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Mohd Saleem S, Shoib S, Dazhamyar AR, Chandradasa M. Afghanistan: Decades of collective trauma, ongoing humanitarian crises, Taliban rulers, and mental health of the displaced population. Asian J Psychiatr 2021; 65:102854. [PMID: 34537535 DOI: 10.1016/j.ajp.2021.102854] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 09/02/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
More than half of the Afghan population suffers from depression, anxiety, and post-traumatic stress disorder, including many survivors of conflict-related violence, yet only about 10 percent receive effective psychosocial therapy from the government. As a result of decades of bloodshed, many Afghans have sustained serious psychological traumas. Due to unfair social standards, women and girls confront additional challenges, and millions of Afghans have suffered psychologically as a result of 41 years of conflict. While effective mental health investment is vital, funds must be spent judiciously to ensure access to adequate assessment while also adhering to human rights standards. The global mental health crises caused by the lengthy political struggle, as well as the COVID-19 pandemic, have collided in Afghanistan, worsening a complex humanitarian disaster and adding to the country's mounting mental health burden. Mental health is an issue that, at least in Afghanistan's current socio-political setting, requires immediate attention. While effective mental health investment is vital, funds must be spent judiciously to ensure access to adequate assessment.
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Affiliation(s)
| | - Sheikh Shoib
- Department of Psychiatry, Jawahar Lal Nehru Memorial Hospital, Srinagar, Jammu & Kashmir, India.
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Salehi AS, Blanchet K, Vassall A, Borghi J. Political economy analysis of the performance-based financing programme in Afghanistan. Glob Health Res Policy 2021; 6:9. [PMID: 33750468 PMCID: PMC7945625 DOI: 10.1186/s41256-021-00191-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 02/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Performance-based financing (PBF) has attracted considerable attention in recent years in low and middle-income countries. Afghanistan’s Ministry of Public Health (MoPH) implemented a PBF programme between 2010 and 2015 to strengthen the utilisation of maternal and child health services in primary health facilities. This study aimed to examine the political economy factors influencing the adoption, design and implementation of the PBF programme in Afghanistan. Methods Retrospective qualitative research methods were employed using semi structured interviews as well as a desk review of programme and policy documents. Key informants were selected purposively from the national level (n = 9), from the province level (n = 6) and the facility level (n = 15). Data analysis was inductive as well as deductive and guided by a political economy analysis framework to explore the factors that influenced the adoption and design of the PBF programme. Thematic content analysis was used to analyse the data. Results The global policy context, and implementation experience in other LMIC, shaped PBF and its introduction in Afghanistan. The MoPH saw PBF as a promise of additional resources needed to rebuild the country’s health system after a period of conflict. The MoPH support for PBF was also linked to their past positive experience of performance-based contracting. Power dynamics and interactions between PBF programme actors also shaped the policy process. The PBF programme established a centralised management structure which strengthened MoPH and donor ability to manage the programme, but overlooked key stakeholders, such as provincial health offices and non-state providers. However, MoPH had limited input in policy design, resulting in a design which was not well tailored to the national setting. Conclusions This study shows that PBF programmes need to be designed and adapted according to the local context, involving all relevant actors in the policy cycle. Future studies should focus on conducting empirical research to not only understand the multiple effects of PBF programmes on the performance of health systems but also the main political economy dynamics that influence the PBF programmes in different stages of the policy process.
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Affiliation(s)
- Ahmad Shah Salehi
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK.
