and the health centres they work in. The patients consulting an MH+ centre were scoring higher on patient participation score than the ones of an MH- centre (adjusted odds ratio of 4.06 with a 95% CI of 1.17-14.10, p = 0.03). All care providers agreed they understood the patients' concerns, and patients shared this view. All patients agreed they wanted to be involved in the decision-making concerning their treatment; providers, however, were reluctant to do so. CONCLUSION Integrating a mental health care package into versatile first-line health services can promote more patient-centred care.
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Affiliation(s)
| | | | | | | | - Bart Criel
- Institute of Tropical Medicine, Antwerp, Belgium.
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Sow A, Criel B, Branger B, Roland M, Spiegelaere MD. Expérience d´intégration de la santé mentale en première ligne de soins en Guinée. Pan Afr Med J 2020; 37:107. [PMID: 33425140 PMCID: PMC7757329 DOI: 10.11604/pamj.2020.37.107.20351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 08/21/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Abdoulaye Sow
- Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
- Université Gamal Abdel Nasser de Conakry, Conakry, Guinée
- Corresponding author: Abdoulaye Sow, Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique.
| | - Bart Criel
- Institut de Médecine Tropicale d´Anvers, Kronenburgstraat 43, 2000 Antwerpen, Belgique
| | - Bernard Branger
- Organisation ESSENTIEL, 11 bis rue Gabriel Luneau 44000 Nantes, France
| | - Michel Roland
- Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
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Waweru E, Sarkar NDP, Ssengooba F, Gruénais ME, Broerse J, Criel B. Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry. PLoS One 2019; 14:e0221649. [PMID: 31461495 PMCID: PMC6713356 DOI: 10.1371/journal.pone.0221649] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 08/12/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders' views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda. METHODS This qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data. FINDINGS AND CONCLUSION While Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing-important components of PCC-translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts.
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Affiliation(s)
- Everlyn Waweru
- Department of Public Health–Health Systems and Equity unit, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Public Health–Quality of Care, Athena Institute, Faculty of Science, Vrije University, Amsterdam, Netherlands
- Faculty of Social Anthropology and Ethnology, University of Bordeaux, Bordeaux, France
| | - Nandini D. P. Sarkar
- Department of Public Health–Health Systems and Equity unit, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Public Health–Quality of Care, Athena Institute, Faculty of Science, Vrije University, Amsterdam, Netherlands
- ISGlobal, Hospital Clinic—University of Barcelona, Barcelona, Spain
| | - Freddie Ssengooba
- Department of Health Policy Planning & Management, Makerere University College of Health Sciences, Kampala, Uganda
| | - Marc- Eric Gruénais
- Faculty of Social Anthropology and Ethnology, University of Bordeaux, Bordeaux, France
| | - Jacqueline Broerse
- Department of Public Health–Quality of Care, Athena Institute, Faculty of Science, Vrije University, Amsterdam, Netherlands
| | - Bart Criel
- Department of Public Health–Health Systems and Equity unit, Institute of Tropical Medicine, Antwerp, Belgium
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Angwenyi V, Aantjes C, Bunders-Aelen J, Lazarus JV, Criel B. Patient-provider perspectives on self-management support and patient empowerment in chronic care: A mixed-methods study in a rural sub-Saharan setting. J Adv Nurs 2019; 75:2980-2994. [PMID: 31225662 PMCID: PMC6900026 DOI: 10.1111/jan.14116] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 04/10/2019] [Accepted: 04/30/2019] [Indexed: 12/22/2022]
Abstract
