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Sieleunou I, Enok Bonong RP. Does health voucher intervention increase antenatal consultations and skilled birth attendances in Cameroon? Results from an interrupted time series analysis. BMC Health Serv Res 2024; 24:602. [PMID: 38720364 PMCID: PMC11080306 DOI: 10.1186/s12913-024-10962-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Limited access to health services during the antenatal period and during childbirth, due to financial barriers, is an obstacle to reducing maternal and child mortality. To improve the use of health services in the three regions of Cameroon, which have the worst reproductive, maternal, neonatal, child and adolescent health indicators, a health voucher project aiming to reduce financial barriers has been progressively implemented since 2015 in these three regions. Our research aimed to assess the impact of the voucher scheme on first antenatal consultation (ANC) and skilled birth attendance (SBA). METHODS Routine aggregated data by month over the period January 2013 to May 2018 for each of the 33 and 37 health facilities included in the study sample were used to measure the effect of the voucher project on the first ANC and SBA, respectively. We estimated changes attributable to the intervention in terms of the levels of outcome indicators immediately after the start of the project and over time using an interrupted time series regression. A meta-analysis was used to obtain the overall estimates. RESULTS Overall, the voucher project contributed to an immediate and statistically significant increase, one month after the start of the project, in the monthly number of ANCs (by 26%) and the monthly number of SBAs (by 57%). Compared to the period before the start of the project, a statistically significant monthly increase was observed during the project implementation for SBAs but not for the first ANCs. The results at the level of health facilities (HFs) were mixed. Some HFs experienced an improvement, while others were faced with the status quo or a decrease. CONCLUSIONS Unlike SBAs, the voucher project in Cameroon had mixed results in improving first ANCs. These limited effects were likely the consequence of poor design and implementation challenges.
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Affiliation(s)
- Isidore Sieleunou
- The Global Financing Facility (GFF), Dakar, Senegal.
- Research for Development International, 30883, Yaoundé, Cameroon.
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Ntawukuriryayo JT, VanderZanden A, Amberbir A, Teklu A, Huda FA, Maskey M, Sall M, Garcia PJ, Subedi RK, Sayinzoga F, Hirschhorn LR, Binagwaho A. Inequity in the face of success: understanding geographic and wealth-based equity in success of facility-based delivery for under-5 mortality reduction in six countries. BMC Pediatr 2024; 23:651. [PMID: 38413911 PMCID: PMC10900542 DOI: 10.1186/s12887-023-04387-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/26/2023] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Between 2000-2015, many low- and middle-income countries (LMICs) implemented evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M). Even among LMICs successful in reducing U5M, this drop was unequal subnationally, with varying success in EBI implementation. Building on mixed methods multi-case studies of six LMICs (Bangladesh, Ethiopia, Nepal, Peru, Rwanda, and Senegal) leading in U5M reduction, we describe geographic and wealth-based equity in facility-based delivery (FBD), a critical EBI to reduce neonatal mortality which requires a trusted and functional health system, and compare the implementation strategies and contextual factors which influenced success or challenges within and across the countries. METHODS To obtain equity gaps in FBD coverage and changes in absolute geographic and wealth-based equity between 2000-2015, we calculated the difference between the highest and lowest FBD coverage across subnational regions and in the FBD coverage between the richest and poorest wealth quintiles. We extracted and compared contextual factors and implementation strategies associated with reduced or remaining inequities from the country case studies. RESULTS The absolute geographic and wealth-based equity gaps decreased in three countries, with greatest drops in Rwanda - decreasing from 50 to 5% across subnational regions and from 43 to 13% across wealth quintiles. The largest increases were seen in Bangladesh - from 10 to 32% across geography - and in Ethiopia - from 22 to 58% across wealth quintiles. Facilitators to reducing equity gaps across the six countries included leadership commitment and culture of data use; in some countries, community or maternal and child health insurance was also an important factor (Rwanda and Peru). Barriers across all the countries included geography, while country-specific barriers included low female empowerment subnationally (Bangladesh) and cultural beliefs (Ethiopia). Successful strategies included building on community health worker (CHW) programs, with country-specific adaptation of pre-existing CHW programs (Rwanda, Ethiopia, and Senegal) and cultural adaptation of delivery protocols (Peru). Reducing delivery costs was successful in Senegal, and partially successful in Nepal and Ethiopia. CONCLUSION Variable success in reducing inequity in FBD coverage among countries successful in reducing U5M underscores the importance of measuring not just coverage but also equity. Learning from FBD interventions shows the need to prioritize equity in access and uptake of EBIs for the poor and in remote areas by adapting the strategies to local context.
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Affiliation(s)
| | | | | | | | - Fauzia Akhter Huda
- Maternal and Child Health Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | - Patricia J Garcia
- School of Public Health at Cayetano, Heredia University, Lima, Peru
- Global Health Department, University of Washington, Seattle, WA, USA
| | | | - Felix Sayinzoga
- Rwanda Biomedical Center, Maternal, Child, and Community Health Division, Kigali, Rwanda
| | - Lisa R Hirschhorn
- University of Global Health Equity, Kigali, Rwanda
- Northwestern University, Chicago, IL, USA
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Midhet F, Hanif M, Khalid SN, Khan RS, Ahmad I, Khan SA. Factors associated with maternal health services utilization in Pakistan: Evidence from Pakistan maternal mortality survey, 2019. PLoS One 2023; 18:e0294225. [PMID: 37972097 PMCID: PMC10653445 DOI: 10.1371/journal.pone.0294225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 10/30/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND This study investigates the factors associated with maternal health services utilization in Pakistan using two outcome indicators, ideal antenatal care (IANC), defined as the pregnant woman receiving all the essential services included in standard antenatal care, and skilled birth attendance (SBA). METHODS This study used the Pakistan Maternal Mortality Survey 2019 data. The study utilized binary logistic regression models to investigate the adjusted association between the outcome variables, separately for IANC and SBA, and the independent variables, education, wealth, parity, and residence. RESULTS Wealth showed a positive association with utilization of IANC (adjusted odds ratio [AOR] = 11.48, 95% CI = 7.76, 16.99) and SBA (AOR = 4.37, 95% CI = 3.30,5. 80). Maternal age was associated only with IANC for women aged 35 or more years (AOR = 1.31, 95% CI = 1.06, 1.62). Increased likelihood of utilization of IANC and SBA services was also observed for women with formal education. Women who had 3-5 previous live births had higher odds of using IANC and SBA than women who had 1-2 or more than five previous live births. Urban residency was not correlated with either IANC or SBA. CONCLUSION When compared to the wealthy and educated quintile, women in the lower wealth quintile and those without any formal education were less likely to utilize ANC and SBA services. A comprehensive and multipronged approach from the health and education sectors is needed to improve maternal health in Pakistan.
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Koy S, Fuerst F, Tuot B, Starke M, Flessa S. The Flipped Break-Even: Re-Balancing Demand- and Supply-Side Financing of Health Centers in Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1228. [PMID: 36674006 PMCID: PMC9858853 DOI: 10.3390/ijerph20021228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 06/17/2023]
Abstract
Supply-side healthcare financing still dominates healthcare financing in many countries where the government provides line-item budgets for health facilities irrespective of the quantity or quality of services rendered. There is a risk that this approach will reduce the efficiency of services and the value of money for patients. This paper analyzes the situation of public health centers in Cambodia to determine the relevance of supply- and demand-side financing as well as lump sum and performance-based financing. Based on a sample of the provinces of Kampong Thom and Kampot in the year 2019, we determined the income and expenditure of each facility and computed the unit cost with comprehensive step-down costing. Furthermore, the National Quality Enhancement Monitoring Tool (NQEMT) provided us with a quality score for each facility. Finally, we calculated the efficiency as the quotient of quality and cost per service unit as well as correlations between the variables. The results show that the largest share of income was received from supply-side financing, i.e., the government supports the health centers with line-item budgets irrespective of the number of patients and the quality of care. This paper demonstrates that the efficiency of public health centers increases if the relevance of performance-based financing increases. Thus, the authors recommend increasing performance-based financing in Cambodia to improve value-based healthcare. There are several alternatives available to re-balance demand- and supply-side financing, and all of them must be thoroughly analyzed before they are implemented.
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Affiliation(s)
- Sokunthea Koy
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Franziska Fuerst
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Bunnareth Tuot
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Maurice Starke
- Improving Social Protection and Health, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh 120102, Cambodia
| | - Steffen Flessa
- Department of Health Care Management, University of Greifswald, 17487 Greifswald, Germany
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Determinants of Maternal Satisfaction with the Quality of Childbirth Services in a University Hospital in Kumasi, Ghana: A Cross-Sectional Study. BIOMED RESEARCH INTERNATIONAL 2022. [DOI: 10.1155/2022/9984113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction. Rendering quality childbirth services that lead to higher levels of maternal satisfaction is an important goal of every health institution. Despite efforts at enhanced client satisfaction over the years, there are still some quality concerns for health policymakers and managers to address. This study sought to assess maternal satisfaction with childbirth services at a university hospital in Kumasi, Ghana. Methods. We conducted a facility-based cross-sectional study among women in postnatal wards after delivery at the University Hospital, Kwame Nkrumah University of Science and Technology. They were recruited using a systematic sampling method, and their perspective about the quality of childbirth services was assessed using a service quality (SERVQUAL) tool. Linear regression analysis was performed to identify the relationship between SERVQUAL attributes and maternal satisfaction. Statistical significance was set at
value < 0.05 at a 95% confidence interval. Results. Of the 277 participants interviewed, 79.8% (221) were satisfied with the childbirth services. Delays (49.5%), unprofessional conduct from health workers (7.2%), poor facilities (10.8%), and an inadequate number of skilled staff (15.5%) were identified as the challenges mothers encountered at the facility. After adjusting for all the components of the SERVQUAL model, reliability (adjusted
,
) and empathy (adjusted
,
) were the most significant predictors of maternal satisfaction with childbirth services. Conclusion. Majority of postnatal women were generally satisfied with the overall childbirth services they received at the University Hospital. The service quality components that significantly predicted maternal satisfaction with childbirth services were “reliability” and “empathy.”
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Sripad P, Merritt MW, Kerrigan D, Abuya T, Ndwiga C, Warren CE. Determining a Trusting Environment for Maternity Care: A Framework Based on Perspectives of Women, Communities, Service Providers, and Managers in Peri-Urban Kenya. Front Glob Womens Health 2022; 3:818062. [PMID: 35528311 PMCID: PMC9069110 DOI: 10.3389/fgwh.2022.818062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 03/17/2022] [Indexed: 11/18/2022] Open
Abstract
Trust in health service providers and facilities is integral to health systems accountability. Understanding determinants of trust, a relational construct, in maternity settings necessitates exploring hierarchical perspectives of users, providers, and influencers in the care environment. We used a theoretically driven qualitative approach to explore trust determinants in a maternity setting across patient-provider, inter-provider, and community-policymaker interactions and relationships in peri-urban Kenya. Focus groups (n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews (n = 33) with WRB, health care providers and managers, and community health workers (CHWs) were conducted in 2013, soon after the national government's March 2013 introduction of a policy mandate for "Free Maternity Care." We used thematic coding, memo writing, and cross-perspective triangulation to develop a multi-faceted trust determinants framework. We found that determinants of trust in a maternity setting can be broadly classified into six types of factors, where each type of factor represents a cluster of determinants that may each positively or negatively influence trust: patient, provider, health facility, community, accountability, and structural. Patient factors are prior experiences, perceived risks and harms, childbirth outcomes, and maternal health literacy. Provider factors are empathy and respect, responsiveness, and perceived capability of providers. Health facility factors are "good services" as perceived by patients, physical environment, process navigability, provider collaboration and oversight, discrimination, and corruption. Community factors are facility reputation and history, information channels, and maternal health literacy. Accountability factors are alignment of actions with expectations, adaptations to policy changes, and voice and feedback. Structural factors are institutional hierarchies and policies in the form of professional codes. Trust determinants are complex, nuanced and reflect power dynamics across relationships. Findings offer insight into socio-political maternity norms and demand a more equitable care interface between users and providers.