| | - Karl Blanchet
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK.,CERAH, University of Geneva, Geneva, Switzerland
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK
| | - Josephine Borghi
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, Department of Global Health and Development, London, UK
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Higgins-Steele A, Farewar F, Ahmad F, Qadir A, Edmond K. Towards universal health coverage and sustainable financing in Afghanistan: progress and challenges. J Glob Health 2019. [PMID: 30410734 PMCID: PMC6207102 DOI: 10.7189/jogh.08.02038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | | | - Abdul Qadir
- Ministry of Public Health, Kabul, Afghanistan
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Khan NN, Puthussery S. Stakeholder perspectives on public-private partnership in health service delivery in Sindh province of Pakistan: a qualitative study. Public Health 2019; 170:1-9. [PMID: 30884348 DOI: 10.1016/j.puhe.2019.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 01/16/2019] [Accepted: 02/04/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to explore the perspectives of stakeholders on public-private partnership (PPP) in healthcare service delivery in Sindh province of Pakistan including the reasons for adopting such policies and the barriers for its implementation. STUDY DESIGN This was a qualitative primary study. METHODS Semistructured in-depth interviews were conducted with 13 stakeholders, including officials from provincial government and district administration (legislators, district managers, deputy commissioners and assistant commissioners) and representatives from private sector organisations with direct or indirect role in implementation of PPP policy, selected using purposive sampling methods. Data were analysed using a thematic approach. RESULTS Participants had very limited in-depth understanding about the concept of PPP. They considered multifaceted corruption in the health system and the success of existing PPP initiatives as the main reasons for the PPP policy adoption. Resistance from healthcare staff was perceived as the main barrier for implementation of PPP. There was a common perception that better monitoring capacity in the private sector management can be a cause of concern for public sector employees who may have become used to less efficient working. A common theme found in the narratives was the possible apprehensions from healthcare staff about the loss of their jobs. CONCLUSION Our findings indicated lack of effective engagement with key stakeholders and the resistance from healthcare staff as the key barriers for PPP implementation in Sindh, Pakistan. These findings provide useful insights for the successful implementation of such initiatives in Pakistan as well as in other similar settings.
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Affiliation(s)
- N N Khan
- Centre of Excellence in Women and Child Health, Aga Khan University, Stadium Road, Karachi, Pakistan.
| | - S Puthussery
- Maternal and Child Health Research Centre, Institute for Health Research, University of Bedfordshire, Putteridge Bury Campus, Hitchin Road, Luton, LU2 8LE, UK.
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Higgins-Steele A, Farewar F, Ahmad F, Qadir A, Edmond K. Towards universal health coverage and sustainable financing in Afghanistan: progress and challenges. J Glob Health 2018; 8:020308. [PMID: 30410734 PMCID: PMC6207102 DOI: 10.7189/jogh.08.020308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | - Abdul Qadir
- Ministry of Public Health, Kabul, Afghanistan
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Naziri M, Higgins-Steele A, Anwari Z, Yousufi K, Fossand K, Amin SS, Hipgrave DB, Varkey S. Scaling up newborn care in Afghanistan: opportunities and challenges for the health sector. Health Policy Plan 2018; 33:271-282. [PMID: 29190374 DOI: 10.1093/heapol/czx136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 11/13/2022] Open
Abstract
Newborn health in Afghanistan is receiving increased attention, but reduction in newborn deaths there has not kept pace with declines in maternal and child mortality. Using the continuum of care and health systems building block frameworks, this article identifies, organizes and provides a synthesis of the available evidence on and gaps in coverage of care and health systems, programmes, policies and practices related to newborn health in Afghanistan. Newborn mortality in Afghanistan is related to the nation's weak health system, itself associated with decades of conflict, low and uneven coverage of essential interventions, demand-side and cultural specificities, and compromised quality. A majority of deliveries still take place at home. Birth asphyxia, low birth weight, perinatal infections and poor post-natal care are responsible for many preventable newborn deaths. Though the situation has improved, there remain many opportunities to accelerate progress. Analyses conducted using the Lives Saved Tools suggest that an additional 10 405 newborn lives could be saved in Afghanistan in 5 years (2015-20), through reasonable increases in coverage of these high-impact interventions. A long-term vision and strong leadership are essential for the Ministry of Public Health to play an effective stewardship role in formulating related policy and strategy, setting standards and monitoring maternal and newborn services. Promotion of equitable access to health services, including health workforce planning, development and management, and the coordination of much-needed donor support are also imperative.
