Community Engagement in Support of Moving Toward Universal Health Coverage

Inequality in benefit distribution of reducing the outpatient cost-sharing: evidence from the outpatient pooling scheme in China

Objective

The implementation of the outpatient pooling scheme in China has substantially elevated the compensation levels for outpatient expenses. This study aims to assess whether socioeconomically disadvantaged enrollees benefit proportionally compared to their non-disadvantaged counterparts.

Method

A cohort comprising 14,581 Urban and Rural Resident Basic Medical Insurance (URRBMI) enrollees and 830 Urban Employee Basic Medical Insurance (UEBMI) enrollees was derived from the China Health and Retirement Longitudinal Study 2018. Outpatient pooling scheme benefits were evaluated based on two metrics: the probability of obtaining benefits and the magnitude of benefits (reimbursement amounts and ratios). Two-part models were employed to adjust outpatient benefits for healthcare needs. Inequality in benefit distribution was assessed using the concentration curve and concentration index (CI).

Results

Following adjustments for healthcare needs, the CI for the probability of receiving outpatient benefits for URRBMI and UEBMI enrollees were - 0.0760 and - 0.0514, respectively, indicating an evident pro-poor pattern under the outpatient pooling scheme. However, the CIs of reimbursement amounts (0.0708) and ratio (0.0761) for URRBMI recipients were positive, signifying a discernible pro-rich inequality in the degree of benefits. Conversely, socioeconomically disadvantaged UEBMI enrollees received higher reimbursement amounts and ratios.

Conclusion

Despite a higher likelihood of socioeconomically disadvantaged groups receiving outpatient benefits, a pro-rich inequality persists in the degree of benefits under the outpatient pooling scheme in China. Comprehensive strategies, including expanding outpatient financial benefits, adopting distinct reimbursement standards, and enhancing the accessibility of outpatient care, need to be implemented to achieve equity in benefits distribution.

Individual and contextual level enablers and barriers determining electronic community health information system implementation in northwest Ethiopia

BACKGROUND

The government of Ethiopia has envisioned digitalizing primary healthcare units through the electronic community health information system (eCHIS) program as a re-engineering strategy aiming to improve healthcare data quality, use, and service provision. The eCHIS is intended as a community-wide initiative to integrate lower health structure with higher administrative health and service delivery unit with the ultimate goal of improving community health. However, the success or failure of the program depends on the level of identifying enablers and barriers of the implementation. Therefore, this study aimed to explore individual and contextual-level enablers and barriers determining eCHIS implementation.

METHOD

We conducted an exploratory study to determine the enablers and barriers to successfully implementing eCHIS in rural Wogera district, northwest Ethiopia. In-depth interviews and key informant interviews were applied at participants from multiple sites. A thematic content analysis was conducted based on the key themes reported. We applied the five components of consolidated framework for implementation research to interpret the findings.

RESULTS

First, based on the intervention's characteristics, implementers valued the eCHIS program. However, its implementation was impacted by the heavy workload, limited or absent network and electricity. Outer-setting challenges were staff turnover, presence of competing projects, and lack of incentive mechanisms. In terms of the inner setting, lack of institutionalization and ownership were mentioned as barriers to the implementation. Resource allocation, community mobilization, leaders' engagement, and availability of help desk need emphasis for a better achievement. With regard to characteristics of the individuals, limited digital literacy, older age, lack of peer-to-peer support, and limited self-expectancy posed challenges to the implementation. Finally, the importance of mentoring and engaging community and religious leaders, volunteers, having defined plan and regular meetings were identified elements of the implementation process and need emphasis.

CONCLUSION

The findings underlined the potential enablers and barriers of eCHIS program for quality health data generation, use, and service provision and highlighted areas that require emphasis for further scale-up. The success and sustainability of the eCHIS require ongoing government commitment, sufficient resource allocation, institutionalization, capacity building, communication, planning, monitoring, and evaluation.

From idea to systems solution: enhancing access to primary care in Malawi

Malawi, like many other countries, faces challenges in providing accessible, affordable, and quality health services to all people. The Malawian policy framework recognizes the value of communities and citizens, as co-creators of health and leaders of localized and innovative initiatives, such as social innovations.Social innovations involve and include communities and citizens, as well as bring about changes in the institutions responsible for care delivery. In this article, we describe the institutionalization process of a citizen-initiated primary care social innovation, named Chipatala Cha Pa Foni, focused on extending access to health information and appropriate service-seeking behavior.An interdisciplinary multi-method qualitative case study design was adopted, drawing on data collected from key informant interviews, observations, and documents over an 18-month period. A composite social innovation framework, informed by institutional theory and positive organizational scholarship, guided the thematic content analysis. Institutional-level changes were analyzed in five key dimensions as well as the role of actors, operating as institutional entrepreneurs, in this process.A subset of actors matched the definition of operating as Institutional Entrepreneurs. They worked in close collaboration to bring about changes in five institutional dimensions: roles, resource flows, authority flows, social identities and meanings. We highlight the changing role of nurses; redistribution and decentralization of health information; shared decision-making, and greater integration of different technical service areas.From this study, the social innovation brought about key institutional and socio-cultural changes in the Malawi health system. These changes supported strengthening the system's integrity for achieving Universal Health Coverage by unlocking and cultivating dormant human-based resources. As a fully institutionalized social innovation, Chipatala Cha Pa Foni has enhanced access to primary care and especially as part of the Covid-19 response.

Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review

The goal of universal health coverage (UHC) from the United Nations (UN) has metamorphized from its early phase of primary health care (PHC) to the recent sustainable development goal (SDG). In this context, we aimed to document theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC in a global scenario. Searching with broad keywords circumadjacent to UHC with scope and inter-disciplinary linkages in conceptual analysis, we further narrated the review with the historical development of UHC in different time periods. We proposed, chronologically, these frames as eras of PHC, the millennium development goal (MDG), and the ongoing sustainable development goal (SDG). Literature showed that modern healthcare access and coverage were in extension stages during the PHC era flagshipped with "health for all (HFA)", prolifically achieving vaccination, communicable disease control, and the use of modern contraceptive methods. Following the PHC era, the MDG era markedly reduced maternal, neonatal, and child mortalities mainly in developing countries. Importantly, UHC has shifted its philosophic stand of HFA to a strategic health insurance and its extension. After 2015, the concept of SDG has evolved. The strategy was further reframed as service and financial assurance. Strategies for further resource allocation, integration of health service with social health protection, human resources for health, strategic community participation, and the challenges of financial securities in some global public health concerns like the public health emergency and travelers' and migrants' health are further discussed. Some policy departures such as global partnership, research collaboration, and experience sharing are broadly discussed for recommendation.

Social innovation in health: strengthening Community Systems for Universal Health Coverage in rural areas

BACKGROUND

In seeking the attainment of Universal Health Coverage (UHC), there has been a renewed emphasis on the role of communities. This article focuses on social innovation and whether this concept holds promise to enhance equity in health services to achieve UHC and serve as a process to enhance community engagement, participation, and agency.

METHODS

A cross-country case study methodology was adopted to analyze three social innovations in health in three low- and middle-income countries (LMICs): Philippines, Malawi, and Colombia. Qualitative methods were used in data collection, and a cross-case analysis was conducted with the aid of a simplified version of the conceptual framework on social innovation as proposed by Cajaiba-Santana. This framework proposes four dimensions of social innovation as a process at different levels of action: the actors responsible for the idea, the new idea, the role of the institutional environment, and the resultant changes in the health and social system.

RESULTS

The study found that each of the three social innovation case studies was based on developing community capacities to achieve health through community co-learning, leadership, and accountability. The process was dependent on catalytic agents, creating a space for innovation within the institutional context. In so doing, these agents challenged the prevailing power dynamics by providing the communities with respect and the opportunity to participate equally in creating and implementing programs. In this way, communities were empowered; they were not simply participants but became active agents in conceptualizing, implementing, monitoring, and sustaining the social innovation initiatives.

CONCLUSION

The study has illustrated how three creative social innovation approaches improved access and quality of health services for vulnerable rural populations and increased agency among the intervention communities. The processes facilitated empowerment, which in turn supported the sustained strengthening of the community system and the achievement of community goals in the domain of health and beyond.

Implementation barriers and facilitators to a COVID-19 intervention in Bangladesh: The benefits of engaging the community for the delivery of the programme

BACKGROUND

BRAC (Bangladesh Rural Advancement Committee), the largest NGO globally, implemented a community-based comprehensive social behavior communication intervention to increase community resilience through prevention, protection, and care for COVID-19. We conducted implementation research to assess fidelity and explore the barriers and facilitators of this intervention implementation.

METHODS

We adopted a concurrent mixed-method triangulation design. We interviewed 666 members of 60 Community Corona Protection Committees (CCPCs) and 80 members of 60 Community Support Teams (CSTs) through multi-stage cluster sampling using a structured questionnaire. The qualitative components relied on 54 key informant interviews with BRAC implementers and government providers.

RESULTS

The knowledge about wearing mask, keeping social distance, washing hands and COVID-19 symptoms were high (on average more than 70%) among CCPC and CST members. While 422 (63.4%) CCPC members reported they 'always' wear a mask while going out, 69 (86.3%) CST members reported the same practice. Only 247 (37.1%) CCPC members distributed masks, and 229 (34.4%) donated soap to the underprivileged population during the last two weeks preceding the survey. The key facilitators included influential community members in the CCPC, greater acceptability of the front-line health workers, free-of-cost materials, and telemedicine services. The important barriers identified were insufficient training, irregular participation of the CCPC members, favouritism of CCPC members in distributing essential COVID-19 preventive materials, disruption in supply and shortage of the COVID-19 preventative materials, improper use of handwashing station, the non-compliant attitude of the community people, challenges to ensure home quarantine, challenges regarding telemedicine with network interruptions, lack of coordination among stakeholders, the short duration of the project.

