Transport remains a neglected yet critical component of health systems. While research on health system strengthening has expanded to include social care and social determinants of health, mobility is often treated as peripheral rather than central to equitable access and service delivery. This commentary reframes mobility as a structural determinant of health. Drawing on global evidence, with examples from Africa, South Asia, Latin America, and high-income contexts such as in Europe, we demonstrate how inadequate or unaffordable transport constrains both patients and frontline care workers, reinforcing inequities across diverse settings. We also highlight how community-driven innovations, such as bicycles, ambulances, and digital accessibility apps, provide resilience in the absence of formal provision. By reframing transport as a determinant of health and a structural enabler of inclusion, this commentary calls for interdisciplinary policy, practice, and research that integrates mobility into health system design and delivery.
{"title":"The mobility imperative: Integrating transport into inclusive and resilient health systems","authors":"Emmanuel Mogaji , Rasheed Olawale Azeez , Sudhanshu Bhatt , Temitope Farinloye , Fidelma Ibili , Simeon Stevenson Turay","doi":"10.1016/j.ssmhs.2026.100181","DOIUrl":"10.1016/j.ssmhs.2026.100181","url":null,"abstract":"<div><div>Transport remains a neglected yet critical component of health systems. While research on health system strengthening has expanded to include social care and social determinants of health, mobility is often treated as peripheral rather than central to equitable access and service delivery. This commentary reframes mobility as a structural determinant of health. Drawing on global evidence, with examples from Africa, South Asia, Latin America, and high-income contexts such as in Europe, we demonstrate how inadequate or unaffordable transport constrains both patients and frontline care workers, reinforcing inequities across diverse settings. We also highlight how community-driven innovations, such as bicycles, ambulances, and digital accessibility apps, provide resilience in the absence of formal provision. By reframing transport as a determinant of health and a structural enabler of inclusion, this commentary calls for interdisciplinary policy, practice, and research that integrates mobility into health system design and delivery.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100181"},"PeriodicalIF":0.0,"publicationDate":"2026-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146077904","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-22DOI: 10.1016/j.ssmhs.2026.100180
Abdur Razzaque Sarker , Anik Hasan, Sangida Akter
Background
Institutional childbirth rates have been rising rapidly worldwide, including in Bangladesh. This study aims to examine out-of-pocket expenditure (OOPE), financial distress, and associated factors related to institutional childbirth in Bangladesh using nationally representative household data.
Methods
This study analysed secondary data from the Bangladesh Demographic and Health Survey 2022. A generalised linear model (GLM) with a log link and gamma (γ) distribution was used to assess the associations between explanatory variables (e.g., mother's age, education, place of delivery) and the OOPE of childbirth.
Results
The average self-reported OOPE per institutional childbirth was USD 201.64 (median USD 180.24). C-section deliveries incurred the highest average OOPE (USD 253.01; median USD 212.05), while normal deliveries averaged USD 83.71 (median USD 53.01). Access to electronic media, wealth status, and place of delivery were significant predictors of OOPE for normal deliveries, while maternal age, education, and delivery location influenced C-section costs. These results indicate that financial distress was more common among C-section deliveries (20 %) than among normal deliveries (12 %). The concentration index (-0.234) showed financial distress was more concentrated among poorer households.
Conclusions
To reduce the financial burden of institutional deliveries, it is essential to strengthen social protection mechanisms, expand health insurance coverage, and ensure equitable access to quality maternal healthcare—key steps toward achieving universal maternal health coverage and reducing preventable maternal and neonatal complications.