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Affiliation(s)
- Malalai Naziri
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
| | | | - Zelaikha Anwari
- Ministry of Public Health, Reproductive, Maternal, Newborn, Child, and Adolescent Directorate, Kabul, Afghanistan and
| | - Khaksar Yousufi
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
| | | | | | - David B Hipgrave
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
| | - Sherin Varkey
- UNICEF Afghanistan, Health Section, UNOCA Jalalabad Road, Kabul, Afghanistan
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Odendaal WA, Ward K, Uneke J, Uro‐Chukwu H, Chitama D, Balakrishna Y, Kredo T. Contracting out to improve the use of clinical health services and health outcomes in low- and middle-income countries. Cochrane Database Syst Rev 2018; 4:CD008133. [PMID: 29611869 PMCID: PMC6494528 DOI: 10.1002/14651858.cd008133.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Contracting out of governmental health services is a financing strategy that governs the way in which public sector funds are used to have services delivered by non-governmental health service providers (NGPs). It represents a contract between the government and an NGP, detailing the mechanisms and conditions by which the latter should provide health care on behalf of the government. Contracting out is intended to improve the delivery and use of healthcare services. This Review updates a Cochrane Review first published in 2009. OBJECTIVES To assess effects of contracting out governmental clinical health services to non-governmental service provider/s, on (i) utilisation of clinical health services; (ii) improvement in population health outcomes; (iii) improvement in equity of utilisation of these services; (iv) costs and cost-effectiveness of delivering the services; and (v) improvement in health systems performance. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, NHS Economic Evaluation Database, EconLit, ProQuest, and Global Health on 07 April 2017, along with two trials registers - ClinicalTrials.gov and the International Clinical Trials Registry Platform - on 17 November 2017. SELECTION CRITERIA Individually randomised and cluster-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies, comparing government-delivered clinical health services versus those contracted out to NGPs, or comparing different models of non-governmental-delivered clinical health services. DATA COLLECTION AND ANALYSIS Two authors independently screened all records, extracted data from the included studies and assessed the risk of bias. We calculated the net effect for all outcomes. A positive value favours the intervention whilst a negative value favours the control. Effect estimates are presented with 95% confidence intervals. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence and we prepared a Summary of Findings table. MAIN RESULTS We included two studies, a cluster-randomised trial conducted in Cambodia, and a controlled before-after study conducted in Guatemala. Both studies reported that contracting out over 12 months probably makes little or no difference in (i) immunisation uptake of children 12 to 24 months old (moderate-certainty evidence), (ii) the number of women who had more than two antenatal care visits (moderate-certainty evidence), and (iii) female use of contraceptives (moderate-certainty evidence).The Cambodia trial reported that contracting out may make little or no difference in the mortality over 12 months of children younger than one year of age (net effect = -4.3%, intervention effect P = 0.36, clustered standard error (SE) = 3.0%; low-certainty evidence), nor to the incidence of childhood diarrhoea (net effect = -16.2%, intervention effect P = 0.07, clustered SE = 19.0%; low-certainty evidence). The Cambodia study found that contracting out probably reduces individual out-of-pocket spending over 12 months on curative care (net effect = $ -19.25 (2003 USD), intervention effect P = 0.01, clustered SE = $ 5.12; moderate-certainty evidence). The included studies did not report equity in the use of clinical health services and in adverse effects. AUTHORS' CONCLUSIONS This update confirms the findings of the original review. Contracting out probably reduces individual out-of-pocket spending on curative care (moderate-certainty evidence), but probably makes little or no difference in other health utilisation or service delivery outcomes (moderate- to low-certainty evidence). Therefore, contracting out programmes may be no better or worse than government-provided services, although additional rigorously designed studies may change this result. The literature provides many examples of contracting out programmes, which implies that this is a feasible response when governments fail to provide good clinical health care. Future contracting out programmes should be framed within a rigorous study design to allow valid and reliable measures of their effects. Such studies should include qualitative research that assesses the views of programme implementers and beneficiaries, and records implementation mechanisms. This approach may reveal enablers for, and barriers to, successful implementation of such programmes.
