SSM - Health Systems最新文献

Background

While low- and middle-income countries continue to struggle to secure adequate COVID-19 vaccine supply, a potentially greater challenge is to induce adequate demand to overcome widespread vaccine hesitancy; vaccination uptake has historically been a contentious political issue in Pakistan. High-level endorsements by trusted actors are one way to potentially increase public vaccine confidence. Methods: Employing a four-armed randomized trial with 2026 participants in June 2021, we examine whether endorsements by different actors (Prime Minister, prominent religious leader, doctors) influenced participants’ willingness to register for the COVID-19 vaccine.

Results

We find high levels of vaccine hesitancy with nearly 35% of participants reporting that they do not intend to vaccinate against COVID-19. Endorsements failed to influence participants' desire to register for vaccination, and only 37 % agreed to register on spot. However, we find that higher trust in government, male gender, and higher income/wealth were associated with participants' willingness to register. A follow-up phone survey was consistent with the main results.

Discussion

Our study finds that endorsements appear to have little effect on people’s immediate willingness to register for vaccination. Our findings suggest messaging on its own may be insufficient to overcome widespread social and structural barriers to vaccine uptake.

Background

The governance of childhood vaccination in crisis-affected populations presents distinctive and intricate challenges and has been criticized for being inadequate. In this study, our aim was to investigate the existing practices related to decision-making on vaccination in crisis-affected settings and develop practical suggestions for enhancing these.

Methods

We followed a qualitative research approach, conducting 31 remote semi-structured interviews with individuals involved in humanitarian vaccination efforts and stakeholders operating at global, regional, and national levels. We used a thematic approach using a mix of inductive and deductive coding to analyse the data while applying the Governance Analytical Framework (GAF).

Results

Our research indicates that decision-making in crisis-affected settings suffers from a lack of structure, documentation, and transparency. Participants highlighted the presence of diverse and conflicting agendas among different stakeholders and the insufficiency of timely, reliable data crucial for effective decision-making. As solutions, participants recommended improved coordination among stakeholders and emphasized the need for meaningful engagement of local actors.

Conclusion

The study uncovered a fragmented, disorganised and complex governance landscape of vaccination services in crisis-affected settings spanning multiple levels and involving various actors. To improve this landscape, it is crucial to intensify efforts to ensure fairness, accountability and effectiveness.

Objective

Drug-resistant tuberculosis (TB) is a significant public health threat in high-burden TB countries, including Nigeria, constraining the achievement of End TB targets. Nonetheless, Nigeria's health system factors shaping the care of patients with multidrug-resistant tuberculosis (MDR-TB) are understudied. The study assessed the enablers and barriers to implementing MDR-TB care and treatment in Abia State, Nigeria.

Methods

This is a qualitative interview study adopting a phenomenological approach. We interviewed twelve participants comprising health workers and TB policymakers with roles in MDR-TB patient management at the national (n = 2) and state (n = 10) levels in May 2022. We used maximum variation sampling to purposively select participants based on their roles, availability, and consent. The data were analysed thematically.

Results

The factors enhancing care for patients with MDR-TB include using a certificate of readiness, community involvement, donor financing, availability of treatment centre, effective facility-community linkage, treatment support, multidisciplinary care team, training service providers, availability of oral drugs, expansion of diagnostic facilities, data tool availability, review meetings, and data-focused supervision. In contrast, the factors constraining MDR-TB management are poor implementation of infection control policy, donor dependence, delayed initiation of treatment, poorly motivated health workers, health worker stigma, shortage of personal protective equipment, and role conflict in data management.

Conclusion

The findings highlight critical health systems strengths and weaknesses in MDR-TB control. MDR-TB care policies must build on the enablers and address the barriers to strengthen the care for patients with MDR-TB.

Background

Ghana introduced a free maternal healthcare policy within its national health insurance program in 2008. Despite this, there are reports of significant out-of-pocket (OOP) payments for maternal healthcare in Ghana. This study examines OOP payments for maternal healthcare services and their catastrophic effects, including the correlates of catastrophic OOP payments.

Methods

Cross-sectional quantitative data were collected from 414 mothers through health facility exit interviews in two regions of Ghana. Catastrophic OOP payments were computed by expressing total health expenditure as a percentage of household total expenditure and non-food expenditure at various thresholds (5 %, 10 %, 20 % and 25 %). The correlates of catastrophic OOP payments were assessed using logistic regression models.