{"title":"Household out-of-pocket expenditure for normal and caesarean childbirth in Bangladesh","authors":"Abdur Razzaque Sarker , Anik Hasan, Sangida Akter","doi":"10.1016/j.ssmhs.2026.100180","DOIUrl":"10.1016/j.ssmhs.2026.100180","url":null,"abstract":"<div><h3>Background</h3><div>Institutional childbirth rates have been rising rapidly worldwide, including in Bangladesh. This study aims to examine out-of-pocket expenditure (OOPE), financial distress, and associated factors related to institutional childbirth in Bangladesh using nationally representative household data.</div></div><div><h3>Methods</h3><div>This study analysed secondary data from the Bangladesh Demographic and Health Survey 2022. A generalised linear model (GLM) with a log link and gamma (γ) distribution was used to assess the associations between explanatory variables (e.g., mother's age, education, place of delivery) and the OOPE of childbirth.</div></div><div><h3>Results</h3><div>The average self-reported OOPE per institutional childbirth was USD 201.64 (median USD 180.24). C-section deliveries incurred the highest average OOPE (USD 253.01; median USD 212.05), while normal deliveries averaged USD 83.71 (median USD 53.01). Access to electronic media, wealth status, and place of delivery were significant predictors of OOPE for normal deliveries, while maternal age, education, and delivery location influenced C-section costs. These results indicate that financial distress was more common among C-section deliveries (20 %) than among normal deliveries (12 %). The concentration index (-0.234) showed financial distress was more concentrated among poorer households.</div></div><div><h3>Conclusions</h3><div>To reduce the financial burden of institutional deliveries, it is essential to strengthen social protection mechanisms, expand health insurance coverage, and ensure equitable access to quality maternal healthcare—key steps toward achieving universal maternal health coverage and reducing preventable maternal and neonatal complications.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100180"},"PeriodicalIF":0.0,"publicationDate":"2026-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146037835","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-20DOI: 10.1016/j.ssmhs.2026.100175
Dillon Newton , Mariam Zarjoo , Philip Brown , Tom Simcock , Joanne Garside , John Stephenson , Sara Eastburn , Charlene Pressley , Ed Ferrari , David Leather , Tony Gore
Rising living costs in high-cost areas of England are causing financial strain for NHS staff, particularly those in lower pay bands. Housing affordability has become a key issue for workforce retention and poses risks to the stability of healthcare services. This study examined financial pressures facing NHS staff in two Integrated Care Systems in South East England and identified policy options to support workforce sustainability. A mixed-methods design was used that combined a survey of healthcare staff with qualitative discussions with housing providers and local authorities to explore the impact of housing costs and financial stress on decisions about whether to remain in post. Findings show that lower-paid staff faced significant difficulties securing affordable housing near their workplaces, contributing to financial hardship and intentions to leave. Stakeholders highlighted barriers such as high land costs, funding constraints and limited collaboration between the NHS and housing sectors, and proposed practical approaches including partnerships with housing providers, repurposing vacant properties and targeted financial support for staff. Stakeholders tended to frame these solutions within existing welfare-based approaches, yet the findings also suggest that where staff can afford to live has direct implications for service continuity. Considering housing for NHS staff as part of the wider infrastructure that supports essential services therefore offers an important direction for future policy.
{"title":"Housing affordability, cost-of-living and NHS workforce retention in a high-cost region of England: A multiphase study","authors":"Dillon Newton , Mariam Zarjoo , Philip Brown , Tom Simcock , Joanne Garside , John Stephenson , Sara Eastburn , Charlene Pressley , Ed Ferrari , David Leather , Tony Gore","doi":"10.1016/j.ssmhs.2026.100175","DOIUrl":"10.1016/j.ssmhs.2026.100175","url":null,"abstract":"<div><div>Rising living costs in high-cost areas of England are causing financial strain for NHS staff, particularly those in lower pay bands. Housing affordability has become a key issue for workforce retention and poses risks to the stability of healthcare services. This study examined financial pressures facing NHS staff in two Integrated Care Systems in South East England and identified policy options to support workforce sustainability. A mixed-methods design was used that combined a survey of healthcare staff with qualitative discussions with housing providers and local authorities to explore the impact of housing costs and financial stress on decisions about whether to remain in post. Findings show that lower-paid staff faced significant difficulties securing affordable housing near their workplaces, contributing to financial hardship and intentions to leave. Stakeholders highlighted barriers such as high land costs, funding constraints and limited collaboration between the NHS and housing sectors, and proposed practical approaches including partnerships with housing providers, repurposing vacant properties and targeted financial support for staff. Stakeholders tended to frame these solutions within existing welfare-based approaches, yet the findings also suggest that where staff can afford to live has direct implications for service continuity. Considering housing for NHS staff as part of the wider infrastructure that supports essential services therefore offers an important direction for future policy.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100175"},"PeriodicalIF":0.0,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146037834","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-20DOI: 10.1016/j.ssmhs.2026.100177