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Affiliation(s)
- Willem A Odendaal
- South African Medical Research CouncilHealth Systems Research UnitCape TownWestern CapeSouth Africa
- Stellenbosch UniversityDepartment of PsychiatryStellenboschSouth Africa
| | - Kim Ward
- University of the Western CapeSchool of PharmacyCape TownSouth Africa
| | - Jesse Uneke
- Ebonyi State UniversityAfrican Institute for Health Policy and Health SystemsAbakalikiNigeria
| | - Henry Uro‐Chukwu
- National Obstetrics Fistula CentreSocial Mobilization and Disease ControlAbakalikiNigeria
| | - Dereck Chitama
- Muhimbili University of Health and Allied SciencesSchool of Public Health and Social SciencesDar es SalaamTanzania
| | - Yusentha Balakrishna
- South African Medical Research CouncilBiostatistics Unit491 Ridge Road, OverportDurbanKwazulu‐NatalSouth Africa4001
| | - Tamara Kredo
- South African Medical Research CouncilCochrane South AfricaPO Box 19070TygerbergCape TownWestern CapeSouth Africa7505
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Stepurko T, Pavlova M, Gryga I, Gaál P, Groot W. Patterns of informal patient payments in Bulgaria, Hungary and Ukraine: a comparison across countries, years and type of services. Health Policy Plan 2017; 32:453-466. [PMID: 27993960 DOI: 10.1093/heapol/czw147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2016] [Indexed: 11/12/2022] Open
Abstract
Informal payments for health care are a well-known phenomenon in many health care systems around the world. While informal payments could be an important source of health care financing, they have an adverse impact on efficiency and access to care, and are a major impediment to ongoing health care reforms. This paper aims to study the scale and patterns of informal patient payments for out-patient and in-patient services in three former-socialist countries: Bulgaria, Hungary and Ukraine. The data are collected in 2010 and 2011 based on national representative samples and are analysed in pooled models to explain variations in payments. The results of the cross-country comparison suggest a relatively higher prevalence of informal patient payments in Ukraine and Hungary than in Bulgaria, where patients also have to pay formal user charges in the public sector. Nevertheless, informal payments for hospitalization in Bulgaria are quite extensive. We observe some differences in informal payments across the years. Variations in payment size are mainly explained by the nature, type and need for services, fee awareness and, on some occasions, by household income. Interpreted within the context of structural differences (e.g. reform paths, regulations, funding, user fees, anti-corruption policies), the findings of our study have implications on how to address informal payments for health care.
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Affiliation(s)
- Tetiana Stepurko
- School of Public Health, National University of 'Kyiv-Mohyla Academy'; Ukraine, Skovorody street 2, Kiev, Ukraine.,Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Irena Gryga
- School of Public Health, National University of 'Kyiv-Mohyla Academy'; Ukraine, Skovorody street 2, Kiev, Ukraine
| | - Péter Gaál
- Faculty of Health and Public Services, Semmelweis University, Budapest, Hungary
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands.,Top Institute Evidence-Based Education Research (TIER); Maastricht University, The Netherlands
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Cross HE, Sayedi O, Irani L, Archer LC, Sears K, Sharma S. Government stewardship of the for-profit private health sector in Afghanistan. Health Policy Plan 2017; 32:338-348. [PMID: 27683341 PMCID: PMC5400060 DOI: 10.1093/heapol/czw130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2016] [Indexed: 11/13/2022] Open
Abstract
Background Since 2003, Afghanistan's largely unregulated for-profit private health sector has grown at a rapid pace. In 2008, the Ministry of Public Health (MoPH) launched a long-term stewardship initiative to oversee and regulate private providers and align the sector with national health goals. Aim We examine the progress the MoPH has made towards more effective stewardship, consider the challenges and assess the early impacts on for-profit performance. Methods We reviewed publicly available documents, publications and the grey literature to analyse the development, adoption and implementation of strategies, policies and regulations. We carried out a series of key informant/participant interviews, organizational capacity assessments and analyses of hospital standards checklists. Using a literature review of health systems strengthening, we proposed an Afghan-specific definition of six key stewardship functions to assess progress towards MoPH stewardship objectives. Results The MoPH and its partners have achieved positive results in strengthening its private sector stewardship functions especially in generating actionable intelligence and establishing strategic policy directions, administrative structures and a legal and regulatory framework. Progress has also been made on improving accountability and transparency, building partnerships and applying minimum required standards to private hospitals. Procedural and operational issues still need resolution and the MoPH is establishing mechanisms for resolving them. Conclusions The MoPH stewardship initiative is notable for its achievements to date under challenging circumstances. Its success is due to the focus on developing a solid policy framework and building institutions and systems aimed at ensuring higher quality private services, and a rational long-term and sustainable role for the private sector. Although the MoPH stewardship initiative is still at an early stage, the evidence suggests that enhanced stewardship functions in the MoPH are leading to a more efficient and effective for-profit private sector. These successful early efforts offer high-leverage potential to rapidly scale up going forward.