Results

The median OOP payments for maternal healthcare was GH₵866.5(US$109.3). The median non-medical OOP cost (GH₵479[US$ 59.9]) was higher than the median medical OOP cost (GH₵296.5[US$ 37.1]). The median OOP cost was higher for delivery (GH₵454[US$56.8]) compared to ANC (GH₵356.5[US$44.5]) and PNC (GH₵21.5[US$2.6]). Non-medical supplies comprise 58 % of the total OOP payments. About 73 % and 90 % of respondents spent more than 5 % of their annual household total and non-food expenditure on maternal healthcare, respectively. Rural areas and care at private facilities were significantly associated (AORs<1; p-values<0.05) with lower probabilities of incurring catastrophic OOP expenditure. Tertiary education was associated (AORs> 1; p-values<0.05) with a higher probability of incurring catastrophic OOP payments.

Conclusion

OOP payments for maternal care are still prevalent in Ghana. We call for a reform of Ghana’s free maternal healthcare policy to include non-medical supplies within its benefit package.

Background

Numerous sources of routine data exist but there is limited information on how they relate or complement each other to improve data availability and the quality of data collected. This paper compares data coverage and completeness on selected maternal health service indicators between (1) a performance-based financing(PBF) database, (2) the national health information system, and (3) health facility registers in selected districts in Cameroon.

Method

Data on antenatal care, skilled birth delivery and family planning were collected from 2010 to 2020 in three purposively selected districts (Buea, Limbe and Tiko) in the southwest region of Cameroon. The coverage and completeness of data from the performance-based financing database, the district health information system (dhis2, a national system) and health facility registers were compared. Data sources for the performance-based financing database and the district health information system are based on data generated from health facilities.

Results

Among the 90 health facilities in the three districts, 13 (14.5 %) facilities could not be accessed due to ongoing political conflict. Therefore, data were collected from 77 health facilities. Of the 77 facilities, half were public, a third private, and the remainder para-public (13 %) or confessional (5 %). Approximately seven registers at each health facility included data on maternal and child health. Problems of these data included incomplete coverage, misplacement of records, and incomplete data in the records identified. There was inconsistency across all sources. dhis2 collected antenatal care only for the first and fourth visits and PBF collected data for any antenatal care visits without specifying the visit number and health facility collected data for all antenatal care visits.

Conclusion

The introduction of dhis2 and PBF programs has strengthened the availability of data in electronic format. Generally, we noted important gaps and heterogeneity in data reporting as well as incomplete data across health sectors and districts. There is need to transform the way data are collected at health facilities and there is also need for capacity building and better data governance to improve data quality and use. This will ensure that reliable, consistent, accurate, and actionable data are available to inform policy towards achieving Universal Health Coverage.

Background

Current Universal Health Coverage (UHC) considerations confirm the need for strong governance in improving health sector performance. However, empirical evidence on the effects of decentralized health system governance remains limited in Low-and-middle-income countries (LMICs). This paper assesses the de facto health governance policies and practices of the decentralized health system of Ghana and its implications, for better policy formulation and implementation.

Material and methods

The study employed a cross-sectional design, comprising of systematic literature review (SLR) and in-depth interviews on health governance components. The literature review (n=103) was performed to document the factors that affect health governance management and policy uptake. A total of 32 purposively sampled key health system actors were individually interviewed face-to-face between January and February, 2018. Thematic content analyses of literature and interviews were done.

Results

Tension regarding power relationships exists between the policies governing the health sector of Ghana, which has rendered the decentralization reform effort in health governance policies and practices uncoordinated, incoherent and sometimes contradictory. Implication of the de facto decentralized health governance policies and practice include: limited involvement of sub-national level in policy development; weak interaction between policy formulators and implementers; and political interference in policy implementations compromising evidence-based policy formulation.

Originality/value

Drawing on diverse literatures and opinions of key health actors, this paper contributes to knowledge on health governance practices in a decentralized and resource constrained health system, and offers practical accounts of the implications of the de facto health governance system of Ghana for health policy formulation and implementation.

Background

There is growing focus on improving maternal-perinatal survival through health system strengthening (HSS). Despite such efforts, facility birth coverage often remains low in low-income settings. We explored factors influencing facility birth utilization during a national HSS initiative in rural Guinea-Bissau.

Methods

Using an explanatory sequential mixed-methods approach nested in the Bandim Health Project’s rural Health and Demographic Surveillance System (HDSS), we conducted 258 structured and 12 in-depth interviews with women who had recently given birth. Data were analysed using descriptive statistics and thematic network analysis guided by theories of social practice.