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Affiliation(s)
- Pooja Sripad
- Population Council, Washington, DC, United States
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Maria W. Merritt
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, United States
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
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Nimako K, Gage A, Benski C, Roder-DeWan S, Ali K, Kandie C, Mohamed A, Odeny H, Oloo M, Otieno JTB, Wanzala M, Okumu R, Kruk ME. Health System Redesign to Shift to Hospital Delivery for Maternal and Newborn Survival: Feasibility Assessment in Kakamega County, Kenya. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:1000-1010. [PMID: 34933993 PMCID: PMC8691889 DOI: 10.9745/ghsp-d-20-00684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
Maternal and newborn health (MNH) service delivery redesign aims to improve maternal and newborn survival by shifting deliveries from poorly equipped primary care facilities to adequately prepared designated delivery hospitals. We assess the feasibility of such a model in Kakamega County, Kenya, by determining the capacity of hospitals to provide services under the redesigned model and the acceptability of the concept to providers and users. We find many existing system assets to implement redesign, including political will to improve MNH outcomes, a strong base of support among providers and users, and a good geographic spread of facilities to support implementation. There are nonetheless health workforce gaps, infrastructure deficits, and transportation challenges that would need to be addressed ahead of policy rollout. Implementing MNH redesign would require careful planning to limit unintended consequences and rigorous evaluation to assess impact and inform scale-up.
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Affiliation(s)
- Kojo Nimako
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Anna Gage
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Caroline Benski
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Khatra Ali
- Kenya Council of Governors, Nairobi, Kenya
| | | | | | - Hellen Odeny
- Kakamega County Department of Health, Kakamega County, Kenya
| | - Micky Oloo
- Department of Public Health, Masinde Muliro University of Science and Technology, Kakamega County, Kenya
| | | | - Maximilla Wanzala
- Department of Public Health, Masinde Muliro University of Science and Technology, Kakamega County, Kenya
| | - Rachel Okumu
- Kakamega County Department of Health, Kakamega County, Kenya
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Lee S, Adam AJ. Designing a Logic Model for Mobile Maternal Health e-Voucher Programs in Low- and Middle-Income Countries: An Interpretive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:295. [PMID: 35010561 PMCID: PMC8744962 DOI: 10.3390/ijerph19010295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/25/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
Despite the increasing transition from paper vouchers to mobile e-vouchers for maternal health in low- and middle-income countries, few studies have reviewed key elements for program planning, implementation, and evaluation. To bridge this gap, this study conducted an interpretive review and developed a logic model for mobile maternal health e-voucher programs. Pubmed, EMBASE, and Cochrane databases were searched to retrieve relevant studies; 27 maternal health voucher programs from 84 studies were identified, and key elements for the logic model were retrieved and organized systematically. Some of the elements identified have the potential to be improved greatly by shifting to mobile e-vouchers, such as payment via mobile money or electronic claims processing and data entry for registration. The advantages of transitioning to mobile e-voucher identified from the logic model can be summarized as scalability, transparency, and flexibility. The present study contributes to the literature by providing insights into program planning, implementation, and evaluation for mobile maternal health e-voucher programs.
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Affiliation(s)
- Seohyun Lee
- Department of Global Public Administration, Mirae Campus, Yonsei University, Wonju 26493, Korea
| | - Abdul-jabiru Adam
- Department of Public Administration, Mirae Campus, Yonsei University Graduate School, Wonju 26493, Korea;
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Predictors and Utilization of Health Institution Services for Childbirth among Mothers in a Southern Nigerian City. Obstet Gynecol Int 2021; 2021:6618676. [PMID: 34917151 PMCID: PMC8670964 DOI: 10.1155/2021/6618676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 07/14/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Poor maternal health indices, including high maternal mortality, are among Nigeria's major public health problems. Most of these deaths can be prevented by timely access and utilization of maternity healthcare services by women. Aim/Objective. This study seeks to identify factors affecting the utilization of health facilities for the delivery of babies among mothers in Calabar, Cross River State, Nigeria. Methodology. The study was a community-based cross-sectional study. A structured questionnaire was administered to 422 women of reproductive age residents in the study area who had given birth at least once within the last five years prior to the survey using a multistage random sampling technique. Data generated were entered, coded, and analyzed using Statistical Packages for Social Sciences (SPSS version 22.0), and results were presented in tables and charts. Chi-squared tests and multiple logistic regression were used for the identification of variables associated with health facility-based delivery. Result The mean age of respondents was 27.3 years (SD = 8.4). Fifty-two percent of the respondents utilized the health facility for delivery, 89.6% attended at least one antenatal clinic (ANC), and 18.9% completed at least 3 ANC sessions. There was a statistically significant association between health facility delivery and marital status (P=0.007), education (P=0.042), and family size (P=0.002). Older women (OR = 0.7, CI = 0.169-3.714), Christians (OR = 1.9, CI = 0.093-41.1), divorcees (OR = 3.7, CI = 0.00-0.00), and respondents who registered early (first trimester) for ANC (OR = 4.9, CI = 0.78-31.48) were found to be higher users of delivery services at the health facility. Conclusion Community health intervention focusing on improving the knowledge and awareness of the significance of utilizing available delivery services at the healthcare facility should be developed and implemented.
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Sidze EM, Wekesah FM, Kisia L, Abajobir A. Inequalities in Access and Utilization of Maternal, Newborn and Child Health Services in sub-Saharan Africa: A Special Focus on Urban Settings. Matern Child Health J 2021; 26:250-279. [PMID: 34652595 PMCID: PMC8888372 DOI: 10.1007/s10995-021-03250-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The aim of this paper is to share the results of a systematic review on the state of inequalities in access to and utilization of maternal, newborn and child health (MNCH) services in the sub-Saharan African region. The focus of the review was on urban settings where growing needs and challenges have been registered over the past few years due to rapid increase in urban populations and urban slums. METHODS The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies published in English between 2000 and 2019 were included. A narrative synthesis of both qualitative and quantitative data was undertaken. The record for registration in PROSPERO was CRD42019122066. RESULTS The review highlights a great variation in MNCH services utilization across urban sub-Saharan Africa (SSA). The main aspects of vulnerability to unequal and poor MNCH services utilization in urban settings of the region include poverty, low level of education, unemployment, lower socioeconomic status and poor livelihoods, younger maternal age, low social integration and social support, socio-cultural taboos, residing in slums, and being displaced, refugee, or migrant. At the health system level, persistent inequalities are associated with distance to health facility, availability of quality services and discriminating attitudes from health care personnel. CONCLUSION Context-specific intervention programs that aim at resolving the identified barriers to access and use MNCH services, particularly for the most vulnerable segments of urban populations, are essential to improve the overall health of the region and universal health coverage (UHC) targets.
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Affiliation(s)
- E M Sidze
- African Population and Health Research Center (APHRC), APHRC Campus, 2nd Floor, Manga Close off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya.
| | - F M Wekesah
- African Population and Health Research Center (APHRC), APHRC Campus, 2nd Floor, Manga Close off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya
| | - L Kisia
- African Population and Health Research Center (APHRC), APHRC Campus, 2nd Floor, Manga Close off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya
| | - A Abajobir
- African Population and Health Research Center (APHRC), APHRC Campus, 2nd Floor, Manga Close off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya
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Roder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Glob Health 2021; 5:bmjgh-2020-002539. [PMID: 33055093 PMCID: PMC7559116 DOI: 10.1136/bmjgh-2020-002539] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 07/04/2020] [Accepted: 08/19/2020] [Indexed: 01/21/2023] Open
Abstract
Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation.
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Affiliation(s)
| | - Kojo Nimako
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Nana A Y Twum-Danso
- Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Archana Amatya
- Health and Nutrition, Save the Children, Kathmandu, Nepal
| | - Ana Langer
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Margaret Kruk
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Joiner A, Lee A, Chowa P, Kharel R, Kumar L, Caruzzo NM, Ramirez T, Reynolds L, Sakita F, Van Vleet L, von Isenburg M, Yaffee AQ, Staton C, Vissoci JRN. Access to care solutions in healthcare for obstetric care in Africa: A systematic review. PLoS One 2021; 16:e0252583. [PMID: 34086753 PMCID: PMC8177460 DOI: 10.1371/journal.pone.0252583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/18/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Emergency Medical Services (EMS) systems exist to reduce death and disability from life-threatening medical emergencies. Less than 9% of the African population is serviced by an emergency medical services transportation system, and nearly two-thirds of African countries do not have any known EMS system in place. One of the leading reasons for EMS utilization in Africa is for obstetric emergencies. The purpose of this systematic review is to provide a qualitative description and summation of previously described interventions to improve access to care for patients with maternal obstetric emergencies in Africa with the intent of identifying interventions that can innovatively be translated to a broader emergency context. METHODS The protocol was registered in the PROSPERO database (International Prospective Register of Systematic Reviews) under the number CRD42018105371. We searched the following electronic databases for all abstracts up to 10/19/2020 in accordance to PRISMA guidelines: PubMed/MEDLINE, Embase, CINAHL, Scopus and African Index Medicus. Articles were included if they were focused on a specific mode of transportation or an access-to-care solution for hospital or outpatient clinic care in Africa for maternal or traumatic emergency conditions. Exclusion criteria included in-hospital solutions intended to address a lack of access. Reference and citation analyses were performed, and a data quality assessment was conducted. Data analysis was performed using a qualitative metasynthesis approach. FINDINGS A total of 6,457 references were imported for screening and 1,757 duplicates were removed. Of the 4,700 studies that were screened against title and abstract, 4,485 studies were excluded. Finally, 215 studies were assessed for full-text eligibility and 152 studies were excluded. A final count of 63 studies were included in the systematic review. In the 63 studies that were included, there was representation from 20 countries in Africa. The three most common interventions included specific transportation solutions (n = 39), community engagement (n = 28) and education or training initiatives (n = 27). Over half of the studies included more than one category of intervention. INTERPRETATION Emergency care systems across Africa are understudied and interventions to improve access to care for obstetric emergencies provides important insight into existing solutions for other types of emergency conditions. Physical access to means of transportation, efforts to increase layperson knowledge and recognition of emergent conditions, and community engagement hold the most promise for future efforts at improving emergency access to care.
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Affiliation(s)
- Anjni Joiner
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Austin Lee
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Phindile Chowa
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Ramu Kharel
- Division of Global Emergency Medicine, Department of Emergency Medicine, Brown University, Providence, RI, United States of America
| | - Lekshmi Kumar
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Nayara Malheiros Caruzzo
- Physical Education Department, State University of Maringá, Maringá, PR, United States of America
| | - Thais Ramirez
- Duke Global Health Institute, Durham, NC, United States of America
| | - Lindy Reynolds
- University of Alabama School of Public Health, Birmingham, AL, United States of America
| | - Francis Sakita
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Lee Van Vleet
- Durham County Emergency Services, Durham, NC, United States of America
| | - Megan von Isenburg
- Medical Center Library, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Anna Quay Yaffee
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Catherine Staton
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Department of Surgery, Duke University School of Medicine, Durham, NC, United States of America
- Duke Global Health Institute, Durham, NC, United States of America
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Ojifinni OO, Popoola OA. Pregnancy experiences and maternal health service utilisation among female traders in Ibadan, Nigeria. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-019-01120-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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14
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The Nairobi Urban Health and Demographic Surveillance of slum dwellers, 2002–2019: Value, processes, and challenges. GLOBAL EPIDEMIOLOGY 2020. [DOI: 10.1016/j.gloepi.2020.100024] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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15
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Mac-Seing M, Zinszer K, Oga Omenka C, de Beaudrap P, Mehrabi F, Zarowsky C. Pro-equity legislation, health policy and utilisation of sexual and reproductive health services by vulnerable populations in sub-Saharan Africa: a systematic review. Glob Health Promot 2020; 27:97-106. [PMID: 32748728 PMCID: PMC7750661 DOI: 10.1177/1757975920941435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Twenty-five years ago, the International Conference on Population and
Development highlighted the need to address sexual and reproductive
health (SRH) rights on a global scale. The sub-Saharan Africa region
continues to have the highest levels of maternal mortality and HIV,
primarily affecting the most vulnerable populations. Recognising the
critical role of policy in understanding population health, we
conducted a systematic review of original primary research which
examined the relationships between equity-focused legislation and
policy and the utilisation of SRH services by vulnerable populations
in sub-Saharan Africa. We searched nine bibliographic databases for
relevant articles published between 1994 and 2019. Thirty-two studies,
conducted in 14 sub-Saharan African countries, met the inclusion
criteria. They focused on maternal health service utilisation, either
through specific fee reduction/removal policies, or through healthcare
reforms and insurance schemes to increase SRH service utilisation.