AIM To explore how provision of self-management support to chronically-ill patients in resource-limited settings contributes to patient empowerment in chronic care. DESIGN Concurrent descriptive mixed methods research. METHODS A survey of 140 patients with chronic conditions administered at four time-points in 12 months. We conducted 14 interviews and four focus-group discussions with patients (N = 31); 13 healthcare provider interviews; and observations of four patient-support group meetings. Data were collected between April 2016 - May 2017 in rural Malawi. Qualitative data were analysed using a thematic approach and descriptive statistical analysis performed on survey data. RESULTS Healthcare professionals facilitated patient empowerment through health education, although literacy levels and environmental factors affected self-management guidance. Information exchanged during patient-provider interactions varied and discussions centred around medical aspects and health promoting behaviour. Less than 40% of survey patients prepared questions prior to clinic consultations. Health education was often unstructured and delegated to non-physician providers, mostly untrained in chronic care. Patients accessed psychosocial support from volunteer-led community home-based care programmes. HIV support-groups regularly interacted with peers and practical skills exchanged in a supportive environment, reinforcing patient's self-mangement competence and proactiveness in health care. CONCLUSION For optimal self-management, reforms at inter-personal and organizational level are needed including; mutual patient-provider collaboration, diversifying access to self-management support resources and restructuring patient support-groups to cater to diverse chronic conditions. IMPACT Our study provides insights and framing of self-management support and empowerment for patients in long-term care in sub-Saharan Africa. Lessons drawn could feed into designing and delivering responsive chronic care interventions.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.,Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine. Nationalestraat, Antwerp, Belgium.,Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Joske Bunders-Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine. Nationalestraat, Antwerp, Belgium
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Mpunga Mukendi D, Chenge F, Mapatano MA, Criel B, Wembodinga G. Distribution and quality of emergency obstetric care service delivery in the Democratic Republic of the Congo: it is time to improve regulatory mechanisms. Reprod Health 2019; 16:102. [PMID: 31307497 PMCID: PMC6631736 DOI: 10.1186/s12978-019-0772-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 07/08/2019] [Indexed: 11/09/2022] Open
Abstract
Background The Demographic and Health Survey 2013–14 indicated that the Democratic Republic of the Congo (DRC) is still challenged by high maternal and neonatal mortality. The aim of this study was to assess the availability, quality and equity of emergency obstetric care (EmOC) in the DRC. Methods A cross-sectional survey of 1,568 health facilities selected by multistage random sampling in 11 provinces of the DRC was conducted in 2014. Data were collected through interviews, document reviews, and direct observation of service delivery. Collected data included availability, quality, and equity of EmOC depending on the location (urban vs. rural), administrative identity, type of facility, and province. Associations between variables were tested by Pearson’s chi-squared test using an alpha significance level of 0.05. Results A total of 1,555 health facilities (99.2%) were surveyed. Of these, 9.1% provided basic EmOC and 2.9% provided comprehensive EmOC. The care was unequally distributed across the provinces and urban vs. rural areas; it was more available in urban areas, with the provinces of Kinshasa and Nord-Kivu being favored compared to other provinces. Caesarean section and blood transfusions were provided by health centers (6.5 and 9.0%, respectively) and health posts (2.3 and 2.3%, respectively), despite current guidelines disallowing the practice. None of the facilities provided quality EmOC, mainly due to the lack of proper standards and guidelines. Conclusions The distribution and quality of EmOC are problematic. The lack of regulation and monitoring appears to be a key contributing factor. We recommend the Ministry of Health go beyond merely granting funds, and also ensure the establishment and monitoring of appropriate standard operating procedures for providers.
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Affiliation(s)
- Dieudonné Mpunga Mukendi
- Kinshasa School of Public Health, University of Kinshasa, P.O. Box: 11850, Kinshasa I, Kinshasa, Democratic Republic of the Congo.