CONCLUSIONS

Engaging the community in combination with health services through a Government-NGO partnership is a sustainable strategy for implementing the COVID-19 prevention program. Engaging the community should be promoted as an integral component of any public health intervention for sustainability. Engagement structures should incorporate a systems perspective to facilitate the relationships, ensure the quality of the delivery program, and be mindful of the heterogeneity of different community members concerning capacity building. Finally, reaching out to the underprivileged through community engagement is also an effective mechanism to progress through universal health coverage.

Health Coverage and Financial Protection in Uganda: A Political Economy Perspective

BACKGROUND

As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition.

METHODS

The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector.

RESULTS

We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship.

CONCLUSION

By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.

A social innovation model for equitable access to quality health services for rural populations: a case from Sumpaz, a rural district of Bogota, Colombia

Background

Despite efforts to extend Universal Health Coverage in Colombia, rural and remote populations still face significant challenges in accessing equitable health services. Social innovation has been growing in Colombia as a creative response to the country’s social problems including access to healthcare. This paper presents the findings of a social innovation case study, which was implemented in the rural area of Sumapaz in  Colombia, with the purpose of holistically addressing the health needs of the local population and enhancing health service access.

Methods

A case study methodology was used to investigate and understand the process by which the Model of Integral Health Care for Rural Areas was developed and how the various strategies were defined and implemented. Qualitative methods were used in the data collection and all data was analysed using Farmer et al. staged framework on grassroots social innovation which includes growing the idea; implementing the idea; sustainability and diffusion.

Results

The social innovation model was designed as a co-learning process based on community participation. The model was implemented adopting a holistic health approach and considerate of the conditions of a rural context. As a result of this process, access to quality health services were enhanced for the vulnerable rural community. The model has also provided outcomes that transcend health and contribute to individual and community development in different areas eg. agriculture.

Conclusion

The Model of Integral Health Care for Rural Areas is a social innovation in health that demonstrates how Universal Health Coverage can be achieved for vulnerable populations through a series of creative strategies which fill systemic voids in access and co-ordination of care, as well as in addresings upstream environmental factors responsible for ill-health.

'It is not fashionable to suffer nowadays': Community motivations to repeatedly participate in outreach HIV testing indicate UHC potential in Tanzania

Objective

This study examined people’s motivations for (repeatedly) utilizing HIV testing services during community-based testing events in urban and rural Shinyanga, Tanzania and potential implications for Universal Health Coverage (UHC).

Methods

As part of a broader multidisciplinary study on the implementation of a HIV Test and Treat model in Shinyanga Region, Tanzania, this ethnographic study focused on community-based testing campaigns organised by the implementing partner. Between April 2018 and December 2019, we conducted structured observations (24), short questionnaires (42) and in-depth interviews with HIV-positive (23) and HIV-negative clients (8). Observations focused on motivations for (re-)testing, and the counselling and testing process. Thematic analysis based on inductive and deductive coding was completed using NVivo software.

Results

Regular HIV testing was encouraged by counsellors. Most participants in testing campaigns were HIV-negative; 51.1% had tested more than once over their lifetimes. Testing campaigns provided an accessible way to learn one’s HIV status. Motivations for repeat testing included: monitoring personal health to achieve (temporary) reassurance, having low levels of trust toward sexual partners, feeling at risk, seeking proof of (ill)-health, and acting responsibly. Repeat testers also associated testing with a desire to start treatment early to preserve a healthy-looking body, should they prove HIV positive.

Conclusions

Community-based testing campaigns serve three valuable functions related to HIV prevention and treatment: 1) enable community members to check their HIV status regularly as part of a personalized prevention strategy that reinforces responsible behaviour; 2) identify recently sero-converted clients who would not otherwise be targeted; and 3) engage community with general prevention and care messaging and services. This model could be expanded to include routine management of other (chronic) diseases and provide an entry for scaling up UHC.

