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Kiwanuka SN, Babirye Z, Kabwama SN, Tusubira AK, Kizito S, Ndejjo R, Bosonkie M, Egbende L, Bondo B, Mapatano MA, Seck I, Bassoum O, Leye MM, Diallo I, Fawole OI, Bello S, Salawu MM, Bamgboye EA, Dairo MD, Adebowale AS, Afolabi RF, Wanyenze RK. Health workforce incentives and dis-incentives during the COVID-19 pandemic: experiences from Democratic Republic of Congo, Nigeria, Senegal, and Uganda. BMC Health Serv Res 2024; 24:422. [PMID: 38570839 PMCID: PMC10993439 DOI: 10.1186/s12913-024-10822-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND The COVID-19 pandemic presented a myriad of challenges for the health workforce around the world due to its escalating demand on service delivery. A motivated health workforce is critical to effectual emergency response and in some settings, incentivizing health workers motivates them and ensures continuity in the provision of health services. We describe health workforce experiences with incentives and dis-incentives during the COVID-19 response in the Democratic Republic of Congo (DRC), Senegal, Nigeria, and Uganda. METHODS This is a multi-country qualitative research study involving four African countries namely: DRC, Nigeria, Senegal, and Uganda which assessed the workplace incentives instituted in response to the COVID-19 pandemic. Key informant interviews (n = 60) were conducted with staff at ministries of health, policy makers and health workers. Interviews were virtual using the telephone or Zoom. They were audio recorded, transcribed verbatim, and analyzed thematically. Themes were identified and quotes were used to support findings. RESULTS Health worker incentives included (i) financial rewards in the form of allowances and salary increments. These motivated health workers, sustaining the health system and the health workers' efforts during the COVID-19 response across the four countries. (ii) Non-financial incentives related to COVID-19 management such as provision of medicines/supplies, on the job trainings, medical care for health workers, social welfare including meals, transportation and housing, recognition, health insurance, psychosocial support, and supervision. Improvised determination and distribution of both financial and non-financial incentives were common across the countries. Dis-incentives included the lack of personal protective equipment, lack of transportation to health facilities during lockdown, long working hours, harassment by security forces and perceived unfairness in access to and inadequacy of financial incentives. CONCLUSION Although important for worker motivation, financial and non-financial incentives generated some dis-incentives because of the perceived unfairness in their provision. Financial and non-financial incentives deployed during health emergencies should preferably be pre-determined, equitably and transparently provided because when arbitrarily applied, these same financial and non-financial incentives can potentially become dis-incentives. Moreover, financial incentives are useful only as far as they are administered together with non-financial incentives such as supportive and well-resourced work environments. The potential negative impacts of interventions such as service delivery re-organization and lockdown within already weakened systems need to be anticipated and due precautions exercised to reduce dis-incentives during emergencies.
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Affiliation(s)
- Suzanne N Kiwanuka
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, Kampala, P.O Box 7072, Uganda.
| | - Ziyada Babirye
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, Kampala, P.O Box 7072, Uganda
| | - Steven N Kabwama
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, Kampala, P.O Box 7072, Uganda
| | - Andrew K Tusubira
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, Kampala, P.O Box 7072, Uganda
| | - Susan Kizito
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, Kampala, P.O Box 7072, Uganda
| | - Rawlance Ndejjo
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, Kampala, P.O Box 7072, Uganda
| | - Marc Bosonkie
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Landry Egbende
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Berthold Bondo
- Barumbu General Referral Hospital, Kinshasa, Democratic Republic of Congo
| | - Mala Ali Mapatano
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of Congo
| | - Ibrahima Seck
- The Cheikh-Anta-Diop University (UCAD), Dakar, Senegal
| | - Oumar Bassoum
- The Cheikh-Anta-Diop University (UCAD), Dakar, Senegal
| | | | | | - Olufunmilayo I Fawole
- Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Segun Bello
- Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Mobolaji M Salawu
- Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Eniola A Bamgboye
- Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | | | - Ayo Steven Adebowale
- Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Rotimi F Afolabi
- Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Rhoda K Wanyenze
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences School of Public Health, Kampala, P.O Box 7072, Uganda
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George J, Jack S, Gauld R, Colbourn T, Stokes T. Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review. BMJ Open 2023; 13:e073669. [PMID: 38081664 PMCID: PMC10729209 DOI: 10.1136/bmjopen-2023-073669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs. METHODS We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed. RESULTS The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation. CONCLUSIONS We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.