Findings across most of the studies showed that health-related
legislation and policy promoted an increase in service utilisation,
over time, especially for antenatal care, skilled birth attendance and
facility-based delivery. However, social health inequalities persisted
among subgroups of women. Neither the reviewed studies nor the
policies specifically addressed youth, people living with HIV and
people with disabilities. In the era of the sustainable development
goals, addressing health inequities in the context of social
determinants of health becomes unavoidable. Systematic and rigorous
quantitative and qualitative research, including longitudinal policy
evaluation, is required to understand the complex relationships
between policy addressing upstream social determinants of health and
health service utilisation.
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Affiliation(s)
- Muriel Mac-Seing
- Department of Social and
Preventive Medicine, School of Public Health, Université de Montréal,
Montreal, Canada
- Centre de recherche en santé
publique, Université de Montréal et CIUSSS du
Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
- Muriel Mac-Seing, Department of
Social and Preventive Medicine, School of Public Health, Université de
Montréal, and Centre de recherche en santé publique, Université de
Montréal et CIUSSS du Centre-Sud-de-l’Île-de-Montréal, 7101, Parc
avenue, 3rd floor, Montreal, Quebec, H3N 1X9, Canada.
| | - Kate Zinszer
- Department of Social and
Preventive Medicine, School of Public Health, Université de Montréal,
Montreal, Canada
- Centre de recherche en santé
publique, Université de Montréal et CIUSSS du
Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
| | - Charity Oga Omenka
- Department of Social and
Preventive Medicine, School of Public Health, Université de Montréal,
Montreal, Canada
- Centre de recherche en santé
publique, Université de Montréal et CIUSSS du
Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
| | - Pierre de Beaudrap
- Centre Population et Développement
(CEPED), Institut de recherche pour le développement, Paris, France
| | - Fereshteh Mehrabi
- Centre de recherche en santé
publique, Université de Montréal et CIUSSS du
Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
- Department of Health Management,
Evaluation and Health Policy, School of Public Health, Université de
Montréal, Montreal, Canada
| | - Christina Zarowsky
- Department of Social and
Preventive Medicine, School of Public Health, Université de Montréal,
Montreal, Canada
- Centre de recherche en santé
publique, Université de Montréal et CIUSSS du
Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
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16
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Mobile Money Use and Healthcare Utilization: Evidence from Rural Uganda. SUSTAINABILITY 2020. [DOI: 10.3390/su12093741] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Lack of cash on hand is a significant obstacle in accessing healthcare services in developing countries. Many expectant mothers in the least developed countries do not receive sufficient care during pregnancy due to financial constraints. If such hurdles in accessing healthcare can be overcome, it will contribute to reduction in maternal and newborn mortality, which is a key target of Sustainable Development Goal 3. This study reports the first assessment of the impact of mobile money services on maternal care utilization. We hypothesize that mobile money adoption would motivate rural Ugandan women to receive antenatal care and to deliver their children at health facilities or with skilled birth attendants. By receiving remittances utilizing mobile money, poor rural households may obtain more cash in hand, which might change women’s health-seeking behavior. We apply community- and mother-fixed effects models with heterogeneity analysis to longitudinal panel data (the RePEAT [Research on Poverty, Environment, and Agricultural Technology] survey) of three waves (2009, 2012, and 2015). The analysis uses pregnancy reports of 2007–2015 from 586 rural Ugandan households. We find suggestive evidence that mobile money adoption positively affects the take-up of antenatal care. Heterogeneity analysis indicates that mobile money brings a larger benefit to geographically challenged households by easing their liquidity constraint as they face higher cost of traveling to distant health facilities. The models failed to reject the null hypothesis of no mobile money effect on the delivery-related outcome variables. This study suggests that promoting financial inclusion by means of mobile money motivates women in rural and remote areas to make antenatal care visits while the evidence of such effect is not found for take-up of facility delivery or delivery with skilled birth attendants.
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Nkangu MN, Okwen PM, Mbuagbaw L, Weledji DK, Roberts JH, Yaya S. A protocol for a pilot cluster randomized control trial of e-vouchers and mobile phone application to enhance access to maternal health services in Cameroon. Pilot Feasibility Stud 2020; 6:45. [PMID: 32313683 PMCID: PMC7155248 DOI: 10.1186/s40814-020-00589-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/20/2020] [Indexed: 01/26/2023] Open
Abstract
Background Cameroon still has relatively high maternal mortality rate (MMR) of 596/100,000 live births. Approximately 40% of births are unattended by skilled healthcare personnel with high out-of-pocket expenditures. Poor resource allocation, poorly functioning referral systems, long trekking distances to health facilities, all of which lead to low rates of use of maternal health services. Objectives The aim of this pilot study is to explore perception and acceptability of mobile health (mhealth) and e-voucher and to determine the feasibility of conducting a large cluster randomized trial to determine the effects of combining e-vouchers and a mobile application compared with usual care in improving access to and use of maternal health services. Methods This is a multimethod study that comprises two phases. The first phase is the development of the mobile phone app, which includes a qualitative formative study through in-depth key informant interviews and focus group discussions. The second phase is a cluster randomized control trial assessing the combination of e-vouchers and a mobile application compared with usual care in improving access to and use of maternal health services. Feasibility will be determined based on evaluating randomization, contamination, enrollment rate, complete follow up, compliance rate, success in matching data from different sources, and data completeness. Ethics and discussion Ethics approval has been granted, and the trial has been registered in the Pan-African Clinical Trials Registry. We will disseminate our findings through peer-reviewed manuscripts and conference presentations. Findings from this study will inform the design and conduct of a larger randomized trial. Trial registration PACTR201808703097367. The trial on the Pan African Clinical Trials Registry.
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Affiliation(s)
- Miriam N Nkangu
- 1School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,Health Promotion Alliance Cameroon (HPAC), Yaounde, Cameroon.,9WHO Collaborating Center for Knowledge Translation and Health Technology Assessment in Health Equity, Ottawa University, Ottawa, Canada.,10Bruyere Research Institute, Ottawa, Canada
| | | | - Lawrence Mbuagbaw
- 3Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.,4Biostatistics Unit, The Research Institute, St Joseph's Healthcare Hamilton, Hamilton, Canada.,Centre for the Development of Best Practices in Health, Yaounde, Cameroon
| | | | - Janet Hatcher Roberts
- 1School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada.,9WHO Collaborating Center for Knowledge Translation and Health Technology Assessment in Health Equity, Ottawa University, Ottawa, Canada.,10Bruyere Research Institute, Ottawa, Canada
| | - Sanni Yaya
- 8School of International Development and Global Studies, University of Ottawa, Ottawa, Canada
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18
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Mahmood SS, Amos M, Hoque S, Mia MN, Chowdhury AH, Hanifi SMA, Iqbal M, Stones W, Pallikadavath S, Bhuiya A. Does healthcare voucher provision improve utilisation in the continuum of maternal care for poor pregnant women? Experience from Bangladesh. Glob Health Action 2020; 12:1701324. [PMID: 31825301 PMCID: PMC6913632 DOI: 10.1080/16549716.2019.1701324] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Improving maternal health is a major development goal, with ambitious targets set for high-mortality countries like Bangladesh. Following a steep decline in the maternal mortality ratio over the past decade in Bangladesh, progress has plateaued at 196/100,000 live births. A voucher scheme was initiated in 2007 to reduce financial, geographical and institutional barriers to access for the poorest. Objective: The current paper reports the effect of vouchers on the use of continuum of maternal care. Methods: Cross-sectional surveys were carried out in the Chattogram and Sylhet divisions of Bangladesh in 2017 among 2400 women with children aged 0–23 months. Using Cluster analysis utilisation groups for antenatal care, facility delivery and postnatal care were formed. Clusters were regressed on voucher receipt to identify the underlying relationship between voucher receipt and utilisation of care while controlling for possible confounders. Results: Four clusters with varying levels of utilisation were identified. A significantly higher proportion of voucher-recipients belonged to the high-utilisation cluster compared to non-voucher recipients (43.5% vs. 15.4%). For the poor voucher recipients, the probability of belonging to the high-utilisation cluster was higher compared to poor non-voucher recipients (33.3% vs. 6.8%) and the probability of being in the low-utilisation cluster was lower than poor non-voucher recipients (13.3% vs. 55.4%). Conclusion: The voucher programme enhanced uptake of the complete continuum of maternal care and the benefits extended to the most vulnerable women. However, a lack of continued transition through the continuum of maternal care was identified. This insight can assist in designing effective interventions to prevent intermittent or interrupted care-seeking. Programmes that improve access to quality healthcare in pregnancy, childbirth and the postnatal period can have wide-ranging benefits. A coherent continuum-based approach to understanding maternal care-seeking behaviour is thus expected to have a greater impact on maternal, newborn and child health outcomes.
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Affiliation(s)
| | - Mark Amos
- Portsmouth Brawajaya Centre for Global Health, University of Portsmouth, Portsmouth, UK
| | - Shahidul Hoque
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Mohammad Nahid Mia
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Asiful Haidar Chowdhury
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh.,IMPACT study, ARK Foundation, Dhaka, Bangladesh
| | | | - Mohammad Iqbal
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - William Stones
- College of Medicine, University of Malawi, Blantyre, Malawi
| | | | - Abbas Bhuiya
- Portsmouth Brawajaya Centre for Global Health, University of Portsmouth, Portsmouth, UK
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19
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Asaolu I, Nuño VL, Ernst K, Taren D, Ehiri J. Healthcare system indicators associated with modern contraceptive use in Ghana, Kenya, and Nigeria: evidence from the Performance Monitoring and Accountability 2020 data. Reprod Health 2019; 16:152. [PMID: 31655615 PMCID: PMC6814992 DOI: 10.1186/s12978-019-0816-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 09/23/2019] [Indexed: 11/10/2022] Open
Abstract
Background Public health literature is replete with evidence on individual and interpersonal indicators of modern contraceptive use. There is, however, limited knowledge regarding healthcare system indicators of modern contraceptive use. This study assessed how the healthcare system influences use of modern contraceptive among women in Ghana, Kenya, and two large population states in Nigeria. Methods This study used data from Phase 1 of the Performance Monitoring and Accountability 2020. The analytical sample was limited to women with a need for contraception, defined as women of reproductive age (15 to 49 years) who wish to delay or limit childbirth. Therefore, this analysis consisted of 1066, 1285, and 1955 women from Nigeria, Ghana, and Kenya respectively. Indicators of healthcare assessed include user-fees, visit by health worker, type of health facility, multiple perinatal services, adolescent reproductive healthcare, density of healthcare workers, and regularity of contraceptive services. All analyses were conducted with SAS (9.4), with statistical significance set at p < 5%. Results The prevalence of modern contraceptive was 22.7, 33.2, and 68.9% in Nigeria, Ghana, and Kenya respectively. The odds of modern contraceptive use were higher among Nigerian women who lived within areas that provide adolescent reproductive healthcare (OR = 2.05; 95% C.I. = 1.05—3.99) and Kenyan women residing in locales with polyclinic or hospitals (OR = 1.91; 1.27—2.88). Also, the odds of contraceptive use were higher among Kenyan women who lived in areas with user-fee for contraceptive services (OR = 1.40; 1.07–1.85), but lower among Ghanaian women residing in such areas (OR = 0.46; 0.23—0.92). Lastly, the odds of modern contraceptive use were higher among women visited by a health-worker visit among women in Ghana (OR = 1.63; 1.11—2.42) and Nigeria (OR = 2.97; 1.56—5.67) than those without a visit. Conclusion This study found an association between country-specific indicators of healthcare and modern contraceptive use. Evidence from this study can inform policy makers, health workers, and healthcare organizations on specific healthcare factors to target in meeting the need for contraception in Ghana, Kenya, and Nigeria.