Miesha Polintan , Elijah Bisung , Ebenezer Dassah
Sex workers are disproportionately affected by the global HIV epidemic, yet distrust in the health system, driven by stigma and criminalization, hinders early testing and treatment. Despite significant progress, Ghana has fallen behind on the UNAIDS 95–95–95 targets. The unique intersectional experiences of sex workers living with HIV (SWLH) often go underreported, as studies primarily focus on sex work or HIV in isolation. This ethnographic study explores how the intersecting identities and care experiences of SWLH influence trust within the health system in Kumasi, Ghana. Semi-structured interviews were conducted with SWLH (n = 18) and key informants (n = 8). The data was analyzed thematically. Four key themes shaped SWLHs’ trust in the health care system: Communication, Confidentiality, Stigma, and Education. Transparent communication, regular check-ins, and provider attentiveness fostered trust, whereas inconsistent follow-ups and non-consensual testing created barriers. While confidentiality safeguards reassured patients, fears of unintentional disclosure by service providers remained. Stigma, both self-imposed and external, led some participants to avoid care or relocate to other communities. Education was critical to treatment adherence, yet misinformation about HIV persisted, underscoring the need for improved public health messaging. Strengthening trust requires patient-centered approaches, including transparent communication, strict confidentiality, stigma reduction, and comprehensive education. These could be achieved through tailored interventions, including enhanced provider training, peer-led programs, and community-centred awareness campaigns. While this research provides critical insights, further studies are needed to explore regional variations and structural influences on trust. Integrating SWLH voices in policy and program development is essential for creating sustainable, inclusive healthcare solutions.
{"title":"“They have my number, but they have not called to check up on me”: Exploring trust in the health care system among sex workers living with HIV in Kumasi, Ghana","authors":"Miesha Polintan , Elijah Bisung , Ebenezer Dassah","doi":"10.1016/j.ssmhs.2026.100177","DOIUrl":"10.1016/j.ssmhs.2026.100177","url":null,"abstract":"<div><div>Sex workers are disproportionately affected by the global HIV epidemic, yet distrust in the health system, driven by stigma and criminalization, hinders early testing and treatment. Despite significant progress, Ghana has fallen behind on the UNAIDS 95–95–95 targets. The unique intersectional experiences of sex workers living with HIV (SWLH) often go underreported, as studies primarily focus on sex work or HIV in isolation. This ethnographic study explores how the intersecting identities and care experiences of SWLH influence trust within the health system in Kumasi, Ghana. Semi-structured interviews were conducted with SWLH (n = 18) and key informants (n = 8). The data was analyzed thematically. Four key themes shaped SWLHs’ trust in the health care system: Communication, Confidentiality, Stigma, and Education. Transparent communication, regular check-ins, and provider attentiveness fostered trust, whereas inconsistent follow-ups and non-consensual testing created barriers. While confidentiality safeguards reassured patients, fears of unintentional disclosure by service providers remained. Stigma, both self-imposed and external, led some participants to avoid care or relocate to other communities. Education was critical to treatment adherence, yet misinformation about HIV persisted, underscoring the need for improved public health messaging. Strengthening trust requires patient-centered approaches, including transparent communication, strict confidentiality, stigma reduction, and comprehensive education. These could be achieved through tailored interventions, including enhanced provider training, peer-led programs, and community-centred awareness campaigns. While this research provides critical insights, further studies are needed to explore regional variations and structural influences on trust. Integrating SWLH voices in policy and program development is essential for creating sustainable, inclusive healthcare solutions.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100177"},"PeriodicalIF":0.0,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146037832","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-20DOI: 10.1016/j.ssmhs.2026.100176
Jacquellyn Nambi Ssanyu , Catherine Birabwa , Kharim Mwebaza Muluya , Felix Kizito , Sarah Namutamba , Moses Kyangwa , Othman Kakaire , Peter Waiswa , Rornald Muhumuza Kananura
Background
In Uganda, religion strongly influences family planning (FP) practices, yet religious leaders are often excluded from FP program design and delivery. Engaging them meaningfully could help address misconceptions and improve voluntary FP uptake.