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Affiliation(s)
- Joby George
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
| | - Susan Jack
- Te Whatu Ora - Southern, National Public Health Service, Dunedin, New Zealand
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
| | - Robin Gauld
- Department of Preventive & Social Medicine, University of Otago, Dunedin, New Zealand
- Otago Business School, University of Otago, Dunedin, New Zealand
| | | | - Tim Stokes
- Department of General Practice & Rural Health, University of Otago, Dunedin, New Zealand
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Jarawan E, Boiangiu M, Zeng W. Strengthening provider accountability: A scoping review of accountability/monitoring frameworks for quality of RMNCH care. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001968. [PMID: 37943720 PMCID: PMC10635430 DOI: 10.1371/journal.pgph.0001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
Increasing health providers' accountability is an important element in improving quality of care (QoC) for reproductive, maternal, neonatal, and child health (RMNCH), so as to improve health outcomes of the population in many low- and middle-income countries (LMICs). Implemented RMNCH monitoring initiatives vary in their settings, methods of data collection, and indicators selected for monitoring. The purpose of this study is to evaluate the monitoring/accountability frameworks used by key global monitoring initiatives and provide insights for countries to develop context-customized indicators for RMNCH monitoring and accountability in middle-income countries. The authors conducted a scoping review of key global monitoring initiatives on their monitoring/accountability framework and associated indicators. Data was extracted into a spreadsheet template for analysis. Monitoring/accountability frameworks corresponding to the selected global RMNCH initiatives were described, analyzed, and then categorized the monitoring indicators used by the initiatives according to the type of indicators, quality domains, monitoring levels, and type of services. The results showed that all frameworks regarded developing quality indicators and their monitoring as important elements of accountability and emphasized the role of health systems blocks as inputs for QoC. The researchers demonstrated the importance of measuring quality through both condition-specific and general health system indicators. However, given the different purposes of global monitoring initiatives, the indicators they used varied. We found a lack of indicators measuring QoC of reproductive health. In terms of quality domains, the timeliness and efficiency of RMNCH services were neglected, as few of these indicators were selected for monitoring. Global monitoring initiatives provide valuable frameworks for countries to understand which key indicators need to be tracked to achieve global objectives and develop the foundation for their own accountability/monitoring systems. Gaps in quality indicator design and use emphasize countries need to build on what the global initiatives have achieved to systematically examine quality concerns, develop a tailored and effective accountability/monitoring framework, and improve population health.
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Affiliation(s)
- Eva Jarawan
- Department of Global Health, School of Health, Georgetown University, Washington, DC, United States of America
| | - Mara Boiangiu
- Georgetown University, Washington, DC, United States of America
| | - Wu Zeng
- Department of Global Health, School of Health, Georgetown University, Washington, DC, United States of America
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Liu M, Wang J, Lou J, Zhao R, Deng J, Liu Z. What is the impact of integrated care on the job satisfaction of primary healthcare providers: a systematic review. HUMAN RESOURCES FOR HEALTH 2023; 21:86. [PMID: 37915032 PMCID: PMC10619237 DOI: 10.1186/s12960-023-00874-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND OBJECTIVES The integration of care influenced the job satisfaction of healthcare professionals, especially affecting primary healthcare providers (PCPs). This study aimed to perform a systematic review to explore the impact of integrated care on the job satisfaction of PCPs on the basis of Herzberg's two-factor theory. METHODS This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched 6 electronic databases, including CNKI, WANFANG, PubMed, Web of Science, Cochrane Library, and Embase. Data were retrieved from inception to 19 March 2023. The Mixed Methods Appraisal Tool (MMAT) version 2018 was used to assess the methodological quality of studies for inclusion in the review. RESULTS A total of 805 articles were retrieved from databases, of which 29 were included in this review. 2 categories, 9 themes, and 14 sub-themes were derived from the data. 2 categories were identified as intrinsic and extrinsic factors. Intrinsic factors included 4 themes: responsibilities, promotion opportunities, recognition, and a sense of personal achievements and growth. Extrinsic factors included 5 themes: salaries and benefits, organizational policy and administration, interpersonal relationships, working conditions, and work status. To specify some key information under certain themes, we also identify sub-themes, such as the sub-theme "workload", "work stress", and "burnout" under the theme "work status". CONCLUSIONS Findings suggested that the integration of care had both negative and positive effects on the job satisfaction of PCPs and the effects were different depending on the types of integration. Since PCPs played a vital role in the successful integration of care, their job satisfaction was an important issue that should be carefully considered when implementing the integration of care.