| | - Faustin Chenge
- Lubumbashi School of Public Health, University of Lubumbashi, Lubumbashi, Democratic Republic of the Congo.,Centre de connaissances santé en RDC (CCSC), Kinshasa, Democratic Republic of the Congo
| | - Mala A Mapatano
- Kinshasa School of Public Health, University of Kinshasa, P.O. Box: 11850, Kinshasa I, Kinshasa, Democratic Republic of the Congo
| | - Bart Criel
- Institute of Tropical Medicine, Antwerpern, Belgium
| | - Gilbert Wembodinga
- Kinshasa School of Public Health, University of Kinshasa, P.O. Box: 11850, Kinshasa I, Kinshasa, Democratic Republic of the Congo
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Lall D, Engel N, Devadasan N, Horstman K, Criel B. Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India. BMC Health Serv Res 2019; 19:44. [PMID: 30658641 PMCID: PMC6339380 DOI: 10.1186/s12913-019-3876-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/04/2019] [Indexed: 12/30/2022] Open
Abstract
Background Chronic diseases have emerged as the leading cause of death globally, and 20% of Indians are estimated to suffer from a chronic condition. Care for chronic diseases poses a major public health challenge, especially when health care delivery has been geared traditionally towards acute care. In this study, we aimed to better understand how primary care for diabetes and hypertension is currently organised in first-line health facilities in rural India, and propose evidence-based ways forward for strengthening local health systems to address chronic problems. Methods We used qualitative and quantitative methods to gain insight into how care is organised and how patients and providers manage within this delivery system. We conducted in-depth interviews with the medical doctors working in three private clinics and in three public primary health centres. We also interviewed 24 patients with chronic diseases receiving care in the two sub-sectors. Non-participant observations and facility assessments were performed to triangulate the findings from the interviews. Results The current delivery system has many problems impeding the delivery of quality care for chronic conditions. In both the public and private facilities studied, the care processes are very doctor-centred, with little room for other health centre staff. Doctors face very high workloads, especially in the public sector, jeopardising proper communication with patients and adequate counselling. In addition, the health information system is fragmented and provides little or no support for patient follow-up and self-management. The patient is largely left on their own in trying to make sense of their condition and in finding their way in a complex and scattered health care landscape. Conclusions The design and organisation of care for persons with chronic diseases in India needs to be rethought. More space and responsibility should be given to the primary care level, and relatively less to the more specialised hospital level. Furthermore, doctors should consider delegating some of their tasks to other staff in the first-line health facility to significantly reduce their workload and increase time available for communication. The health information system needs to be adapted to better ensure continuity of care and support self-management by patients. Electronic supplementary material The online version of this article (10.1186/s12913-019-3876-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dorothy Lall
- Institute of Public Health, 2nd Cross, Girinagar, 1st Phase, Bengaluru, 560085, India.
| | - Nora Engel
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, P.O. Box 616 6200, MD, Maastricht, The Netherlands
| | - Narayanan Devadasan
- Institute of Public Health, 2nd Cross, Girinagar, 1st Phase, Bengaluru, 560085, India
| | - Klasien Horstman
- Department of Health, Ethics & Society, CAPHRI Care and Public Health Research Institute, P.O. Box 616 6200, MD, Maastricht, The Netherlands
| | - Bart Criel
- Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerpen, Belgium
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Sow A, Van Dormael M, Criel B, de Spiegelaere M. Intégration de la santé mentale dans les centres de santé communautaires en Guinée Conakry. Santé Publique 2019; 31:305-313. [DOI: 10.3917/spub.192.0305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Lall D, Engel N, Devadasan N, Horstman K, Criel B. Models of care for chronic conditions in low/middle-income countries: a 'best fit' framework synthesis. BMJ Glob Health 2018; 3:e001077. [PMID: 30687524 PMCID: PMC6326308 DOI: 10.1136/bmjgh-2018-001077] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 11/23/2022] Open
Abstract
Management of chronic conditions is a challenge for healthcare delivery systems world over and especially for low/middle-income countries (LMIC). Redesigning primary care to deliver quality care for chronic conditions is a need of the hour. However, much of the literature is from the experience of high-income countries. We conducted a synthesis of qualitative findings regarding care for chronic conditions at primary care facilities in LMICs. The themes identified were used to adapt the existing chronic care model (CCM) for application in an LMIC using the ‘best fit’ framework synthesis methodology. Primary qualitative research studies were systematically searched and coded using themes of the CCM. The results that could not be coded were thematically analysed to generate themes to enrich the model. Search strategy keywords were: primary health care, diabetes mellitus type 2, hypertension, chronic disease, developing countries, low, middle-income countries and LMIC country names as classified by the World Bank. The search yielded 404 articles, 338 were excluded after reviewing abstracts. Further, 42 articles were excluded based on criteria. Twenty-four studies were included for analysis. All themes of the CCM, identified a priori, were represented in primary studies. Four additional themes for the model were identified: a focus on the quality of communication between health professionals and patients, availability of essential medicines, diagnostics and trained personnel at decentralised levels of healthcare, and mechanisms for coordination between healthcare providers. We recommend including these in the CCM to make it relevant for application in an LMIC.