Methods
We applied Community-Based Participatory Action Research and Human-Centered Design to engage 16 religious leaders from Muslim, Catholic, Anglican, and Pentecostal faiths in Jinja City and Iganga Municipality, eastern Uganda. Faith-specific discussions were conducted using a structured agenda and co-moderated by participants. Data from audio recordings and notes were transcribed, translated, and analyzed thematically.
Results
All religious leaders expressed openness to FP but differed in their definitions and preferred methods. Christian leaders associated FP with responsible parenthood and manageable family sizes, while Muslim leaders emphasized parental responsibility without limiting fertility, stressing faith in divine provision. Natural methods were widely accepted, while hormonal methods were met with caution due to health concerns. There was unanimous opposition to providing FP to unmarried adolescents, with abstinence endorsed as the only acceptable option. Leaders welcomed the opportunity to share FP messages through their platforms, provided materials were accurate, respectful of religious values, and comprehensive in scope.
Conclusions
Religious leaders can play a pivotal role in advancing FP awareness and acceptance when engaged as partners in design and messaging. Programs should prioritize culturally sensitive communication, clarify misconceptions, and co-create strategies that align with faith-based perspectives. These approaches can enhance trust, shift social norms, and improve access to FP services, especially in communities where religious influence is strong.
{"title":"Co-designing family planning interventions: Insights from religious leaders in urban eastern Uganda","authors":"Jacquellyn Nambi Ssanyu , Catherine Birabwa , Kharim Mwebaza Muluya , Felix Kizito , Sarah Namutamba , Moses Kyangwa , Othman Kakaire , Peter Waiswa , Rornald Muhumuza Kananura","doi":"10.1016/j.ssmhs.2026.100176","DOIUrl":"10.1016/j.ssmhs.2026.100176","url":null,"abstract":"<div><h3>Background</h3><div>In Uganda, religion strongly influences family planning (FP) practices, yet religious leaders are often excluded from FP program design and delivery. Engaging them meaningfully could help address misconceptions and improve voluntary FP uptake.</div></div><div><h3>Methods</h3><div>We applied Community-Based Participatory Action Research and Human-Centered Design to engage 16 religious leaders from Muslim, Catholic, Anglican, and Pentecostal faiths in Jinja City and Iganga Municipality, eastern Uganda. Faith-specific discussions were conducted using a structured agenda and co-moderated by participants. Data from audio recordings and notes were transcribed, translated, and analyzed thematically.</div></div><div><h3>Results</h3><div>All religious leaders expressed openness to FP but differed in their definitions and preferred methods. Christian leaders associated FP with responsible parenthood and manageable family sizes, while Muslim leaders emphasized parental responsibility without limiting fertility, stressing faith in divine provision. Natural methods were widely accepted, while hormonal methods were met with caution due to health concerns. There was unanimous opposition to providing FP to unmarried adolescents, with abstinence endorsed as the only acceptable option. Leaders welcomed the opportunity to share FP messages through their platforms, provided materials were accurate, respectful of religious values, and comprehensive in scope.</div></div><div><h3>Conclusions</h3><div>Religious leaders can play a pivotal role in advancing FP awareness and acceptance when engaged as partners in design and messaging. Programs should prioritize culturally sensitive communication, clarify misconceptions, and co-create strategies that align with faith-based perspectives. These approaches can enhance trust, shift social norms, and improve access to FP services, especially in communities where religious influence is strong.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100176"},"PeriodicalIF":0.0,"publicationDate":"2026-01-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146037833","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-19DOI: 10.1016/j.ssmhs.2026.100174
India Hotopf , Samuel Amon , Leonard Baatiema , Patricia Akweongo , Joanna Raven
The HWF is central for Universal Health Coverage (UHC), but the retention crisis threatens progress. Women comprise 70 % of HWFs, facing unique challenges. Gender transformative action is needed, but there are knowledge gaps, especially in low-resource settings. Ghana faces a HWF crisis in deprived, remote areas. A project piloting retention interventions in deprived districts highlighted gendered dimensions. This study sought to elucidate the gendered HWF challenges and make gender transformative recommendations. This qualitative study embedded an intersectional approach. Thirty-six (36) key informant interviews (KIIs) were conducted to explore retention challenges, current policies/activities and recommendations. Respondents were purposively selected for cadre and gender. Intersectional gender analysis was conducted using the framework analysis approach and Morgan’s gender framework. Women health workers (HWs) account for most of the deprived district HWF, with the small number of men assigned to more remote districts in island communities, due to perceived resilience to scarce amenities. There was a shortage of HWs in deprived districts, and retention was low, due to women’s unique challenges - primarily family responsibilities. Women juggled difficult working conditions with singlehanded childcare and responsibility for maintaining relationships, hindered by poor communication networks and transport, including unsafe/expensive motorbike journeys and boat crossing fears. Inadequate salaries, high accommodation costs and inability to conduct locum work caused financial stress, with safety and security concerns (e.g., sexual harassment, motorbike accidents and robberies) also common. Current policies are gender-blind; recommendations include tailoring incentives to women with childcaring responsibilities, improving accommodation, security, community support and sexual harassment policy/awareness.