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Affiliation(s)
- Ibitola Asaolu
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA.
| | - Velia Leybas Nuño
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
| | - Kacey Ernst
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
| | - Douglas Taren
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
| | - John Ehiri
- Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
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20
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Massavon W, Wilunda C, Nannini M, Agaro C, Amandi S, Orech JB, De Vivo E, Lochoro P, Putoto G. Community perceptions on demand-side incentives to promote institutional delivery in Oyam district, Uganda: a qualitative study. BMJ Open 2019; 9:e026851. [PMID: 31501099 PMCID: PMC6738676 DOI: 10.1136/bmjopen-2018-026851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To examine the perceptions of community members and other stakeholders on the use of baby kits and transport vouchers to improve the utilisation of childbirth services. DESIGN A qualitative study. SETTING Oyam district, Uganda. PARTICIPANTS We conducted 10 focus group discussions with 59 women and 55 men, and 18 key informant interviews with local leaders, village health team members, health facility staff and district health management team members. We analysed the data using qualitative content analysis. RESULTS Five broad themes emerged: (1) context, (2) community support for the interventions, (3) health-seeking behaviours postintervention, (4) undesirable effects of the interventions and (5) implementation issues and lessons learnt. Context regarded perceived long distances to health facilities and high transport costs. Regarding community support for the interventions, the schemes were perceived to be acceptable and helpful particularly to the most vulnerable. Transport vouchers were preferred over baby kits, although both interventions were perceived to be necessary. Health-seeking behaviours entailed perceived increased utilisation of maternal health services and 'bypassing', promotion of collaboration between traditional birth attendants and formal health workers, stimulation of men's involvement in maternal health, and increased community awareness of maternal health. Undesirable effects of the interventions included increased workload for health workers, sustainability concerns and perceived encouragement to reproduce and dependency. Implementation issues included information gaps leading to confusion, mistrust and discontent, transport voucher scheme design; implementation; and payment problems, poor attitude of some health workers and poor quality of care, insecurity, and a shortage of baby kits. Community involvement was key to solving the challenges. CONCLUSIONS The study provides further insights into the implementation of incentive schemes to improve maternal health services utilisation. The findings are relevant for planning and implementing similar schemes in low-income countries.
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Affiliation(s)
| | - Calistus Wilunda
- Maternal and Child Wellbeing Unit, African Population and Health Research Center, Nairobi, Kenya
- Division of Epidemiology and Prevention, National Cancer Center Japan, Chuo-ku, Japan
| | - Maria Nannini
- School of Economics and Development, University of Florence, Florence, Italy
| | - Caroline Agaro
- District Health Office, Oyam District Local Government, Loro, Uganda
| | - Simon Amandi
- District Health Office, Oyam District Local Government, Loro, Uganda
| | - John Bosco Orech
- District Health Office, Oyam District Local Government, Loro, Uganda
| | | | | | - Giovanni Putoto
- Operational Research Unit, Doctors with Africa CUAMM, Padua, Italy
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Satisfaction with Maternal Healthcare Services in the Ketu South Municipality, Ghana: A Qualitative Case Study. BIOMED RESEARCH INTERNATIONAL 2019; 2019:2516469. [PMID: 31093496 PMCID: PMC6481155 DOI: 10.1155/2019/2516469] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/05/2019] [Accepted: 03/31/2019] [Indexed: 11/17/2022]
Abstract
Background Women's satisfaction with maternal healthcare services is vital in quality healthcare delivery. However, the dearth of in-depth information on the issue is a challenge in Ghana. In this study, we explore women's satisfaction with maternal care services at a health facility in the Ketu South Municipality, Ghana. Methods This is a qualitative study that used a purposive sampling technique to select 15 women who attended a child welfare clinic at the facility for in-depth interviews. The interviews were tape-recorded, and the results presented in quotes in accordance with the themes that emerged. Results The study found that respondents were generally satisfied with the quality of maternal healthcare services provided to them. However, they were dissatisfied with drug administration procedures at the facility. Respondents generally reported poor attitudes on the part of healthcare providers at the health facility. Some logistics were also reported to be in unfavorable condition. Nonetheless, respondents generally had positive perceptions about maternal care services provided to them by the healthcare facility. Conclusions Drug administration procedures and attitude of healthcare providers toward clients as well as logistics need to be improved to enhance satisfaction with services at the health facility, particularly among pregnant women and mothers.
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Machiyama K, Mumah JN, Mutua M, Cleland J. Childbearing desires and behaviour: a prospective assessment in Nairobi slums. BMC Pregnancy Childbirth 2019; 19:100. [PMID: 30922262 PMCID: PMC6437922 DOI: 10.1186/s12884-019-2245-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Advancing an understanding of childbearing desires is an important precursor to achievement of the policy goal of reducing unintended pregnancies. It has been long debated that concepts of fertility desires and planning may be particularly problematic in sub-Saharan Africa. However, examination of the utility of fertility preference measures and their link to reproductive behaviour is still rare in the region. The aim of this study is to assess the predictive validity of future childbearing desires on subsequent reproduction among women living in the highly unpredictable circumstances of Nairobi slums. METHODS We used data from a longitudinal study (2007-2010) nested in the Nairobi Urban Health Demographic Surveillance System that is located in two slums in Nairobi, Kenya. We analysed baseline fertility desires among 4577 postpartum women. Cox proportional hazard model was employed to examine the effect of fertility desires on subsequent reproduction. RESULTS One-third of the women wanted no more children and 37% wanted to wait for at least five years at baseline. While two-thirds of the women who wanted to have a child soon became pregnant within three years, less than one-third of those wanting no more children became pregnant. The multivariable analysis shows that the probability of becoming pregnant among women who expressed desires to stop or delay childbearing at least for five years was 50% less than among women who wanted to have a child in two to four years. In addition to prospective fertility desires, level of woman's education, residence and ethnicity exerted important influences on implementation of baseline preferences. CONCLUSIONS Our study finds a strong link between baseline fertility desires and subsequent reproduction. A large difference in pregnancy risk was observed between those who wanted no more children and those who wanted another child. The link between a woman's stated desire to stop childbearing and subsequent childbearing is just as strong in the Nairobi slums as elsewhere. In addition, the findings revealed a pronounced gradient in pregnancy risk according to preferred spacing length, which support other evidence on the important contribution of long-term spacing or postponement to fertility decline in sub-Saharan Africa.
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Affiliation(s)
- Kazuyo Machiyama
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Joyce N Mumah
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya
| | - Michael Mutua
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya
| | - John Cleland
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Kuwawenaruwa A, Ramsey K, Binyaruka P, Baraka J, Manzi F, Borghi J. Implementation and effectiveness of free health insurance for the poor pregnant women in Tanzania: A mixed methods evaluation. Soc Sci Med 2019; 225:17-25. [DOI: 10.1016/j.socscimed.2019.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 01/24/2019] [Accepted: 02/03/2019] [Indexed: 11/25/2022]
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Dennis ML, Abuya T, Campbell OMR, Benova L, Baschieri A, Quartagno M, Bellows B. Evaluating the impact of a maternal health voucher programme on service use before and after the introduction of free maternity services in Kenya: a quasi-experimental study. BMJ Glob Health 2018; 3:e000726. [PMID: 29736273 PMCID: PMC5935164 DOI: 10.1136/bmjgh-2018-000726] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/05/2018] [Accepted: 03/26/2018] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION From 2006 to 2016, the Government of Kenya implemented a reproductive health voucher programme in select counties, providing poor women subsidised access to public and private sector care. In June 2013, the government introduced a policy calling for free maternity services to be provided in all public facilities. The concurrent implementation of these interventions presents an opportunity to provide new insights into how users adapt to a changing health financing and service provision landscape. METHODS We used data from three cross-sectional surveys to assess changes over time in use of 4+ antenatal care visits, facility delivery, postnatal care and maternal healthcare across the continuum among a sample of predominantly poor women in six counties. We conducted a difference-in-differences analysis to estimate the impact of the voucher programme on these outcomes, and whether programme impact changed after free maternity services were introduced. RESULTS Between the preintervention/roll-out phase and full implementation, the voucher programme was associated with a 5.5% greater absolute increase in use of facility delivery and substantial increases in use of the private sector for all services. After free maternity services were introduced, the voucher programme was associated with a 5.7% higher absolute increase in use of the recommended package of maternal health services; however, disparities in access to facility births between voucher and comparison counties declined. Increased use of private sector services by women in voucher counties accounts for their greater access to care across the continuum. CONCLUSIONS Our findings show that the voucher programme is associated with a modest increase in women's use of the full continuum of maternal health services at the recommended timings after free maternity services were introduced. The greater use of private sector services in voucher counties also suggests that there is need to expand women's access to acceptable and affordable providers.
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Affiliation(s)
- Mardieh L Dennis
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Oona Maeve Renee Campbell
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lenka Benova
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Angela Baschieri
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matteo Quartagno
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Keya KT, Bellows B, Rob U, Warren C. Improving Access to Delivery Care and Reducing the Equity Gap Through Voucher Program in Bangladesh: Evidence From Difference-in-Differences Analysis. INTERNATIONAL QUARTERLY OF COMMUNITY HEALTH EDUCATION 2018; 38:137-145. [PMID: 29298635 DOI: 10.1177/0272684x17749568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To test a statistically significant change in delivery by medically trained providers following introduction of a demand-side financing voucher, a population-based quasi-experimental study was undertaken, with 3,300 mothers in 2010 and 3,334 mothers at follow-up in 2012 in government-implemented voucher program and control areas. Results found that voucher program was significantly associated with increased public health facility use (difference-in-differences (DID) 13.9) and significantly increased delivery complication management care (DID 13.2) at facility although a null effect was found in facility-based delivery increase. A subset analysis of the five well-functioning facilities showed that facility deliveries increased DID 5.3 percentage points. Quintile-based analysis of all facilities showed that facility delivery increased more than threefold in lower quintile households comparing to twofold in control sites. The program needs better targeting to the beneficiaries, ensuring available gynecologist-anesthetist pair and midwives, effective monitoring, and timely fund reimbursements to facilities.
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Sripad P, Ozawa S, Merritt MW, Jennings L, Kerrigan D, Ndwiga C, Abuya T, Warren CE. Exploring Meaning and Types of Trust in Maternity Care in Peri-Urban Kenya: A Qualitative Cross-Perspective Analysis. QUALITATIVE HEALTH RESEARCH 2018; 28:305-320. [PMID: 28821220 DOI: 10.1177/1049732317723585] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Trust offers a distinctive lens on facility responsiveness during labor and birth. Though acknowledged in prior literature, limited work exists linking conceptual and empirical spheres. This study explores trust in the maternity setting in Kenya through a theoretically driven qualitative approach. Focus groups ( n = 8, N = 70) with women who recently gave birth (WRB), pregnant women, and male partners, and in-depth-interviews ( n = 33) with WRB, frontline providers, and management, were conducted in and around a peri-urban public hospital. Combined coding and memo-writing showed that trust in maternity care is nested within understandings of institutional and societal trust. Content areas of trust include confidence, communication, integrity, mutual respect, competence, fairness, confidentiality, and systems trust. Trust is relevant, multidimensional, and dynamic. Examining trust provides a basis for developing quantitative measures and reveals structural underpinnings, repercussions for trust in other health areas, and health systems inequities, which have implications for maternal health policy, programming, and service utilization.
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Affiliation(s)
| | - Sachiko Ozawa
- 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Maria W Merritt
- 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- 3 Johns Hopkins Berman Institute of Bioethics, Baltimore, Maryland, USA
| | - Larissa Jennings
- 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Deanna Kerrigan
- 2 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Massavon W, Wilunda C, Nannini M, Majwala RK, Agaro C, De Vivo E, Lochoro P, Putoto G, Criel B. Effects of demand-side incentives in improving the utilisation of delivery services in Oyam District in northern Uganda: a quasi-experimental study. BMC Pregnancy Childbirth 2017; 17:431. [PMID: 29258475 PMCID: PMC5737523 DOI: 10.1186/s12884-017-1623-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 12/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda. METHODS We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention. RESULTS Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. 'Bypassing' was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6. CONCLUSION The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system.