Reinforcing locally led solutions for universal health coverage: a logic model with applications in Benin, Namibia and Uganda

Development assistance for health programmes is often characterised as donor-led models with minimal country ownership and limited sustainability. This article presents new ways for low-income and middle-income countries to gain more control of their development assistance programming as they move towards universal health coverage (UHC). We base our findings on the experience of the African Collaborative for Health Financing Solutions (ACS), an innovative US Agency for International Development-funded project. The ACS project stems from the premise that the global health community can more effectively support UHC processes in countries if development partners change three long-standing paradigms: (1) time-limited projects to enhancing long-lasting processes, (2) fly-in/fly-out development support to leveraging and strengthening local and regional expertise and (3) static knowledge creation to supporting practical and co-developed resources that enhance learning and capture implementation experience. We assume that development partners can facilitate progress towards UHC if interventions follow five action steps, including (1) align to country demand, (2) provide evidence-based and tailored health financing technical support, (3) respond to knowledge and learnings throughout activity design and implementation, (4) foster multi-stakeholder collaboration and ownership and (5) strengthen accountability mechanisms. Since 2017, the ACS project has applied these five action steps in its implementing countries, including Benin, Namibia and Uganda. This article shares with the global health community preliminary achievements of implementing a unique, challenging but promising experience.

Risk factors, awareness of disease and use of medications in a deprived population: differences between indigent natives and undocumented migrants in Italy

BACKGROUND

Undocumented migrants experience many health problems; a comparison with a suitable control group of natives living in the same socio-economic conditions is still lacking.

METHODS

Demographic data and data on risk factors, chronic conditions and dietary habits were obtained for 6933 adults (2950 Italians and 3983 undocumented migrants) receiving medical assistance from 40 non-governmental organizations all over the country.

RESULTS

Attributed to the fact that these were unselected groups, differences were found in their demographic features, the main ones being their marital status (singles: 50.5% among Italians and 42.8% among migrants; P < 0.001). Smokers were more frequent among Italians (45.3% versus 42.7% P = 0.03); the same happened with hypertension (40.5% versus 34.5% P < 0.001). Migrants were more often overweight (44.1% versus 40.5% P < 0.001) and reporting a chronic condition (20.2% versus 14.4% P < 0.001). Among those on medications (n = 1354), Italians were fewer (n = 425) and on different medications. Differences emerged also in dietary habits.

CONCLUSIONS

Differences in health conditions exist between native-borns and undocumented migrants, not because of a bias related to socio-economic conditions. Further studies are needed to design sustainable health policies and tailored prevention plans.

The implementation of pharmaceutical services in public hospitals in Mexico: an analysis of the legal framework and organizational practice

BACKGROUND

The implementation of pharmaceutical services in hospitals contributes to the appropriate use of medicines and patient safety. However, the relationship of implementation with the legal framework and organizational practice has not been studied in depth. The objective of this research is to determine the role of these two factors (the legal framework and organizational practice) in the implementation of pharmaceutical services in public hospitals of the Ministry of Health of Mexico.

METHODS

Semi-structured interviews were conducted with four groups of actors involved. The analysis focused on the legal framework, defined as the rules, laws and regulations, and on organizational practice, defined as the implementation of the legal framework by related individuals, that is, how they put it into practice.

RESULTS

The main problems identified were the lack of alignment between the rules and the incentives for compliance. Decision-makers identified the lack of managerial capacity in hospitals as the main implementation barrier, while hospital pharmacists pointed to poor regulation and the lack of clarity of the legal framework as the problems to consider.

CONCLUSIONS

Although the legal framework related to hospital pharmaceutical services in Mexico is inadequate, organizational factors (such as adequate skills of professional pharmacists and the support of the hospital director) have facilitated gradual implementation. To improve implementation, priority should be given to evaluation and modification of the current legislation along with the development of an official minimum standard for activities and services in hospital pharmacies.

Assessing the functionality of an emergency obstetric referral system and continuum of care among public healthcare facilities in a low resource setting: an application of process mapping approach

BACKGROUND

Weak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study.

METHODS

The study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system.

RESULTS

Out of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial.

CONCLUSION

Our findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.

The values and principles underpinning community engagement approaches to tackling antimicrobial resistance (AMR)

This paper presents seven values underpinning the application of Community Engagement (CE) approaches to the One Health challenge of antimicrobial resistance (AMR) developed during an international workshop in June 2019. We define a value as a quality or standard which a CE project is aiming for, whilst a principle is an objective which underpins the value and facilitates its achievement. The values of Clarity, Creativity, (being) Evidence-led, Equity, Interdisciplinarity, Sustainability and Flexibility were identified by a network of 40 researchers and practitioners who utilise CE approaches to tackle complex One Health challenges including, but not limited to, AMR. We present our understanding of these seven values and their underlying principles as a flexible tool designed to support stakeholders within CE for AMR projects. We include practical guidance on working toward each value, plus case studies of the values in action within existing AMR interventions. Finally, we consider the extent to which CE approaches are appropriate to tackle AMR challenges. We reflect on these in relation to the tool, and current literature for both CE and AMR research. Authors and co-producers anticipate this tool being used to scene-set, road map and trouble shoot the development, implementation, and evaluation of CE projects to address AMR and other One Health challenges. However, the tool is not prescriptive but responsive to the context and needs of the community, opening opportunity to build a truly collaborative and community-centred approach to AMR research.