{"title":"Exploring the gendered dimensions of health workforce (HWF) retention challenges and transformative solutions in three deprived districts of Ghana: An exploratory qualitative study","authors":"India Hotopf , Samuel Amon , Leonard Baatiema , Patricia Akweongo , Joanna Raven","doi":"10.1016/j.ssmhs.2026.100174","DOIUrl":"10.1016/j.ssmhs.2026.100174","url":null,"abstract":"<div><div>The HWF is central for Universal Health Coverage (UHC), but the retention crisis threatens progress. Women comprise 70 % of HWFs, facing unique challenges. Gender transformative action is needed, but there are knowledge gaps, especially in low-resource settings. Ghana faces a HWF crisis in deprived, remote areas. A project piloting retention interventions in deprived districts highlighted gendered dimensions. This study sought to elucidate the gendered HWF challenges and make gender transformative recommendations. This qualitative study embedded an intersectional approach. Thirty-six (36) key informant interviews (KIIs) were conducted to explore retention challenges, current policies/activities and recommendations. Respondents were purposively selected for cadre and gender. Intersectional gender analysis was conducted using the framework analysis approach and Morgan’s gender framework. Women health workers (HWs) account for most of the deprived district HWF, with the small number of men assigned to more remote districts in island communities, due to perceived resilience to scarce amenities. There was a shortage of HWs in deprived districts, and retention was low, due to women’s unique challenges - primarily family responsibilities. Women juggled difficult working conditions with singlehanded childcare and responsibility for maintaining relationships, hindered by poor communication networks and transport, including unsafe/expensive motorbike journeys and boat crossing fears. Inadequate salaries, high accommodation costs and inability to conduct locum work caused financial stress, with safety and security concerns (e.g., sexual harassment, motorbike accidents and robberies) also common. Current policies are gender-blind; recommendations include tailoring incentives to women with childcaring responsibilities, improving accommodation, security, community support and sexual harassment policy/awareness.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100174"},"PeriodicalIF":0.0,"publicationDate":"2026-01-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146037905","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-15DOI: 10.1016/j.ssmhs.2026.100173
Ann Scheunemann , Moleboheng Mohlalisi , Sebaka Malope , Brian W. Jack , David C. Henderson
Despite increased focus on mental health as a sustainable development goal and human right, treatment gaps between service need and access remain high globally. Treatment gaps are impacted by the availability and desirability of the services being provided with mental health systems and can be assessed through the health systems building blocks framework, which identifies six factors for providing mental health services that are responsive to the needs of the individuals and communities served. This study explored service user and provider experiences of treatment gaps within Lesotho’s mental health system, across socioecological levels of care and the building blocks framework, as well as recommendations for improvement. Qualitative data were collected with 218 participants across 25 five groups and four interviews, including health workers, mental health workers, and community members. Participants and data collection sites were selected for diversity, ensuring that all districts, ecological regions, and geographic areas were represented. Two themes and seven sub-themes were identified. Participants felt that communication across governmental and nongovernmental sectors and between levels of care was limited and suggested developing policies to better guide service delivery. Service delivery could also be improved by diversifying care options and providers. Participants identified shortages in the mental health workforce and recommended better support for employees, training more providers, and better capacitating specialists and generals to provide care. Access could be enhanced through infrastructure development. These findings provide direction for strengthening mental health services in resource-constrained settings, through collaboration to improve service availability and responsiveness to improve desirability.