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Affiliation(s)
- William Massavon
- Doctors with Africa CUAMM, Aber Hospital, P. O. Box 130, Lira, Uganda
| | - Calistus Wilunda
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida Konoecho, Sakyoku, Kyoto, Kyoto, 606-8501 Japan
- Doctors with Africa CUAMM, Via San Francisco 126, 35121 Padua, Italy
| | - Maria Nannini
- School of Economics and Development, University of Florence, Via delle Pandette, 32, (50127) Florence, Italy
| | - Robert Kaos Majwala
- Doctors with Africa CUAMM, Aber Hospital, P. O. Box 130, Lira, Uganda
- Kampala Capital City Authority, Plot 1-3 Kyagwe Road, P.O. Box 7010, Kampala, Uganda
| | - Caroline Agaro
- District Health Office, Oyam District Local Government, P. O. Box 30 Loro, Oyam Town Council, Oyam, Uganda
| | - Emanuela De Vivo
- Doctors with Africa CUAMM, Aber Hospital, P. O. Box 130, Lira, Uganda
| | - Peter Lochoro
- Doctors with Africa CUAMM, Plot 3297 Church Road, P.O. Box 7214, Kampala, Uganda
| | - Giovanni Putoto
- Doctors with Africa CUAMM, Via San Francisco 126, 35121 Padua, Italy
| | - Bart Criel
- Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
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Rahman S, Choudhury AA, Khanam R, Moin SMI, Ahmed S, Begum N, Shoma NN, Quaiyum MA, Baqui AH. Effect of a package of integrated demand- and supply-side interventions on facility delivery rates in rural Bangladesh: Implications for large-scale programs. PLoS One 2017; 12:e0186182. [PMID: 29073229 PMCID: PMC5657632 DOI: 10.1371/journal.pone.0186182] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/06/2017] [Indexed: 12/03/2022] Open
Abstract
Background According to the Bangladesh Demographic and Health Survey 2014, only approximately 37 percent of women deliver in a health facility. Among the eight administrative divisions of Bangladesh, the facility delivery rate is lowest in the Sylhet division (22.6 percent) where we assessed the effect of integrated supply- and demand-side interventions on the facility-based delivery rate. Methods Population-based cohort data of pregnant women from an ongoing maternal and newborn health improvement study being conducted in a population of ~120,000 in Sylhet district were used. The study required collection and processing of biological samples immediately after delivery. Therefore, the project assembled various strategies to increase institutional delivery rates. The supply-side intervention included capacity expansion of the health facilities through service provider refresher training, 24/7 service coverage, additions of drugs and supplies, and incentives to the providers. The demand-side component involved financial incentives to cover expenses, a provision of emergency transport, and referral support to a tertiary-level hospital. We conducted a before-and-after observational study to assess the impact of the intervention in a total of 1,861 deliveries between December 2014 and November 2016. Results Overall, implementation of the intervention package was associated with 52.6 percentage point increase in the proportions of facility-based deliveries from a baseline rate of 25.0 percent to 77.6 percent in 24 months. We observed lower rates of institutional deliveries when only supply-side interventions were implemented. The proportion rose to 47.1 percent and continued increasing when the project emphasized addressing the financial barriers to accessing obstetric care in a health facility. Conclusions An integrated supply- and demand-side intervention was associated with a substantial increase in institutional delivery. The package can be tailored to identify which combination of interventions may produce the optimum result and be scaled. Rigorous implementation research studies are needed to draw confident conclusions and to provide information about the costs, feasibility for scale-up and sustainability.
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Affiliation(s)
- Sayedur Rahman
- Johns Hopkins University-Bangladesh, Dhaka, Bangladesh
- * E-mail:
| | | | - Rasheda Khanam
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | | | | | - Nazma Begum
- Johns Hopkins University-Bangladesh, Dhaka, Bangladesh
| | | | - Md Abdul Quaiyum
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh
| | - Abdullah H. Baqui
- International Center for Maternal and Newborn Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Hunter BM, Murray SF. Demand-side financing for maternal and newborn health: what do we know about factors that affect implementation of cash transfers and voucher programmes? BMC Pregnancy Childbirth 2017; 17:262. [PMID: 28854877 PMCID: PMC5577737 DOI: 10.1186/s12884-017-1445-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 08/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Demand-side financing (DSF) interventions, including cash transfers and vouchers, have been introduced to promote maternal and newborn health in a range of low- and middle-income countries. These interventions vary in design but have typically been used to increase health service utilisation by offsetting some financial costs for users, or increasing household income and incentivising 'healthy behaviours'. This article documents experiences and implementation factors associated with use of DSF in maternal and newborn health. METHODS A secondary analysis (using an adapted Supporting the Use of Research Evidence framework - SURE) was performed on studies that had previously been identified in a systematic review of evidence on DSF interventions in maternal and newborn health. RESULTS The article draws on findings from 49 quantitative and 49 qualitative studies. The studies give insights on difficulties with exclusion of migrants, young and multiparous women, with demands for informal fees at facilities, and with challenges maintaining quality of care under increasing demand. Schemes experienced difficulties if communities faced long distances to reach participating facilities and poor access to transport, and where there was inadequate health infrastructure and human resources, shortages of medicines and problems with corruption. Studies that documented improved care-seeking indicated the importance of adequate programme scope (in terms of programme eligibility, size and timing of payments and voucher entitlements) to address the issue of concern, concurrent investments in supply-side capacity to sustain and/or improve quality of care, and awareness generation using community-based workers, leaders and women's groups. CONCLUSIONS Evaluations spanning more than 15 years of implementation of DSF programmes reveal a complex picture of experiences that reflect the importance of financial and other social, geographical and health systems factors as barriers to accessing care. Careful design of DSF programmes as part of broader maternal and newborn health initiatives would need to take into account these barriers, the behaviours of staff and the quality of care in health facilities. Research is still needed on the policy context for DSF schemes in order to understand how they become sustainable and where they fit, or do not fit, with plans to achieve equitable universal health coverage.
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Affiliation(s)
- Benjamin M. Hunter
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS UK
| | - Susan F. Murray
- King’s College London, Department of International Development, The Strand, London, WC2R 2LS UK
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Hunter BM, Harrison S, Portela A, Bick D. The effects of cash transfers and vouchers on the use and quality of maternity care services: A systematic review. PLoS One 2017; 12:e0173068. [PMID: 28328940 PMCID: PMC5362260 DOI: 10.1371/journal.pone.0173068] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 02/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cash transfers and vouchers are forms of 'demand-side financing' that have been widely used to promote maternal and newborn health in low- and middle-income countries during the last 15 years. METHODS This systematic review consolidates evidence from seven published systematic reviews on the effects of different types of cash transfers and vouchers on the use and quality of maternity care services, and updates the systematic searches to June 2015 using the Joanna Briggs Institute approach for systematic reviewing. The review protocol for this update was registered with PROSPERO (CRD42015020637). RESULTS Data from 51 studies (15 more than previous reviews) and 22 cash transfer and voucher programmes suggest that approaches tied to service use (either via payment conditionalities or vouchers for selected services) can increase use of antenatal care, use of a skilled attendant at birth and in the case of vouchers, postnatal care too. The strongest evidence of positive effect was for conditional cash transfers and uptake of antenatal care, and for vouchers for maternity care services and birth with a skilled birth attendant. However, effects appear to be shaped by a complex set of social and healthcare system barriers and facilitators. Studies have typically focused on an initial programme period, usually two or three years after initiation, and many lack a counterfactual comparison with supply-side investment. There are few studies to indicate that programmes have led to improvements in quality of maternity care or maternal and newborn health outcomes. CONCLUSION Future research should use multiple intervention arms to compare cost-effectiveness with similar investment in public services, and should look beyond short- to medium-term service utilisation by examining programme costs, longer-term effects on service utilisation and health outcomes, and the equity of those effects.
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Affiliation(s)
- Benjamin M. Hunter
- Department of International Development, King’s College London, London, United Kingdom
| | - Sean Harrison
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Debra Bick
- Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, United Kingdom
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Black RE, Levin C, Walker N, Chou D, Liu L, Temmerman M. Reproductive, maternal, newborn, and child health: key messages from Disease Control Priorities 3rd Edition. Lancet 2016; 388:2811-2824. [PMID: 27072119 DOI: 10.1016/s0140-6736(16)00738-8] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
As part of Disease Control Priorities 3rd Edition, the World Bank will publish a volume on Reproductive, Maternal, Newborn, and Child Health that identifies essential cost-effective health interventions that can be scaled up to reduce maternal, newborn, and child deaths, and stillbirths. This Review summarises the volume's key findings and estimates the effect and cost of expanded implementation of these interventions. Recognising that a continuum of care from the adolescent girl, woman, or mother to child is needed, the volume includes details of preventive and therapeutic health interventions in integrated packages: Maternal and Newborn Health and Child Health (along with folic acid supplementation, a key reproductive health intervention). Scaling up all interventions in these packages from coverage in 2015 to hypothetically immediately achieve 90% coverage would avert 149 000 maternal deaths, 849 000 stillbirths, 1 498 000 neonatal deaths, and 1 515 000 additional child deaths. In alternative calculations that consider only the effects of reducing the number of pregnancies by provision of contraceptive services as part of a Reproductive Health package, meeting 90% of the unmet need for contraception would reduce global births by almost 28 million and consequently avert deaths that could have occurred at 2015 rates of fertility and mortality. Thus, 67 000 maternal deaths, 440 000 neonatal deaths, 473 000 child deaths, and 564 000 stillbirths could be averted from avoided pregnancies. Particularly effective interventions in the Maternal and Newborn Health and Child Health packages would be management of labour and delivery, care of preterm births, and treatment of serious infectious diseases and acute malnutrition. Nearly all of these essential interventions can be delivered by health workers in the community or in primary health centres, which can increase population access to needed services. The annual incremental cost of immediately scaling up these essential interventions would be US$6·2 billion in low-income countries, $12·4 billion in lower-middle-income countries, and $8·0 billion in upper-middle-income countries. With the additional funding, greater focus on high-effect integrated interventions and innovations in service delivery, such as task shifting to other groups of health workers and supply and demand incentives, can help rectify major gaps in accessibility and quality of care. In recent decades, reduction of avoidable maternal and child deaths has been a global priority. With continued priority and expansion of essential reproductive, maternal, newborn, and child health interventions to high coverage, equity, and quality, as well as interventions to address underlying problems such as women's low status in society and violence against women, these deaths and substantial morbidity can be largely eliminated in another generation.
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Affiliation(s)
- Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Doris Chou
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Li Liu
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marleen Temmerman
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Kuwawenaruwa A, Mtei G, Baraka J, Tani K. The effects of MCH insurance cards on improving equity in access and use of maternal and child health care services in Tanzania: a mixed methods analysis. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2016; 35:37. [PMID: 27863508 PMCID: PMC5116140 DOI: 10.1186/s41043-016-0075-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 11/10/2016] [Indexed: 05/17/2023]
Abstract
BACKGROUND Inequity in access and use of child and maternal health services is impeding progress towards reduction of maternal mortality in low-income countries. To address low usage of maternal and newborn health care services as well as financial protection of families, some countries have adopted demand-side financing. In 2010, Tanzania introduced free health insurance cards to pregnant women and their families to influence access, use, and provision of health services. However, little is known about whether the use of the maternal and child health cards improved equity in access and use of maternal and child health care services. METHODS A mixed methods approach was used in Rungwe district where maternal and child health insurance cards had been implemented. To assess equity, three categories of beneficiaries' education levels were used and were compared to that of women of reproductive age in the region from previous surveys. To explore factors influencing women's decisions on delivery site and use of the maternal and child health insurance card and attitudes towards the birth experience itself, a qualitative assessment was conducted at representative facilities at the district, ward, facility, and community level. A total of 31 in-depth interviews were conducted on women who delivered during the previous year and other key informants. RESULTS Women with low educational attainment were under-represented amongst those who reported having received the maternal and child health insurance card and used it for facility delivery. Qualitative findings revealed that problems during the current pregnancy served as both a motivator and a barrier for choosing a facility-based delivery. Decision about delivery site was also influenced by having experienced or witnessed problems during previous birth delivery and by other individual, financial, and health system factors, including fines levied on women who delivered at home. CONCLUSIONS To improve equity in access to facility-based delivery care using strategies such as maternal and child health insurance cards is necessary to ensure beneficiaries and other stakeholders are well informed of the programme, as giving women insurance cards only does not guarantee facility-based delivery.