Findings

In the structured interviews, most women reported that they had planned a facility birth (171/258, 66 %), and 28 % reported access barriers (73/258). However, only half of the interviewed women actually gave birth at a health facility (128/258, 50 %), suggesting that facility births frequently remained unattainable. In the in-depth interviews, women described multiple “prerequisites” that needed to be met to access facility births such as financial means for out-of-pocket payments (OOPs). Despite official user fee waivers, OOPs were reported by 71 % of the structured-interview participants with facility births (91/128) but only three of these women referred to OOPs as barriers.

Conclusions

Our findings suggest that the women do not feel entitled to free-of-charge facility births, which may explain underreporting of financial barriers. Ubiquitous OOPs are further suggestive of ‘commodification’ of facility births, such that individual ability to pay remains key to utilization. Our findings raise equity concerns and call for closer monitoring of the implementation of HSS initiatives.

There are 1.3 billion people with disabilities globally. On average, they experience greater healthcare needs and more barriers accessing healthcare. Yet, health systems have failed to adequately include people with disabilities. The purpose of this study was to develop and pilot-test a tool for assessing disability inclusion in health system performance. We presented the “Missing Billion” disability-inclusive health system framework, which includes 4 system-level components and 5 service delivery components, and outputs and outcomes. We developed a tool, consisting of 48 indicators related to the framework components. We consulted international experts, who considered the framework and indicator set to be logical and comprehensive. The tool was pilot-tested in the Maldives (2020) and Zimbabwe (2021), working with local researchers to collect relevant data through document review and key informant interviews. The pilot data demonstrated that collecting data on the indicators was feasible. The tool highlighted areas where the health systems were performing well in terms of disability inclusion (e.g. governance) and other areas where there were large gaps (e.g. leadership) or lack of data (e.g. accessibility, outputs and outcomes). The indicators were updated and refined. We established a process for undertaking the assessment, highlighting the importance of leadership and ownership by the Ministry of Health, to facilitate data collection and implementation of recommendations. In conclusion, this new tool for assessing disability inclusion in health systems performance can help to identify key issues and guide and monitor action.

Introduction

During the COVID-19 pandemic, Close-to-Community (CTC) healthcare providers emerged to compensate for the lack of healthcare workers in areas with high concentrations of Syrian refugees. Gender norms and power relations shaped the experiences of those CTC providers.

Methodology

A qualitative study explored the lived experiences of men and women CTC providers in Beqaa - Lebanon. It examined their gendered experiences during the COVID-19 response using in-depth interviews with informal CTC providers who are members of the Syrian refugee community themselves, and key informant interviews with their managers. Thematic data analysis and synthesis were guided by gender analysis frameworks and supported by NVivo 12.

Results

CTC providers faced many challenges in their work including illegal work, absence of benefits, high workload, insufficient income, transportation challenges, disturbances in family life, and social isolation. Working illegally as refugees led to underpayment and absence of benefits. Gender norms and power dynamics significantly influenced the experiences of these CTC providers. Women CTC providers faced increased workload, lower payment, limited opportunities for extra hours, the pressure of juggling work and family life, transport challenges, psychological distress and lack of support from their organizations.

Conclusion

The COVID-19 pandemic has shed light on how gender shapes vulnerabilities within the healthcare response. Women and men informal CTC providers experienced different challenges providing healthcare services for their communities during the COVID-19 response. There is a need to address the vulnerabilities for women CTC providers and develop and implement practical interventions to address them.

Introduction

In June 2022, WHO recommended the administration of Perennial Malaria Chemoprevention (PMC) alongside Expanded Immunization Programmes for children under two years. We investigated the health systems readiness for PMC implementation in Togo.

Method

As part of the multi-country MULTIPLY project, we conducted a mixed methods implementation research study in the 27 health facilities of Haho district in Togo. All district health care providers (n=188) and a sample of community health workers (n=43) were invited to respond to a self-administered Knowledge-Attitudes-Practices questionnaire. Structured observations in 4 health facilities and 19 semi-structured interviews were conducted. Descriptive analysis was conducted on quantitative data. Qualitative data was analysed thematically, using an inductive approach. We report here on the implementation context for PMC, its infrastructural feasibility and its acceptability among health care workers (HCWs).

Results

Overall, respondents perceived PMC as relevant in the context of high malaria burden and had a good knowledge about malaria and its prevention. HCWs foresaw good community acceptability of PMC. Although some HCWs did not understand the rationale of PMC if children are not sick, they also believed PMC would be effective, in line with their perceptions of preventive malaria treatment during pregnancy. Several challenges were foreseen such as distance barriers for accessing health facilities, difficulties in accessing drinking water, supplies for PMC administration, or lack of dedicated health workforce and area for PMC administration.

Conclusion

At district-level in Togo, overall pre-intervention acceptability of PMC was encouraging. Structural and operational challenges were identified as possible barriers to implementation feasibility.