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Affiliation(s)
| | | | - Laili Irani
- The Population Reference Bureau, Washington DC
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Frost A, Wilkinson M, Boyle P, Patel P, Sullivan R. An assessment of the barriers to accessing the Basic Package of Health Services (BPHS) in Afghanistan: was the BPHS a success? Global Health 2016; 12:71. [PMID: 27846910 PMCID: PMC5111262 DOI: 10.1186/s12992-016-0212-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/23/2016] [Indexed: 11/10/2022] Open
Abstract
Afghanistan is one of the most fragile and conflict-affected countries in the world. It has experienced almost uninterrupted conflict for the last thirty years, with the present conflict now lasting over a decade. With no history of a functioning healthcare system, the creation of the Basic Package of Health Services (BPHS) in 2003 was a response to Afghanistan's dire health needs following decades of war. Its objective was to provide a bare minimum of essential health services, which could be scaled up rapidly through contracting mechanisms with Non-Governmental Organisations (NGOs). The central thesis of this article is that, despite the good intentions of the BPHS, not enough has been done to overcome the barriers to accessing its services. This analysis, enabled through a review of the existing literature, identifies and categorises these barriers into the three access dimensions of: acceptability, affordability and availability. As each of these is explored individually, analysis will show the extent to which these barriers to access are a critical issue, consider the underlying reasons for their existence and evaluate the efforts to overcome these barriers. Understanding these barriers and the policies that have been implemented to address them is critical to the future of health system strengthening in Afghanistan.
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Affiliation(s)
- Alexandra Frost
- Centre for Global Health, King’s Health Partners and King’s College London, London, UK
- Conflict and Health Research Group, King’s College London, London, UK
| | - Matthew Wilkinson
- Conflict and Health Research Group, King’s College London, London, UK
- Centre of Islamic Studies, SOAS, University of London, London, UK
| | - Peter Boyle
- International Prevention Research Institute, France and University of Strathclyde Institute of Global Public Health @iPRI, Lyon, France
| | - Preeti Patel
- Conflict and Health Research Group, King’s College London, London, UK
- Department of War Studies, King’s College London, London, UK
| | - Richard Sullivan
- Centre for Global Health, King’s Health Partners and King’s College London, London, UK
- Conflict and Health Research Group, King’s College London, London, UK
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Akseer N, Salehi AS, Hossain SMM, Mashal MT, Rasooly MH, Bhatti Z, Rizvi A, Bhutta ZA. Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study. LANCET GLOBAL HEALTH 2016; 4:e395-413. [DOI: 10.1016/s2214-109x(16)30002-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 03/05/2016] [Accepted: 03/14/2016] [Indexed: 10/21/2022]
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Odu BP, Mitchell S, Isa H, Ugot I, Yusuf R, Cockcroft A, Andersson N. Equity and seeking treatment for young children with fever in Nigeria: a cross-sectional study in Cross River and Bauchi States. Infect Dis Poverty 2015; 4:1. [PMID: 25671126 PMCID: PMC4322819 DOI: 10.1186/2049-9957-4-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 11/18/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Poor children have a higher risk of contracting malaria and may be less likely to receive effective treatment. Malaria is an important cause of morbidity and mortality in Nigerian children and many cases of childhood fever are due to malaria. This study examined socioeconomic factors related to taking children with fever for treatment in formal health facilities. METHODS A household survey conducted in Bauchi and Cross River states of Nigeria asked parents where they sought treatment for their children aged 0-47 months with severe fever in the last month and collected information about household socio-economic status. Fieldworkers also recorded whether there was a health facility in the community. We used treatment of severe fever in a health facility to indicate likely effective treatment for malaria. Multivariate analysis in each state examined associations with treatment of childhood fever in a health facility. RESULTS 43% weighted (%wt) of 10,862 children had severe fever in the last month in Cross River, and 45%wt of 11,053 children in Bauchi. Of these, less than half (31%wt Cross River, 44%wt Bauchi) were taken to a formal health facility for treatment. Children were more likely to be taken to a health facility if there was one in the community (OR 2.31 [95% CI 1.57-3.39] in Cross River, OR 1.33 [95% CI 1.0-1.7] in Bauchi). Children with fever lasting less than five days were less likely to be taken for treatment than those with more prolonged fever, regardless of whether there was such a facility in their community. Educated mothers were more likely to take children with fever to a formal health facility. In communities with a health facility in Cross River, children from less-poor households were more likely to go to the facility (OR 1.30; 95% CI 1.07-1.58). CONCLUSION There is inequity of access to effective malaria treatment for children with fever in the two states, even when there is a formal health facility in the community. Understanding the details of inequity of access in the two states could help the state governments to plan interventions to increase access equitably. Increasing geographic access to health facilities is needed but will not be enough.