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Affiliation(s)
- Dorothy Lall
- Health Service Research, Institute of Public Health, Bengaluru, India
| | - Nora Engel
- Department of Health Ethics and Society, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | | | - Klasien Horstman
- Department of Health Ethics and Society, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Bart Criel
- Department of Health Financing, Institute of Tropica Medicine, Antwerp, Belgium
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Abstract
OBJECTIVES In recent years, Bangladesh has made remarkable advances in health outcomes; however, the benefits of these gains are unequally shared among citizens and population groups. Dalits (jaat sweepers), a marginalised traditional working community, have relatively poor access to healthcare services. This study sought to explore the sociopolitical and cultural factors associated with health inequalities among Dalits in an urban setting. DESIGN An exploratory qualitative study design was adopted. Fourteen in-depth interviews, five focus group discussions and seven key informant interviews were conducted. The acquired data were analysed using an iterative approach which incorporated deductive and inductive methods in identifying codes and themes. SETTINGS This study was conducted in two sweeper communities in Dhaka city. PARTICIPANTS Participants were Dalit men and women (in-depth interviews, mean age±SD 30±10; and focus group discussions), and the community leaders and non-governmental organisation workers (key informant interviews). RESULTS The health status of members of these Dalit groups is determined by an array of social, economic and political factors. Dalits (untouchables) are typically considered to fall outside the caste-based social structure and existing vulnerabilities are embedded and reinforced by this identity. Dalits' experience of precarious access to healthcare or poor healthcare is an important manifestation of these inequalities and has implications for the economic and social life of Dalit populations living together in geographically constrained spaces. CONCLUSIONS The provision of clinical healthcare services alone is insufficient to mitigate the negative effects of discriminations and to improve the health status of Dalits. A better understanding of the precise influences of sociocultural determinants of health inequalities is needed, together with the identification of the strategies and programmes needed to address these determinants with the aim of developing more inclusive health service delivery systems.
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Affiliation(s)
- Ashraful Kabir
- Dushtha Shasthya Kendra, Dhaka, Bangladesh
- Department of Anthropology, Dhaka University, Dhaka, Bangladesh
| | | | - Ahsan Ali
- Department of Anthropology, Dhaka University, Dhaka, Bangladesh
| | - Nadia Farhana
- Department of Business Administration, Southeast University, Dhaka, Bangladesh
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Angwenyi V, Aantjes C, Kondowe K, Mutchiyeni JZ, Kajumi M, Criel B, Lazarus JV, Quinlan T, Bunders-Aelen J. Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi. BMJ Glob Health 2018; 3:e000996. [PMID: 30498595 PMCID: PMC6254745 DOI: 10.1136/bmjgh-2018-000996] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/17/2018] [Accepted: 09/22/2018] [Indexed: 11/30/2022] Open
Abstract
Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi's community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi's strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy's implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of pre-existing roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs' expected duties and interactions with paid CHT personnel is recommended.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Carolien Aantjes
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Ketwin Kondowe
- Phalombe District Health Office, Ministry of Health, Phalombe, Malawi
| | | | - Murphy Kajumi
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Tim Quinlan
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Durban, South Africa