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Affiliation(s)
- August Kuwawenaruwa
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Gemini Mtei
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Jitihada Baraka
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Kassimu Tani
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
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Wekesah FM, Mbada CE, Muula AS, Kabiru CW, Muthuri SK, Izugbara CO. Effective non-drug interventions for improving outcomes and quality of maternal health care in sub-Saharan Africa: a systematic review. Syst Rev 2016; 5:137. [PMID: 27526773 PMCID: PMC4986260 DOI: 10.1186/s13643-016-0305-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/20/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA. METHODS African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability). RESULTS Seventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess. CONCLUSIONS Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015023750.
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Affiliation(s)
- Frederick M. Wekesah
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Julius Global Health, Julius Center for Health Sciences and Primary Care, Utrecht Medical Center, Utrecht Huispost Str. 6.131, P.O. Box 85500, 3508 GA Utrecht, Netherlands
| | - Chidozie E. Mbada
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
- Department of Medical Rehabilitation, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Adamson S. Muula
- Department of Public Health, School of Public Health and Family Health, College of Medicine, University of Malawi, Private Bag 360, Chichiri, Blantyre, Malawi
- African Center for Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
| | - Caroline W. Kabiru
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Stella K. Muthuri
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
| | - Chimaraoke O. Izugbara
- African Population Health Research Center, 2nd Floor, APHRC Campus, Manga Close, Off Kirawa Road, Kitisuru, P. O. Box 10787, Nairobi, 00100 Kenya
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Bucher S, Konana O, Liechty E, Garces A, Gisore P, Marete I, Tenge C, Shipala E, Wright L, Esamai F. Self-reported practices among traditional birth attendants surveyed in western Kenya: a descriptive study. BMC Pregnancy Childbirth 2016; 16:219. [PMID: 27514379 PMCID: PMC4981994 DOI: 10.1186/s12884-016-1007-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 08/04/2016] [Indexed: 11/21/2022] Open
Abstract
Background The high rate of home deliveries conducted by unskilled birth attendants in resource-limited settings is an important global health issue because it is believed to be a significant contributing factor to maternal and newborn mortality. Given the large number of deliveries that are managed by unskilled or traditional birth attendants outside of health facilities, and the fact that there is on-going discussion regarding the role of traditional birth attendants in the maternal newborn health (MNH) service continuum, we sought to ascertain the practices of traditional birth attendants in our catchment area. The findings of this descriptive study might help inform conversations regarding the roles that traditional birth attendants can play in maternal-newborn health care. Methods A structured questionnaire was used in a survey that included one hundred unskilled birth attendants in western Kenya. Descriptive statistics were employed. Results Inappropriate or outdated practices were reported in relation to some obstetric complications and newborn care. Encouraging results were reported with regard to positive relationships that traditional birth attendants have with their local health facilities. Furthermore, high rates of referral to health facilities was reported for many common obstetric emergencies and similar rates for reporting of pregnancy outcomes to village elders and chiefs. Conclusions Potentially harmful or outdated practices with regard to maternal and newborn care among traditional birth attendants in western Kenya were revealed by this study. There were high rates of traditional birth attendant referrals of pregnant mothers with obstetric complications to health facilities. Policy makers may consider re-educating and re-defining the roles and responsibilities of traditional birth attendants in maternal and neonatal health care based on the findings of this survey. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1007-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sherri Bucher
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University School of Medicine, 699 Riley Hospital Drive, RR208, Indianapolis, IN, 46202-5119, USA.
| | - Olive Konana
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University School of Medicine, 699 Riley Hospital Drive, RR208, Indianapolis, IN, 46202-5119, USA
| | - Edward Liechty
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University School of Medicine, 699 Riley Hospital Drive, RR208, Indianapolis, IN, 46202-5119, USA
| | | | - Peter Gisore
- Department Child Health and Paediatrics, Moi University School of Medicine, Moi University, Eldoret, Kenya
| | - Irene Marete
- Department Child Health and Paediatrics, Moi University School of Medicine, Moi University, Eldoret, Kenya
| | - Constance Tenge
- Department Child Health and Paediatrics, Moi University School of Medicine, Moi University, Eldoret, Kenya
| | | | - Linda Wright
- Center for Research for Mothers and Children, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Fabian Esamai
- Department Child Health and Paediatrics, Moi University School of Medicine, Moi University, Eldoret, Kenya
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Kuwawenaruwa A, Mtei G, Baraka J, Tani K. Implementing demand side targeting mechanisms for maternal and child health-experiences from national health insurance fund program in Rungwe District, Tanzania. Global Health 2016; 12:41. [PMID: 27480025 PMCID: PMC4970262 DOI: 10.1186/s12992-016-0180-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 07/04/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Low and middle income countries have adopted targeting mechanisms as a means of increasing program efficiency in reaching marginalized people in the community given the available resources. Design of targeting mechanisms has been changing over time and it is important to understand implementers' experience with such targeting mechanisms since such mechanisms impact equity in access and use of maternal health care services. METHODS The case study approach was considered as appropriate method for exploring implementers' and decision-makers' experiences with the two targeting mechanisms. In-depth interviews in order to explore implementer experience with the two targeting mechanisms. A total of 10 in-depth interviews (IDI) and 4 group discussions (GDs) were conducted with implementers at national level, regional, district and health care facility level. A thematic analysis approach was adopted during data analysis. RESULTS The whole process of screening and identifying poor pregnant women resulted in delay in implementation of the intervention. Individual targeting was perceived to have some form of stigmatization; hence beneficiaries did not like to be termed as poor. Geographical targeting had a few cons as health care providers experienced an increase in workload while staff remained the same and poor quality of information in the claim forms. However geographical targeting increase in the number of women going to higher level of care (district/regional referral hospital), increase in facility revenue and insurance coverage. CONCLUSION Interventions which are using targeting mechanisms to reach poor people are useful in increasing access and use of health care services for marginalized communities so long as they are well designed and beneficiaries as well as all implementers and decision makers are involved from the very beginning. Implementation of demand side financing strategies using targeting mechanisms should go together with supply side interventions in order to achieve project objectives.
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Affiliation(s)
- August Kuwawenaruwa
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Gemini Mtei
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Jitihada Baraka
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
| | - Kassimu Tani
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78 373, Dar es Salaam, Tanzania
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Cole DC, Levin C, Loechl C, Thiele G, Grant F, Girard AW, Sindi K, Low J. Planning an integrated agriculture and health program and designing its evaluation: Experience from Western Kenya. EVALUATION AND PROGRAM PLANNING 2016; 56:11-22. [PMID: 27003730 PMCID: PMC4863223 DOI: 10.1016/j.evalprogplan.2016.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 03/05/2016] [Accepted: 03/07/2016] [Indexed: 05/15/2023]
Abstract
Multi-sectoral programs that involve stakeholders in agriculture, nutrition and health care are essential for responding to nutrition problems such as vitamin A deficiency among pregnant and lactating women and their infants in many poor areas of lower income countries. Yet planning such multi-sectoral programs and designing appropriate evaluations, to respond to different disciplinary cultures of evidence, remain a challenge. We describe the context, program development process, and evaluation design of the Mama SASHA project (Sweetpotato Action for Security and Health in Africa) which promoted production and consumption of a bio-fortified, orange-fleshed sweetpotato (OFSP). In planning the program we drew upon information from needs assessments, stakeholder consultations, and a first round of the implementation evaluation of a pilot project. The multi-disciplinary team worked with partner organizations to develop a program theory of change and an impact pathway which identified aspects of the program that would be monitored and established evaluation methods. Responding to the growing demand for greater rigour in impact evaluations, we carried out quasi-experimental allocation by health facility catchment area, repeat village surveys for assessment of change in intervention and control areas, and longitudinal tracking of individual mother-child pairs. Mid-course corrections in program implementation were informed by program monitoring, regular feedback from implementers and partners' meetings. To assess economic efficiency and provide evidence for scaling we collected data on resources used and project expenses. Managing the multi-sectoral program and the mixed methods evaluation involved bargaining and trade-offs that were deemed essential to respond to the array of stakeholders, program funders and disciplines involved.
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Affiliation(s)
- Donald C Cole
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; International Potato Center (CIP), Peru.
| | | | | | - Graham Thiele
- CGIAR Research Program on Roots, Tubers and Bananas, Lima, Peru
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Kankeu HT, Ventelou B. Socioeconomic inequalities in informal payments for health care: An assessment of the ‘Robin Hood’ hypothesis in 33 African countries. Soc Sci Med 2016; 151:173-86. [DOI: 10.1016/j.socscimed.2016.01.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 12/31/2015] [Accepted: 01/09/2016] [Indexed: 11/28/2022]
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Lunze K, Higgins-Steele A, Simen-Kapeu A, Vesel L, Kim J, Dickson K. Innovative approaches for improving maternal and newborn health--A landscape analysis. BMC Pregnancy Childbirth 2015; 15:337. [PMID: 26679709 PMCID: PMC4683742 DOI: 10.1186/s12884-015-0784-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 12/09/2015] [Indexed: 12/31/2022] Open
Abstract
Background Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study’s aim was to analyze the landscape of innovative MNH approaches and related published evidence. Methods Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol. Results Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery. Conclusions Future implementation and evaluation efforts need to assess innovations’ effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0784-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karsten Lunze
- Department of Medicine Boston, Boston University, Boston, MA, USA. .,Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA.
| | - Ariel Higgins-Steele
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA. .,Concern Worldwide, 355 Lexington Avenue, New York, NY, 10017, USA.
| | - Aline Simen-Kapeu
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA.
| | - Linda Vesel
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA. .,Concern Worldwide, 355 Lexington Avenue, New York, NY, 10017, USA.
| | - Julia Kim
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA. .,GNH Centre Bhutan, Jaffa's Commercial Building, Room 302, Thimphu, Bhutan.
| | - Kim Dickson
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA.
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Hurst TE, Semrau K, Patna M, Gawande A, Hirschhorn LR. Demand-side interventions for maternal care: evidence of more use, not better outcomes. BMC Pregnancy Childbirth 2015; 15:297. [PMID: 26566812 PMCID: PMC4644345 DOI: 10.1186/s12884-015-0727-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 10/31/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reducing maternal and neonatal mortality is essential to improving population health. Demand-side interventions are designed to increase uptake of critical maternal health services, but associated change in service uptake and outcomes is varied. We undertook a literature review to understand current evidence of demand-side intervention impact on improving utilization and outcomes for mothers and newborn children. METHODS We completed a rapid review of literature in PubMed. Title and abstracts of publications identified from selected search terms were reviewed to identify articles meeting inclusion criteria: demand-side intervention in low or middle-income countries (LMIC), published after September 2004 and before March 2014, study design describing and reporting on >1 priority outcome: utilization (antenatal care visits, facility-based delivery, delivery with a skilled birth attendant) or health outcome measures (maternal mortality ratio (MMR), stillbirth rate, perinatal mortality rate (PMR), neonatal mortality rate (NMR)). Bibliographies were searched to identify additional relevant papers. Articles were abstracted using a standardized data collection template with double extraction on a sample to ensure quality. Quality of included studies was assessed using McMaster University's Quality Assessment Tool from the Effective Public Health Practice Project (EPHPP). RESULTS Five hundred and eighty two articles were screened with 50 selected for full review and 16 meeting extraction criteria (eight community mobilization interventions (CM), seven financial incentive interventions (FI), and one with both). We found that demand-side interventions were effective in increasing uptake of key services with five CM and all seven FI interventions reporting increased use of maternal health services. Association with health outcome measures were varied with two studies reporting reductions in MMR and four reporting reduced NMR. No studies found a reduction in stillbirth rate. Only four of the ten studies reporting on both utilization and outcomes reported improvement in both measures. CONCLUSIONS We found strong evidence that demand-side interventions are associated with increased utilization of services with more variable evidence of their impact on reducing early neonatal and maternal mortality. Further research is needed to understand how to maximize the potential of demand-side interventions to improve maternal and neonatal health outcomes including the role of quality improvement and coordination with supply-side interventions.