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Affiliation(s)
- Bikom Patrick Odu
- CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg, 2196 South Africa
| | - Steven Mitchell
- CIET/PRAM, Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Suite 300, Montreal, QC H3Z 1Z1 Canada
| | - Hajara Isa
- CIET Trust, 71 Oxford Road, Saxonwold, Johannesburg, 2196 South Africa
| | - Iyam Ugot
- Community Health Department and Roll Back Malaria Program, Calabar, Cross River State Nigeria
| | | | | | - Neil Andersson
- CIET/PRAM, Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Suite 300, Montreal, QC H3Z 1Z1 Canada
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Howard N, Woodward A, Patel D, Shafi A, Oddy L, ter Veen A, Atta N, Sondorp E, Roberts B. Perspectives on reproductive healthcare delivered through a basic package of health services in Afghanistan: a qualitative study. BMC Health Serv Res 2014; 14:359. [PMID: 25167872 PMCID: PMC4169831 DOI: 10.1186/1472-6963-14-359] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 08/19/2014] [Indexed: 12/04/2022] Open
Abstract
Background Contracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are particularly constrained. Afghanistan, the longest-running example of Basic Package of Health Services (BPHS) contracting in a conflict-affected setting, enables study of how implementation of a national intervention influences access to prioritised health services. This study explores stakeholder perspectives of sexual and reproductive health (SRH) services delivered through the BPHS in Afghanistan, using Bamyan Province as a case study. Methods Twenty-six in-depth interviews were conducted with health-system practitioners (e.g. policy/regulatory, middle management, frontline providers) and four focus groups with service-users. Inductive thematic coding used the WHO Health System Framework categories (i.e. service delivery, workforce, medicines, information, financing, stewardship), while allowing for emergent themes. Results Improvements were noted by respondents in all health-system components discussed, with significant improvements identified in service coverage and workforce, particularly improved gender balance, numbers, training, and standardisation. Despite improvements, remaining weaknesses included service access and usage - especially in remote areas, staff retention, workload, and community accountability. Conclusions By including perspectives on SRH service provision and BPHS contracting across health-system components and levels, this study contributes to broader debates on the effects of contracting on perceptions and experiences among practitioners and service-users in conflict-affected countries.
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Affiliation(s)
- Natasha Howard
- London School of Hygiene and Tropical Medicine, London, UK.
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Cameron M, Cockcroft A, Waichigo GW, Marokoane N, Laetsang D, Andersson N. From knowledge to action: participant stories of a population health intervention to reduce gender violence and HIV in three southern African countries. AIDS Care 2014; 26:1534-40. [PMID: 24991886 PMCID: PMC4193283 DOI: 10.1080/09540121.2014.931560] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This paper describes implementation research of an intervention in a complex HIV prevention randomised trial in southern Africa. Researchers collected stories of change attributed by 106 community members to an audio-drama edutainment intervention in 41 sites in Botswana, Namibia and Swaziland. The team analysed themes in the stories following a behaviour change model of conscious knowledge, attitudes, subjective norms, intention to change, agency, discussion and action (CASCADA). Storytellers attributed positive changes to the intervention in the areas of gender violence, multiple sexual partners, transactional and intergenerational sex and condom use. Their stories illustrate each of the steps in the CASCADA behaviour change model. As well as supporting an enabling environment for other interventions in the trial, the audio-drama also helped some participants to make personal changes. Collecting and discussing the stories were encouraging for the trial fieldworkers. Documenting the experiences of participants and framing the analysis of stories in an explicit behaviour change model allowed us to reflect on potential mechanisms and pathways through which the intervention impacts on individuals and communities. It helped in the design of the quantitative instruments to measure intermediate outcomes of the trial.
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Michael M, Pavignani E, Hill PS. Too good to be true? An assessment of health system progress in Afghanistan, 2002-2012. Med Confl Surviv 2013; 29:322-45. [PMID: 24494581 DOI: 10.1080/13623699.2013.840819] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The bold decision was taken in Afghanistan in 2002 to provide donor-funded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field.