{"title":"Developing more responsive mental health services in Lesotho: Using a socioecological framework to explore the system’s building blocks","authors":"Ann Scheunemann , Moleboheng Mohlalisi , Sebaka Malope , Brian W. Jack , David C. Henderson","doi":"10.1016/j.ssmhs.2026.100173","DOIUrl":"10.1016/j.ssmhs.2026.100173","url":null,"abstract":"<div><div>Despite increased focus on mental health as a sustainable development goal and human right, treatment gaps between service need and access remain high globally. Treatment gaps are impacted by the availability and desirability of the services being provided with mental health systems and can be assessed through the health systems building blocks framework, which identifies six factors for providing mental health services that are responsive to the needs of the individuals and communities served. This study explored service user and provider experiences of treatment gaps within Lesotho’s mental health system, across socioecological levels of care and the building blocks framework, as well as recommendations for improvement. Qualitative data were collected with 218 participants across 25 five groups and four interviews, including health workers, mental health workers, and community members. Participants and data collection sites were selected for diversity, ensuring that all districts, ecological regions, and geographic areas were represented. Two themes and seven sub-themes were identified. Participants felt that communication across governmental and nongovernmental sectors and between levels of care was limited and suggested developing policies to better guide service delivery. Service delivery could also be improved by diversifying care options and providers. Participants identified shortages in the mental health workforce and recommended better support for employees, training more providers, and better capacitating specialists and generals to provide care. Access could be enhanced through infrastructure development. These findings provide direction for strengthening mental health services in resource-constrained settings, through collaboration to improve service availability and responsiveness to improve desirability.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100173"},"PeriodicalIF":0.0,"publicationDate":"2026-01-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145978448","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-10DOI: 10.1016/j.ssmhs.2026.100168
Laura Jacques , Jenny A. Higgins , Corinne M. Hale , Eliza A. Bennett , Abigail S. Cutler
Objective
To document how Wisconsin healthcare institutions’ (in)action under a near-total abortion ban post-Dobbs influenced physician experience and patient care.
Study Design
We recruited 21 obstetrician-gynecologists from academic, community, and religiously affiliated healthcare systems across Wisconsin, a midwestern U.S. state, between June 2022 and December 2023 to participate in 45–60-minute semi-structured Zoom interviews about the impact of Dobbs on Wisconsin reproductive healthcare delivery. We analyzed transcripts using an inductive-deductive approach and employed a framework method to identify key themes.
Results
After Dobbs, participants reported that most healthcare institutions abdicated responsibility, leaving providers to navigate legal uncertainties and create clinical workflows to ensure safe patient care. Tepid or absent institutional responses were widely perceived as exacerbating clinician distress and mistrust in healthcare systems.
Conclusion
These findings provide firsthand evidence that healthcare institutions are not passive conduits of state law, but active agents whose decisions shape how reproductive healthcare is delivered, or denied, in a post-Dobbs landscape. Institutional inaction, inconsistent guidance, and failure to support physicians have added another layer of harm to an already strained reproductive healthcare system.