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Affiliation(s)
- Taylor E Hurst
- Department of Global Health and Population, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, USA.
| | - Katherine Semrau
- Ariadne Labs, 401 Park Drive 3 East, Boston, MA, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA.
| | - Manasa Patna
- Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, MA, USA. .,Harvard Medical School, Boston, MA, USA.
| | - Atul Gawande
- Ariadne Labs, 401 Park Drive 3 East, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Lisa R Hirschhorn
- Ariadne Labs, 401 Park Drive 3 East, Boston, MA, USA. .,Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.
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Borghi J, Ramsey K, Kuwawenaruwa A, Baraka J, Patouillard E, Bellows B, Binyaruka P, Manzi F. Protocol for the evaluation of a free health insurance card scheme for poor pregnant women in Mbeya region in Tanzania: a controlled-before and after study. BMC Health Serv Res 2015; 15:258. [PMID: 26141724 PMCID: PMC4490646 DOI: 10.1186/s12913-015-0905-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 06/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of demand-side financing mechanisms to increase health service utilisation among target groups and enhance service quality is gaining momentum in many low- and middle-income countries. However, there is limited evidence on the effects of such schemes on equity, financial protection, quality of care, and cost-effectiveness. A scheme providing free health insurance cards to poor pregnant women and their households was first introduced in two regions of Tanzania in 2011 and gradually expanded in 2012. METHODS A controlled before and after study will examine in one district the effect of the scheme on utilization, quality, and cost of healthcare services accessed by poor pregnant women and their households in Tanzania. Data will be collected 4 months before implementation of the scheme and 17 months after the start of implementation from a survey of 24 health facilities, 288 patients exiting consultations and 1500 households of women who delivered in the previous year in one intervention district (Mbarali). 288 observations of provider-client interactions will also be carried out. The same data will be collected from a comparison district in a nearby region. A process evaluation will ascertain how the scheme is implemented in practice and the level of implementation fidelity and potential moderators. The process evaluation will draw from impact evaluation data and from three rounds of data collection at the national, regional, district, facility and community levels. An economic evaluation will measure the cost-effectiveness of the scheme relative to current practice from a societal perspective. DISCUSSION This evaluation will generate evidence on the impact and cost-effectiveness of targeted health insurance for pregnant women in a low income setting, as well as building a better understanding of the implementation process and challenges for programs of this nature.
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Affiliation(s)
- Josephine Borghi
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania. .,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Kate Ramsey
- Columbia University, Mailman School of Public Health, New York, NY, USA
| | | | - Jitihada Baraka
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania
| | - Edith Patouillard
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | | | - Peter Binyaruka
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania
| | - Fatuma Manzi
- Ifakara Health Institute, Kiko Avenue, Dar es Salaam, Tanzania
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Njuki R, Abuya T, Kimani J, Kanya L, Korongo A, Mukanya C, Bracke P, Bellows B, Warren CE. Does a voucher program improve reproductive health service delivery and access in Kenya? BMC Health Serv Res 2015; 15:206. [PMID: 26002611 PMCID: PMC4443655 DOI: 10.1186/s12913-015-0860-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 05/05/2015] [Indexed: 11/29/2022] Open
Abstract
Background Current assessments on Output-Based Aid (OBA) programs have paid limited attention to the experiences and perceptions of the healthcare providers and facility managers. This study examines the knowledge, attitudes, and experiences of healthcare providers and facility managers in the Kenya reproductive health output-based approach voucher program. Methods A total of 69 in-depth interviews with healthcare providers and facility managers in 30 voucher accredited facilities were conducted. The study hypothesized that a voucher program would be associated with improvements in reproductive health service provision. Data were transcribed and analyzed by adopting a thematic framework analysis approach. A combination of inductive and deductive analysis was conducted based on previous research and project documents. Results Facility managers and providers viewed the RH-OBA program as a feasible system for increasing service utilization and improving quality of care. Perceived benefits of the program included stimulation of competition between facilities and capital investment in most facilities. Awareness of family planning (FP) and gender-based violence (GBV) recovery services voucher, however, remained lower than the maternal health voucher service. Relations between the voucher management agency and accredited facilities as well as existing health systems challenges affect program functions. Conclusions Public and private sector healthcare providers and facility managers perceive value in the voucher program as a healthcare financing model. They recognize that it has the potential to significantly increase demand for reproductive health services, improve quality of care and reduce inequities in the use of reproductive health services. To improve program functioning going forward, there is need to ensure the benefit package and criteria for beneficiary identification are well understood and that the public facilities are permitted greater autonomy to utilize revenue generated from the voucher program.
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Affiliation(s)
- Rebecca Njuki
- Centre for Population Health Research and Management, P.O BOX 1907-00202, Nairobi, Kenya.
| | - Timothy Abuya
- Population Council, P.O Box 17643-00200, Nairobi, Kenya.
| | - James Kimani
- Population Council, P.O Box 17643-00200, Nairobi, Kenya.
| | - Lucy Kanya
- Population Council, P.O Box 17643-00200, Nairobi, Kenya.
| | - Allan Korongo
- Department of Sociology, University of Nairobi, P.O Box 30197-00200, Nairobi, Kenya.
| | - Collins Mukanya
- Department of Sociology, University of Nairobi, P.O Box 30197-00200, Nairobi, Kenya.
| | | | - Ben Bellows
- Population Council, P.O Box 17643-00200, Nairobi, Kenya.
| | - Charlotte E Warren
- Population Council, 4301 Connecticut Ave NW, 20008, Washington, DC, USA.
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Gipson JD, Gyaltsen K, Gyal L, Kyi T, Hicks AL, Pebley AR. Tibetan women's perspectives and satisfaction with delivery care in a rural birth center. Int J Gynaecol Obstet 2015; 129:244-7. [PMID: 25790795 DOI: 10.1016/j.ijgo.2014.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Revised: 12/14/2014] [Accepted: 02/22/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To identify sociodemographic characteristics and factors involved in Tibetan women's decisions to deliver at the Tibetan Birth and Training Center (TBTC) in rural western China. METHODS In the present mixed-methods study, a random sample of married women who delivered at the TBTC between June 2011 and June 2012 were surveyed. Additionally, four focus group discussions were conducted among married women living in the TBTC catchment area. Descriptive analyses were conducted, and dominant themes were identified. RESULTS In focus group discussions, women (n=33) reported that improved roads and transportation meant that access to health facilities was easier than in the past. Although some of the 114 survey participants voiced negative perceptions of healthcare facilities and providers, 99 (86.8%) indicated that they chose to deliver at the TBTC because they preferred to have a doctor present. Most women (75 [65.8%]) said their mother/mother-in-law made the final decision about delivery location. Women valued logistic and cultural aspects of the TBTC, and 108 (94.7%) said that they would recommend the TBTC to a friend. CONCLUSION Study participants preferred delivery care that combines safety and comfort. The findings highlight avenues for further promotion of facility delivery among populations with lower rates of skilled deliveries.
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Affiliation(s)
- Jessica D Gipson
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA; California Center for Population Research, UCLA, Los Angeles, CA, USA.
| | - Kunchok Gyaltsen
- Tso-ngon (Qinghai) University Tibetan Medical College (TUTMC), Xining City, Qinghai Province, China; Kumbum Tibetan Medical Hospital, Kumbum Monastery, Lusar (CH: Huangzhong), Qinghai Province, China
| | - Lhusham Gyal
- Tso-ngon (Qinghai) University Tibetan Medical College (TUTMC), Xining City, Qinghai Province, China
| | - Tsering Kyi
- Tibetan Birth and Training Center, Tongren County of Huangnan Prefecture, Qinghai Province, China
| | - Andrew L Hicks
- California Center for Population Research, UCLA, Los Angeles, CA, USA; Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Anne R Pebley
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA; California Center for Population Research, UCLA, Los Angeles, CA, USA
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De Costa A, Vora KS, Ryan K, Sankara Raman P, Santacatterina M, Mavalankar D. The state-led large scale public private partnership 'Chiranjeevi Program' to increase access to institutional delivery among poor women in Gujarat, India: How has it done? What can we learn? PLoS One 2014; 9:e95704. [PMID: 24787692 PMCID: PMC4006779 DOI: 10.1371/journal.pone.0095704] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 03/28/2014] [Indexed: 11/23/2022] Open
Abstract
Background Many low-middle income countries have focused on improving access to and quality of obstetric care, as part of promoting a facility based intra-partum care strategy to reduce maternal mortality. The state of Gujarat in India, implements a facility based intra-partum care program through its large for-profit private obstetric sector, under a state-led public-private-partnership, the Chiranjeevi Yojana (CY), under which the state pays accredited private obstetricians to perform deliveries for poor/tribal women. We examine CY performance, its contribution to overall trends in institutional deliveries in Gujarat over the last decade and its effect on private and public sector deliveries there. Methods District level institutional delivery data (public, private, CY), national surveys, poverty estimates, census data were used. Institutional delivery trends in Gujarat 2000–2010 are presented; including contributions of different sectors and CY. Piece-wise regression was used to study the influence of the CY program on public and private sector institutional delivery. Results Institutional delivery rose from 40.7% (2001) to 89.3% (2010), driven by sharp increases in private sector deliveries. Public sector and CY contributed 25–29% and 13–16% respectively of all deliveries each year. In 2007, 860 of 2000 private obstetricians participated in CY. Since 2007, >600,000 CY deliveries occurred i.e. one-third of births in the target population. Caesareans under CY were 6%, higher than the 2% reported among poor women by the DLHS survey just before CY. CY did not influence the already rising proportion of private sector deliveries in Gujarat. Conclusion This paper reports a state-led, fully state-funded, large-scale public-private partnership to improve poor women’s access to institutional delivery - there have been >600,000 beneficiaries. While caesarean proportions are higher under CY than before, it is uncertain if all beneficiaries who require sections receive these. Other issues to explore include quality of care, provider attrition and the relatively low coverage.
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Affiliation(s)
- Ayesha De Costa
- Dept of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden
- * E-mail:
| | - Kranti S. Vora
- Indian Institute of Public Health, Gandhinagar, Gujarat, India
| | - Kayleigh Ryan
- Dept of Public Health Sciences, Karolinska Insitutet, Stockholm, Sweden
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Grainger C, Gorter A, Okal J, Bellows B. Lessons from sexual and reproductive health voucher program design and function: a comprehensive review. Int J Equity Health 2014; 13:33. [PMID: 24779653 PMCID: PMC4024100 DOI: 10.1186/1475-9276-13-33] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 03/19/2014] [Indexed: 11/25/2022] Open
Abstract
Background Developing countries face challenges in financing healthcare; often the poor do not receive the most basic services. The past decade has seen a sharp increase in the number of voucher programs, which target output-based subsidies for specific services to poor and underserved groups. The dearth of literature that examines lessons learned risks the wheel being endlessly reinvented. This paper examines commonalities and differences in voucher design and implementation, highlighting lessons learned for the design of new voucher programmes. Methodology The methodology comprised: discussion among key experts to develop inclusion/exclusion criteria; up-dating the literature database used by the DFID systematic review of voucher programs; and networking with key contacts to identify new programs and obtain additional program documents. We identified 40 programs for review and extracted a dataset of more than 120 program characteristics for detailed analysis. Results All programs aimed to increase utilisation of healthcare, particularly maternal health services, overwhelmingly among low-income populations. The majority contract(ed) private providers, or public and private providers, and all facilitate(d) access to services that are well defined, time-limited and reflect the country’s stated health priorities. All voucher programs incorporate a governing body, management agency, contracted providers and target population, and all share the same incentive structure: the transfer of subsidies from consumers to service providers, resulting in a strong effect on both consumer and provider behaviour. Vouchers deliver subsidies to individuals, who in the absence of the subsidy would likely not have sought care, and in all programs a positive behavioural response is observed, with providers investing voucher revenue to attract more clients. A large majority of programs studied used targeting mechanisms. Conclusions While many programs remain too small to address national-level need among the poor, large programs are being developed at a rate of one every two years, with further programs in the pipeline. The importance of addressing inequalities in access to basic services is recognized as an important component in the drive to achieve universal health coverage; vouchers are increasingly acknowledged as a promising targeting mechanism in this context, particularly where social health insurance is not yet feasible.