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Affiliation(s)
- Mei Liu
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China
| | - Jian Wang
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China.
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China.
| | - Jiaxu Lou
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China
| | - Ruonan Zhao
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China
| | - Jiahui Deng
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China
| | - Ziyu Liu
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, 250012, China.
- NHC Key Lab of Health Economics and Policy Research, Shandong University, Jinan, 250012, China.
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Karamagi HC, Ben Charif A, Ngusbrhan Kidane S, Yohanes T, Kariuki D, Titus M, Batungwanayo C, Seydi ABW, Berhane A, Nzinga J, Njuguna D, Kipruto HK, Andrews Annan E, Droti B. Investments for effective functionality of health systems towards Universal Health Coverage in Africa: A scoping review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0001076. [PMID: 36962623 PMCID: PMC10021830 DOI: 10.1371/journal.pgph.0001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/24/2022] [Indexed: 11/18/2022]
Abstract
The health challenges in Africa underscore the importance of effectively investing in health systems. Unfortunately, there is no information on systems investments adequate for an effective functional health system. We aimed to address this by conducting a scoping review of existing evidence following the Joanna Briggs Institute Manual for Evidence Synthesis and preregistered with the Open Science Framework (https://osf.io/bvg4z). We included any empirical research describing interventions that contributed to the functionality of health systems in Africa or any low-income or lower-middle-income regions. We searched Web of Science, MEDLINE, Embase, PsycINFO, Cochrane Library, CINAHL, and ERIC from their inception, and hand-searched other relevant sources. We summarized data using a narrative approach involving thematic syntheses and descriptive statistics. We identified 554 unique reports describing 575 interventions, of which 495 reported evidence of effectiveness. Most interventions were undertaken in Africa (80.9%), covered multiple elements of health systems (median: 3), and focused on service delivery (77.4%) and health workforce (65.6%). Effective interventions contributed to improving single (35.6%) or multiple (64.4%) capacities of health systems: access to essential services (75.6%), quality of care (70.5%), demand for essential services (38.6%), or health systems resilience (13.5%). For example, telemedicine models which covered software (technologies) and hardware (health workers) elements were used as a strategy to address issues of access to essential services. We inventoried these effective interventions for improving health systems functionality in Africa. Further analyses could deepen understanding of how such interventions differ in their incorporation of evidence for potential scale across African countries.
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Affiliation(s)
- Humphrey Cyprian Karamagi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | | | - Solyana Ngusbrhan Kidane
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Tewelde Yohanes
- Division of Policy and Planning, Ministry of Health, Asmara, Eritrea
| | | | | | | | - Aminata Binetou-Wahebine Seydi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Araia Berhane
- Conmmunicable Diseases Control Division, Ministry of Health, Asmara, Eritrea
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - David Njuguna
- Health Economist, Ministry of Health, Nairobi, Kenya
| | - Hillary Kipchumba Kipruto
- Essential Drugs and Medicines, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Edith Andrews Annan
- Essential Drugs and Medicines, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Benson Droti
- Health Information Systems, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Congo
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Diaconu K, Falconer J, Verbel A, Fretheim A, Witter S. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev 2021; 5:CD007899. [PMID: 33951190 PMCID: PMC8099148 DOI: 10.1002/14651858.cd007899.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is growing interest in paying for performance (P4P) as a means to align the incentives of healthcare providers with public health goals. Rigorous evidence on the effectiveness of these strategies in improving health care and health in low- and middle-income countries (LMICs) is lacking; this is an update of the 2012 review on this topic. OBJECTIVES To assess the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and 10 other databases between April and June 2018. We also searched two trial registries, websites, online resources of international agencies, organizations and universities, and contacted experts in the field. Studies identified from rerunning searches in 2020 are under 'Studies awaiting classification.' SELECTION CRITERIA We included randomized or non-randomized trials, controlled before-after studies, or interrupted time series studies conducted in LMICs (as defined by the World Bank in 2018). P4P refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: patient health outcomes, changes in targeted measures of provider performance (such as the delivery of healthcare services), unintended effects, or changes in resource use. DATA COLLECTION AND ANALYSIS We extracted data as per original review protocol and narratively synthesised findings. We used standard methodological procedures expected by Cochrane. Given diversity and variability in intervention types, patient populations, analyses and outcome reporting, we deemed meta-analysis inappropriate. We noted the range of effects associated with P4P against each outcome of interest. Based on intervention descriptions provided in documents, we classified