{"title":"How U.S. healthcare institutions’ actions, or inactions, shaped physician experiences after Dobbs: A qualitative study","authors":"Laura Jacques , Jenny A. Higgins , Corinne M. Hale , Eliza A. Bennett , Abigail S. Cutler","doi":"10.1016/j.ssmhs.2026.100168","DOIUrl":"10.1016/j.ssmhs.2026.100168","url":null,"abstract":"<div><h3>Objective</h3><div>To document how Wisconsin healthcare institutions’ (in)action under a near-total abortion ban post-<em>Dobbs</em> influenced physician experience and patient care.</div></div><div><h3>Study Design</h3><div>We recruited 21 obstetrician-gynecologists from academic, community, and religiously affiliated healthcare systems across Wisconsin, a midwestern U.S. state, between June 2022 and December 2023 to participate in 45–60-minute semi-structured Zoom interviews about the impact of <em>Dobbs</em> on Wisconsin reproductive healthcare delivery. We analyzed transcripts using an inductive-deductive approach and employed a framework method to identify key themes.</div></div><div><h3>Results</h3><div>After <em>Dobbs</em>, participants reported that most healthcare institutions abdicated responsibility, leaving providers to navigate legal uncertainties and create clinical workflows to ensure safe patient care. Tepid or absent institutional responses were widely perceived as exacerbating clinician distress and mistrust in healthcare systems.</div></div><div><h3>Conclusion</h3><div>These findings provide firsthand evidence that healthcare institutions are not passive conduits of state law, but active agents whose decisions shape how reproductive healthcare is delivered, or denied, in a post-<em>Dobbs</em> landscape. Institutional inaction, inconsistent guidance, and failure to support physicians have added another layer of harm to an already strained reproductive healthcare system.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100168"},"PeriodicalIF":0.0,"publicationDate":"2026-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145978384","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-09DOI: 10.1016/j.ssmhs.2026.100171
Luthfi Azizatunnisa' , Hannah Kuper , Ari Probandari , Lena Morgon Banks
Background
Jaminan Kesehatan Nasional (JKN), Indonesia’s National Health Insurance, is the world’s largest single-payer scheme. However, an estimated 35 % of people with disabilities remain not-enrolled, and many enrolled individuals continue to face high out-of-pocket spending and catastrophic health expenditure. This study aims to explore barriers and facilitators to accessing and using JKN amongst people with disabilities, with a focus on Yogyakarta Province.
Methods
We conducted a qualitative study using phenomenology approach. We interviewed 22 people with disabilities and 14 key informants (i.e., national and subnational government, organisation of people with disabilities (OPDs), and national disability representatives). Data collection and analysis were guided by the Universal Health Coverage framework.
Findings
Enrolment was facilitated by formal employment, government subsidies, outreach by social workers and support from OPDs. Key enrolment barriers included lack of identity documents, restrictive poverty criteria for subsidies, and accessibility constraints. Service use was supported by improved referral mechanisms but limited by inadequate coverage of assistive technology (AT) and rehabilitation, uneven distribution and quality of health facilities, perceived negative attitude from health workers, and physical and informational inaccessibility. Financial protection under JKN was limited by high out-of-pocket payments driven by gaps in benefit coverage, indirect costs, and underutilisation of services.
Interpretation
Improving equity for people with disabilities under JKN requires reforms that account for disability-related costs, expand benefit coverage for AT and rehabilitation, strengthen accessibility standards in health facilities, and pilot disability-inclusive reforms at sub-national level leveraging regional autonomy.
{"title":"“I was given the card, but no one explained to me how to use it”: Challenges and facilitators of people with disabilities in Indonesia in accessing and using Jaminan Kesehatan Nasional (National Health Insurance)","authors":"Luthfi Azizatunnisa' , Hannah Kuper , Ari Probandari , Lena Morgon Banks","doi":"10.1016/j.ssmhs.2026.100171","DOIUrl":"10.1016/j.ssmhs.2026.100171","url":null,"abstract":"<div><h3>Background</h3><div>Jaminan Kesehatan Nasional (JKN), Indonesia’s National Health Insurance, is the world’s largest single-payer scheme. However, an estimated 35 % of people with disabilities remain not-enrolled, and many enrolled individuals continue to face high out-of-pocket spending and catastrophic health expenditure. This study aims to explore barriers and facilitators to accessing and using JKN amongst people with disabilities, with a focus on Yogyakarta Province.</div></div><div><h3>Methods</h3><div>We conducted a qualitative study using phenomenology approach. We interviewed 22 people with disabilities and 14 key informants (i.e., national and subnational government, organisation of people with disabilities (OPDs), and national disability representatives). Data collection and analysis were guided by the Universal Health Coverage framework.