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Affiliation(s)
| | | | - Jerry Okal
- Population Council, Ralph Bunche Rd,, PO Box 17643-00500, Nairobi, Kenya.
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Murray SF, Hunter BM, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review. BMC Pregnancy Childbirth 2014; 14:30. [PMID: 24438560 PMCID: PMC3897964 DOI: 10.1186/1471-2393-14-30] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 01/13/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Demand-side financing, where funds for specific services are channelled through, or to, prospective users, is now employed in health and education sectors in many low- and middle-income countries. This systematic review aimed to critically examine the evidence on application of this approach to promote maternal health in these settings. Five modes were considered: unconditional cash transfers, conditional cash transfers, short-term payments to offset costs of accessing maternity services, vouchers for maternity services, and vouchers for merit goods. We sought to assess the effects of these interventions on utilisation of maternity services and on maternal health outcomes and infant health, the situation of underprivileged women and the healthcare system. METHODS The protocol aimed for collection and synthesis of a broad range of evidence from quantitative, qualitative and economic studies. Nineteen health and social policy databases, seven unpublished research databases and 27 websites were searched; with additional searches of Indian journals and websites. Studies were included if they examined demand-side financing interventions to increase consumption of services or goods intended to impact on maternal health, and met relevant quality criteria. Quality assessment, data extraction and analysis used Joanna Briggs Institute standardised tools and software. Outcomes of interest included maternal and infant mortality and morbidity, service utilisation, factors required for successful implementation, recipient and provider experiences, ethical issues, and cost-effectiveness. Findings on Effectiveness, Feasibility, Appropriateness and Meaningfulness were presented by narrative synthesis. RESULTS Thirty-three quantitative studies, 46 qualitative studies, and four economic studies from 17 countries met the inclusion criteria. Evidence on unconditional cash transfers was scanty. Other demand-side financing modes were found to increase utilisation of maternal healthcare in the index pregnancy or uptake of related merit goods. Evidence of effects on maternal and infant mortality and morbidity outcomes was insufficient. Important implementation aspects include targeting and eligibility criteria, monitoring, respectful treatment of beneficiaries, suitable incentives for providers, quality of care and affordable referral systems. CONCLUSIONS Demand-side financing schemes can increase utilisation of maternity services, but attention must be paid to supply-side conditions, the fine-grain of implementation and sustainability. Comparative studies and research on health impact and cost-effectiveness are required.
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Affiliation(s)
- Susan F Murray
- King’s International Development Institute, King’s College London, London, UK
| | - Benjamin M Hunter
- King’s International Development Institute, King’s College London, London, UK
| | - Ramila Bisht
- Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
| | - Tim Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Debra Bick
- Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK
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Alfonso YN, Bishai D, Bua J, Mutebi A, Mayora C, Ekirapa-Kiracho E. Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda. Health Policy Plan 2013; 30:88-99. [PMID: 24371219 DOI: 10.1093/heapol/czt100] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The maternal mortality ratio (MMR) in Uganda has declined significantly during the last 20 years, but Uganda is not on track to reach the millennium development goal of reducing MMR by 75% by 2015. More evidence on the cost-effectiveness of supply- and demand-side financing programs to reduce maternal mortality could inform future strategies. This study analyses the cost-effectiveness of a voucher scheme (VS) combined with health system strengthening in rural Uganda against the status quo. The VS, implemented in 2010, provided vouchers for delivery services at public and private health facilities (HF), as well as round-trip transportation provided by private sector workers (bicycles or motorcycles generally). The VS was part of a quasi-experimental non-randomized control trial. Improvements in institutional delivery coverage (IDC) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence-based Lives Saved Tool. Costs were estimated from primary and secondary data. Results show that the demand for births at HFs enrolled in the VS increased by 52.3 percentage points. Out of this value, conservative estimates indicate that at least 9.4 percentage points are new HF users. This 9.4% bump in IDC implies 20 deaths averted, which is equivalent to 1356 disability-adjusted-life years (DALYs) averted. Cost-effectiveness analysis comparing the status quo and VS's most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$302 and per death averted of US$20 756. Although there are limitations in the data measures, a favourable cost-effectiveness ratio persists even under extreme assumptions. Demand-side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable.
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Affiliation(s)
- Y Natalia Alfonso
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
| | - David Bishai
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
| | - John Bua
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
| | - Aloysius Mutebi
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
| | - Crispus Mayora
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
| | - Elizabeth Ekirapa-Kiracho
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
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47
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Obare F, Warren C, Abuya T, Askew I, Bellows B. Assessing the population-level impact of vouchers on access to health facility delivery for women in Kenya. Soc Sci Med 2013; 102:183-9. [PMID: 24565156 DOI: 10.1016/j.socscimed.2013.12.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Revised: 11/05/2013] [Accepted: 12/05/2013] [Indexed: 11/28/2022]
Abstract
Although available evidence indicates that vouchers improve service utilization among the target populations, we do not know whether increased utilization results from improved access (new clients who would not have used services without the voucher) or from shifting clients from non-accredited to contracted service providers. This paper examines whether the safe motherhood voucher program in Kenya is associated with improved access to health facility delivery using information on births within two years preceding the survey in voucher and comparison sites. Data were collected in 2010-2011 and in 2012 among 2933 and 3094 women aged 15-49 years reporting 962 and 1494 births within two years before the respective surveys. Analysis entails cross-tabulations and estimation of multilevel random-intercept logit models. The results show that the proportion of births occurring at home declined by more than 10 percentage points while the proportion of births delivered in health facilities increased by a similar margin over time in voucher sites. The increase in facility-based births occurred in both public and private health facilities. There was also a significant increase in the likelihood of facility-based delivery (odds ratios [OR]: 2.04; 95% confidence interval [CI]: 1.40-2.98 in the 2006 voucher arm; OR: 1.72; 95% CI: 1.22-2.43 in the 2010-2011 voucher arm) in voucher sites over time. In contrast, there were no significant changes in the likelihood of facility-based delivery in the comparison arm over time. These findings suggest that the voucher program contributed to improved access to institutional delivery by shifting births from home to health facilities. However, available evidence from qualitative data shows that some women who purchased the vouchers did not use them because of high transportation costs to accredited facilities. The implication is that substantial improvements in service uptake could be achieved if the program subsidized transportation costs as well.
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Affiliation(s)
| | | | | | - Ian Askew
- Population Council, P.O. Box 17643, Nairobi, Kenya
| | - Ben Bellows
- Population Council, P.O. Box 17643, Nairobi, Kenya
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48
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Arthur S, Bangha M, Sankoh O. Review of contributions from HDSSs to research in sexual and reproductive health in low- and middle-income countries. Trop Med Int Health 2013; 18:1463-87. [DOI: 10.1111/tmi.12209] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Osman Sankoh
- INDEPTH Network; Accra Ghana
- School of Public Health; University of the Witwatersrand; Johannesburg South Africa
- Faculty of Public Health; Hanoi Medical University; Hanoi Vietnam
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49
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Amendah DD, Mutua MK, Kyobutungi C, Buliva E, Bellows B. Reproductive health voucher program and facility based delivery in informal settlements in Nairobi: a longitudinal analysis. PLoS One 2013; 8:e80582. [PMID: 24260426 PMCID: PMC3832453 DOI: 10.1371/journal.pone.0080582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 10/04/2013] [Indexed: 11/28/2022] Open
Abstract
Introduction In Kenya, the maternal mortality rate had ranged from 328 to 501 deaths per 100,000 live births over the last three decades. To reduce these rates, the government launched in 2006 a means-tested reproductive health output-based approach (OBA) voucher program that covers costs of antenatal care, a facility-based delivery (FBD) and a postnatal visit in prequalified healthcare facilities. This paper investigated whether women who bought the voucher for their index child and had a FBD were more likely to deliver a subsequent child in a facility compared to those who did not buy vouchers. Methods and Findings We used population-based cohort data from two Nairobi slums where the voucher program was piloted. We selected mothers of at least two children born between 2006 and 2012 and divided the mothers into two groups: Index-OBA mothers bought the voucher for the index child (N=352), and non-OBA mothers did not buy the voucher during the study period (N=514). The most complete model indicated that the adjusted odds-ratio of FBD of subsequent child when the index child was born in a facility was 3.89 (p<0.05) and 4.73 (p<0.01) in Group 2. Discussion and Conclusion The study indicated that the voucher program improved poor women access to FBD. Furthermore, the FBD of an index child appeared to have a persistent effect, as a subsequent child of the same mother was more likely to be born in a facility as well. While women who purchased the voucher have higher odds of delivering their subsequent child in a facility, those odds were smaller than those of the women who did not buy the voucher. However, women who did not buy the voucher were less likely to deliver in a good healthcare facility, negating their possible benefit of facility-based deliveries. Pathways to improve access to FBD to all near poor women are needed.
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Affiliation(s)
| | | | | | - Evans Buliva
- Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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50
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Kanya L, Obare F, Warren C, Abuya T, Askew I, Bellows B. Safe motherhood voucher programme coverage of health facility deliveries among poor women in South-western Uganda. Health Policy Plan 2013; 29 Suppl 1:i4-11. [PMID: 24173430 PMCID: PMC4095921 DOI: 10.1093/heapol/czt079] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
There has been increased interest in and experimentation with demand-side mechanisms such as the use of vouchers that place purchasing power in the hands of targeted consumers to improve the uptake of healthcare services in low-income settings. A key measure of the success of such interventions is the extent to which the programmes have succeeded in reaching the target populations. This article estimates the coverage of facility deliveries by a maternal health voucher programme in South-western
Uganda and examines whether such coverage is correlated with district-level characteristics such as poverty density and the number of contracted facilities. Analysis entails estimating the voucher coverage of health facility deliveries among the general population and poor population (PP) using programme data for 2010, which was the most complete calendar year of implementation of the Uganda safe motherhood (SM) voucher programme. The results show that: (1) the programme paid for 38% of estimated deliveries among the PP in the targeted districts, (2) there was a significant negative correlation between the poverty density in a district and proportions of births to poor women that were covered by the programme and (3) improving coverage of health facility deliveries for poor women is dependent upon increasing the sales and redemption rates. The findings suggest that to the extent that the programme stimulated demand for SM services by new users, it has the potential of increasing facility-based births among poor women in the region. In addition, the significant negative correlation between the poverty density and the proportions of facility-based births to poor women that are covered by the voucher programme suggests that there is need to increase both voucher sales and the rate of redemption to improve coverage in districts with high levels of poverty.
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Affiliation(s)
- Lucy Kanya
- Population Council, P. O. Box 17643-00500 Nairobi, Kenya and Population Council, 4301 Connecticut Avenue, NW, Washington, DC 20008 USA
| | - Francis Obare
- Population Council, P. O. Box 17643-00500 Nairobi, Kenya and Population Council, 4301 Connecticut Avenue, NW, Washington, DC 20008 USA
| | - Charlotte Warren
- Population Council, P. O. Box 17643-00500 Nairobi, Kenya and Population Council, 4301 Connecticut Avenue, NW, Washington, DC 20008 USA
| | - Timothy Abuya
- Population Council, P. O. Box 17643-00500 Nairobi, Kenya and Population Council, 4301 Connecticut Avenue, NW, Washington, DC 20008 USA
| | - Ian Askew
- Population Council, P. O. Box 17643-00500 Nairobi, Kenya and Population Council, 4301 Connecticut Avenue, NW, Washington, DC 20008 USA
| | - Ben Bellows
- Population Council, P. O. Box 17643-00500 Nairobi, Kenya and Population Council, 4301 Connecticut Avenue, NW, Washington, DC 20008 USA
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