| | - Joske Bunders-Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Michaux G, Mwembo-Tambwe A, Belrhiti Z, Monet F, Criel B. Développement des Zones de Santé d'Apprentissage et de Recherche en République Démocratique du Congo : enseignements utiles d'une évaluation qualitative des expériences antérieures en Afrique Subsaharienne. Glob Health Promot 2018; 27:139-148. [PMID: 30319019 DOI: 10.1177/1757975918784537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Trois Zones d'Apprentissage et de Recherche (ZAR) sont développées par le programme RIPSEC en République Démocratique duCongo (RDC). Cette stratégie consiste à utiliser un district sanitaire comme substrat pour former des managers des districts de santé et mener des recherches sur les systèmes de santé. L'objet de cet article est d'explorer les principes, les effets et les conditions de succès de cette stratégie à travers une évaluation qualitative des expériences ZAR antérieures en Afrique Subsaharienne. Elle concerne quatre expériences, deux menées au Niger, une en RDC et une au Congo-Brazzaville. Les données proviennent des témoignages de responsables du développement des expériences, présentés dans un séminaire en 2014 et approfondis par des entretiens en 2015, et des publications traitant des expériences. Les faits communs aux quatre expériences sont la diffusion nationale et souvent internationale des bonnes pratiques et des modèles organisationnels, leur développement inscrit dans le long-terme et l'implication des managers des ZAR dans tous les volets de leur transformation. Le centrage de la recherche sur les problèmes de la ZAR et la promotion de la réflexivité dans les décisions managériales sont importants pour cette transformation. L'utilisation des résultats par le programme RIPSEC, les logiques imbriquées dans le concept ZAR et l'apport potentiel de l'implication d'écoles de santé publiques nationales dans leur développement sont ensuite discutés. La validité de l'étude est limitée mais renforcer le leadership des managers des districts sanitaires est un défi fréquent pour les systèmes de santé aux ressources limitées. Cet article peut aider à développer une stratégie pour le renforcer.
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Affiliation(s)
- Geneviève Michaux
- Instituut voor Tropische Geneeskunde, Public Health, Antwerpen, Belgique
| | - Albert Mwembo-Tambwe
- Université de Lubumbashi, Département de Gynécologie et Obstétrique, Lubumbashi, République Démocratique du Congo
| | | | - Francis Monet
- Instituut voor Tropische Geneeskunde, Public Health, Antwerpen, Belgique
| | - Bart Criel
- Institut de Médecine Tropicale Prince Leopold, Santé Publique, Anvers, Flandre, Belgique
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Sow A, Van Dormael M, Criel B, Conde S, Dewez M, de Spiegelaere M. [Stigmatisation of mental illness by medical students in Conakry, Guinea]. Sante Publique 2018; 30:253-261. [PMID: 30148313 DOI: 10.3917/spub.182.0253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Stigmatisation of mental illness constitutes a major problem in the development of mental healthcare programs, especially when it originates from health professionals themselves. The aim of this research is to investigate possible attitudes of stigmatisation among first and final year medical students registered at the University of Conakry faculty of medicine in Guinea-Conakry (West Africa). METHODS Focus group discussions identified students' attitudes and perceptions in relation to mental illness, their explanatory models, their opinions concerning traditional and modern therapeutic practices with regard to mental illness, and their interest to possibly incorporate psychiatry in their future medical practice. RESULTS Many students explicitly regret the stigmatisation of mental health patients, but nevertheless share the general population's prevailing attitudes of discrimination. The dominant stereotype of mental illness is that of madness, although final year medical students describe a more diverse spectrum of mental health problems. There is strong adherence to secular occult explanations of mental illness and advocacy for traditional medicine in addressing these illnesses, including among final year medical students. DISCUSSION No student would opt for psychiatry as a specialisation, although some expressed interest in integrating psychiatry into their future medical practice. However, this research indicates that stigmatising attitudes are not cut in stone. Under the impetus of specific teaching programmes, attitudes can evolve to create room for tolerance and compassion.