design schemes and explored variation in effect by scheme design. MAIN RESULTS We included 59 studies: controlled before-after studies (19), non-randomized (16) or cluster randomized trials (14); and interrupted time-series studies (9). One study included both an interrupted time series and a controlled before-after study. Studies focused on a wide range of P4P interventions, including target payments and payment for outputs as modified by quality (or quality and equity assessments). Only one study assessed results-based aid. Many schemes were funded by national governments (23 studies) with the World Bank funding most externally funded schemes (11 studies). Targeted services varied; however, most interventions focused on reproductive, maternal and child health indicators. Participants were predominantly located in public or in a mix of public, non-governmental and faith-based facilities (54 studies). P4P was assessed predominantly at health facility level, though districts and other levels were also involved. Most studies assessed the effects of P4P against a status quo control (49 studies); however, some studies assessed effects against comparator interventions (predominantly enhanced financing intended to match P4P funds (17 studies)). Four studies reported intervention effects against both comparator and status quo. Controlled before-after studies were at higher risk of bias than other study designs. However, some randomised trials were also downgraded due to risk of bias. The interrupted time-series studies provided insufficient information on other concurrent changes in the study context. P4P compared to a status quo control For health services that are specifically targeted, P4P may slightly improve health outcomes (low certainty evidence), but few studies assessed this. P4P may also improve service quality overall (low certainty evidence); and probably increases the availability of health workers, medicines and well-functioning infrastructure and equipment (moderate certainty evidence). P4P may have mixed effects on the delivery and use of services (low certainty evidence) and may have few or no distorting unintended effects on outcomes that were not targeted (low-certainty evidence), but few studies assessed these. For secondary outcomes, P4P may make little or no difference to provider absenteeism, motivation or satisfaction (low certainty evidence); but may improve patient satisfaction and acceptability (low certainty evidence); and may positively affect facility managerial autonomy (low certainty evidence). P4P probably makes little to no difference to management quality or facility governance (low certainty evidence). Impacts on equity were mixed (low certainty evidence). For health services that are untargeted, P4P probably improves some health outcomes (moderate certainty evidence); may improve the delivery, use and quality of some health services but may make little or no difference to others (low certainty evidence); and may have few or no distorting unintended effects (low certainty evidence). The effects of P4P on the availability of medicines and other resources are uncertain (very low certainty evidence). P4P compared to other strategies For health outcomes and services that are specifically targeted, P4P may make little or no difference to health outcomes (low certainty evidence), but few studies assessed this. P4P may improve service quality (low certainty evidence); and may have mixed effects on the delivery and use of health services and on the availability of equipment and medicines (low certainty evidence). For health outcomes and services that are untargeted, P4P may make little or no difference to health outcomes and to the delivery and use of health services (low certainty evidence). The effects of P4P on service quality, resource availability and unintended effects are uncertain (very low certainty evidence). Findings of subgroup analyses Results-based aid, and schemes using payment per output adjusted for service quality, appeared to yield the greatest positive effects on outcomes. However, only one study evaluated results-based aid, so the effects may be spurious. Overall, schemes adjusting both for quality of service and rewarding equitable delivery of services appeared to perform best in relation to service utilization outcomes. AUTHORS' CONCLUSIONS The evidence base on the impacts of P4P schemes has grown considerably, with study quality gradually increasing. P4P schemes may have mixed effects on outcomes of interest, and there is high heterogeneity in the types of schemes implemented and evaluations conducted. P4P is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g., who receives payments ), the amount of additional funding, ancillary components (such as technical support) and contextual factors (including organizational context).
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Affiliation(s)
- Karin Diaconu
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Jennifer Falconer
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Adrian Verbel
- Research Group for Evidence Based Public Health, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Atle Fretheim
- Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
- Norwegian Institute of Public Health, Oslo, Norway
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Hanson K, Rasanathan K, George A. The State of Health Policy and Systems Research: Reflections From the 2018 5th Global Symposium. Health Policy Plan 2020; 34:ii1-ii3. [PMID: 31723960 DOI: 10.1093/heapol/czz113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2019] [Indexed: 12/22/2022] Open
Affiliation(s)
- Kara Hanson
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK
| | | | - Asha George
- Health Systems Global, 0179 Kavsadze str. 3, Office 5, Tbilisi, Georgia.,School of Public Health, University of the Western Cape, Robert Sobukwe Road, Bellville, Cape Town, South Africa
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