</div></div><div><h3>Findings</h3><div>Enrolment was facilitated by formal employment, government subsidies, outreach by social workers and support from OPDs. Key enrolment barriers included lack of identity documents, restrictive poverty criteria for subsidies, and accessibility constraints. Service use was supported by improved referral mechanisms but limited by inadequate coverage of assistive technology (AT) and rehabilitation, uneven distribution and quality of health facilities, perceived negative attitude from health workers, and physical and informational inaccessibility. Financial protection under JKN was limited by high out-of-pocket payments driven by gaps in benefit coverage, indirect costs, and underutilisation of services.</div></div><div><h3>Interpretation</h3><div>Improving equity for people with disabilities under JKN requires reforms that account for disability-related costs, expand benefit coverage for AT and rehabilitation, strengthen accessibility standards in health facilities, and pilot disability-inclusive reforms at sub-national level leveraging regional autonomy.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100171"},"PeriodicalIF":0.0,"publicationDate":"2026-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145926906","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In the Eastern Mediterranean Region (EMR), 78.1 million people experience hearing loss of any degree, with 22.1 million having disabling hearing loss, projected to reach 51.7 million by 2050. Unless global action is taken, the worldwide burden could reach over 700 million people with disabling hearing loss by 2050. This systematic review presents the first comprehensive health systems analysis of ear and hearing care (EHC) in the region. Following PRISMA guidelines, we analysed 146 articles through the WHO health systems framework to identify systemic barriers to effective EHC integration. Our findings reveal significant health systems challenges: fragmented governance with limited cross-sectoral coordination; inadequate financing with heavy reliance on out-of-pocket payments; critical workforce shortages across the region; and inequitable service distribution between urban and rural areas. While progress has been made with initiatives such as neonatal screening programs and primary care integration, these achievements remain limited in scope. Socioeconomic factors create additional barriers, affecting both hearing loss development and healthcare access. Alternative service delivery models, including telemedicine and task-sharing, show potential but lack systematic implementation. The economic burden of unaddressed hearing loss in the EMR ($30 billion annually) contrasts with potential returns of up to $7 per dollar invested. We propose five key actions: integrating EHC into universal health coverage, establishing comprehensive services across care levels, implementing awareness campaigns, developing monitoring systems, and promoting implementation research. This analysis provides evidence-based recommendations for health system reforms to address hearing loss while optimising resource allocation in diverse EMR contexts.
{"title":"Situational analysis of health systems for ear and hearing care in the World Health Organization (WHO) Eastern Mediterranean Region: A systematic review and evidence synthesis to inform national policies and strategies","authors":"Dialechti Tsimpida , Hala Sakr , Abdelrahman Elwishahy , Shelly Chadha , Chander Chitra , Saied Mahmoudian","doi":"10.1016/j.ssmhs.2026.100170","DOIUrl":"10.1016/j.ssmhs.2026.100170","url":null,"abstract":"<div><div>In the Eastern Mediterranean Region (EMR), 78.1 million people experience hearing loss of any degree, with 22.1 million having disabling hearing loss, projected to reach 51.7 million by 2050. Unless global action is taken, the worldwide burden could reach over 700 million people with disabling hearing loss by 2050. This systematic review presents the first comprehensive health systems analysis of ear and hearing care (EHC) in the region. Following PRISMA guidelines, we analysed 146 articles through the WHO health systems framework to identify systemic barriers to effective EHC integration. Our findings reveal significant health systems challenges: fragmented governance with limited cross-sectoral coordination; inadequate financing with heavy reliance on out-of-pocket payments; critical workforce shortages across the region; and inequitable service distribution between urban and rural areas. While progress has been made with initiatives such as neonatal screening programs and primary care integration, these achievements remain limited in scope. Socioeconomic factors create additional barriers, affecting both hearing loss development and healthcare access. Alternative service delivery models, including telemedicine and task-sharing, show potential but lack systematic implementation. The economic burden of unaddressed hearing loss in the EMR ($30 billion annually) contrasts with potential returns of up to $7 per dollar invested. We propose five key actions: integrating EHC into universal health coverage, establishing comprehensive services across care levels, implementing awareness campaigns, developing monitoring systems, and promoting implementation research. This analysis provides evidence-based recommendations for health system reforms to address hearing loss while optimising resource allocation in diverse EMR contexts.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"6 ","pages":"Article 100170"},"PeriodicalIF":0.0,"publicationDate":"2026-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145978449","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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