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Angwenyi V, Aantjes C, Kajumi M, De Man J, Criel B, Bunders-Aelen J. Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi. PLoS One 2018; 13:e0199977. [PMID: 29965990 PMCID: PMC6028088 DOI: 10.1371/journal.pone.0199977] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 06/17/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other sub-Saharan African countries, calls for a shift in how health care services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and are advocated as universal strategies. In sub-Saharan Africa, there is need for more evidence around the practice of patient self-management, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource-constrained setting in Malawi. METHODS This is primarily a qualitative study, involving patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients (from the third of four-part data collection series), 14 in-depth interviews, and four focus-group discussions with patients (n = 31 respondents). A framework approach was used for qualitative analysis, and descriptive statistical analysis was performed on survey data. RESULTS Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included: 1) ability to acquire appropriate disease knowledge; 2) poverty level; 3) the presence of support from family caregivers and community-based support initiatives; 4) the nature of one's social relations; and 5) the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to care, as they experienced frequent drug stock-outs and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges. CONCLUSION Our findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. We recommend expanding current peer-patient and support group initiatives to patients with NCDs, and further investments in the decentralisation of integrated health services to primary care level in Malawi.
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Affiliation(s)
- Vibian Angwenyi
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit, Amsterdam, The Netherlands
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
- * E-mail:
| | - Carolien Aantjes
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit, Amsterdam, The Netherlands
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Murphy Kajumi
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Jeroen De Man
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Bart Criel
- Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Joske Bunders-Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit, Amsterdam, The Netherlands
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Sarkar NDP, Bardaji A, Peeters Grietens K, Bunders-Aelen J, Baingana F, Criel B. The Social Nature of Perceived Illness Representations of Perinatal Depression in Rural Uganda. Int J Environ Res Public Health 2018; 15:ijerph15061197. [PMID: 29880729 PMCID: PMC6025508 DOI: 10.3390/ijerph15061197] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 05/14/2018] [Accepted: 05/31/2018] [Indexed: 11/23/2022]
Abstract
While the global health community advocates for greater integration of mental health into maternal health agendas, a more robust understanding of perinatal mental health, and its role in providing integrated maternal health care and service delivery, is required. The present study uses the Illness Representation Model, a theoretical cognitive framework for understanding illness conceptualisations, to qualitatively explore multiple stakeholder perspectives on perinatal depression in rural Uganda. A total of 70 in-depth interviews and 9 focus group discussions were conducted with various local health system stakeholders, followed by an emergent thematic analysis using NVivo 11. Local communities perceived perinatal depression as being both the fault of women, and not. It was perceived as having socio-economic and cultural causal factors, in particular, as being partner-related. In these communities, perinatal depression was thought to be a common occurrence, and its negative consequences for women, infants and the community at large were recognised. Coping and help-seeking behaviours prescribed by the participants were also primarily socio-cultural in nature. Placing the dynamics and mechanisms of these local conceptualisations of perinatal depression alongside existing gaps in social and health care systems highlights both the need of, and the opportunities for, growth and prioritisation of integrated perinatal biomedical, mental, and social health programs in resource-constrained settings.
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Affiliation(s)
- Nandini D P Sarkar
- Health Systems and Equity Unit, Department of Public Health, Institute of Tropical Medicine at Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium.
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands.
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Rosselló 132, 08036 Barcelona, Spain.
| | - Azucena Bardaji
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Rosselló 132, 08036 Barcelona, Spain.
| | - Koen Peeters Grietens
- Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine at Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium.
| | - Joske Bunders-Aelen
- Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands.
| | - Florence Baingana
- School of Public Health, Makerere University, Kampala PO Box 7072, Uganda.
| | - Bart Criel
- Health Systems and Equity Unit, Department of Public Health, Institute of Tropical Medicine at Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium.
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