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Affiliation(s)
- Markus Michael
- lndependent Consultant for Public Health and Humanitarian Aid, Sao Paulo, Brazil.
| | - Enrico Pavignani
- School of Population Health, The University of Queensland, Maputo, Mozambique
| | - Peter S Hill
- School of Population Health, The University of Queensland, Brisbane, Australia
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Rahmani Z, Brekke M. Antenatal and obstetric care in Afghanistan--a qualitative study among health care receivers and health care providers. BMC Health Serv Res 2013; 13:166. [PMID: 23642217 PMCID: PMC3654902 DOI: 10.1186/1472-6963-13-166] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 05/02/2013] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite attempts from the government to improve ante- and perinatal care, Afghanistan has once again been labeled "the worst country in which to be a mom" in Save the Children's World's Mothers' Report. This study investigated how pregnant women and health care providers experience the existing antenatal and obstetric health care situation in Afghanistan. METHODS Data were obtained through one-to-one semi-structured interviews of 27 individuals, including 12 women who were pregnant or had recently given birth, seven doctors, five midwives, and three traditional birth attendants. The interviews were carried out in Kabul and the village of Ramak in Ghazni Province. Interviews were taped, transcribed, and analyzed according to the principles of Giorgi's phenomenological analysis. RESULTS Antenatal care was reported to be underused, even when available. Several obstacles were identified, including a lack of knowledge regarding the importance of antenatal care among the women and their families, financial difficulties, and transportation problems. The women also reported significant dissatisfaction with the attitudes and behavior of health personnel, which included instances of verbal and physical abuse. According to the health professionals, poor working conditions, low salaries, and high stress levels contributed to this matter. Personal contacts inside the hospital were considered necessary for receiving high quality care, and bribery was customary. Despite these serious concerns, the women expressed gratitude for having even limited access to health care, especially treatment provided by a female doctor. Health professionals were proud of their work and enjoyed the opportunity to help their community. CONCLUSION This study identified several obstacles which must be addressed to improve reproductive health in Afghanistan. There was limited understanding of the importance of antenatal care and a lack of family support. Financial and transportation problems led to underuse of available care, especially by poorly educated rural women. Patients frequently complained of being treated disrespectfully, and health care providers correspondingly complained about poor working conditions leading to exhaustion and a lack of compassion. Widespread corruption, including the necessity of personal contacts inside hospitals, was also emphasized as an obstacle to equitable antenatal and obstetric health care.
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Affiliation(s)
- Zuhal Rahmani
- Faculty of Medicine, University of Oslo, Norway, Blindern, P.O. Box 1078, Oslo, 0316, Norway
| | - Mette Brekke
- Department of General Practice, Institute of Health and Society, University of Oslo, P.O. Box 1130, Blindern, Oslo, 0318, Norway
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Cockcroft A, Milne D, Oelofsen M, Karim E, Andersson N. Health services reform in Bangladesh: hearing the views of health workers and their professional bodies. BMC Health Serv Res 2011; 11 Suppl 2:S8. [PMID: 22375856 PMCID: PMC3332567 DOI: 10.1186/1472-6963-11-s2-s8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background In Bangladesh, widespread dissatisfaction with government health services did not improve during the Health and Population Sector Programme (HPSP) reforms from 1998-2003. A 2003 national household survey documented public and health service users' views and experience. Attitudes and behaviour of health workers are central to quality of health services. To investigate whether the views of health workers influenced the reforms, we surveyed local health workers and held evidence-based discussions with local service managers and professional bodies. Methods Some 1866 government health workers in facilities serving the household survey clusters completed a questionnaire about their views, experience, and problems as workers. Field teams discussed the findings from the household and health workers' surveys with local health service managers in five upazilas (administrative sub-districts) and with the Bangladesh Medical Association (BMA) and Bangladesh Nurses Association (BNA). Results Nearly one half of the health workers (45%) reported difficulties fulfilling their duties, especially doctors, women, and younger workers. They cited inadequate supplies and infrastructure, bad behaviour of patients, and administrative problems. Many, especially doctors (74%), considered they were badly treated as employees. Nearly all said lack of medicines in government facilities was due to inadequate supply, not improved during the HPSP. Two thirds of doctors and nurses complained of bad behaviour of patients. A quarter of respondents thought quality of service had improved as a result of the HPSP. Local service managers and the BMA and BNA accepted patients had negative views and experiences, blaming inadequate resources, high patient loads, and patients' unrealistic expectations. They said doctors and nurses were demotivated by poor working conditions, unfair treatment, and lack of career progression; private and unqualified practitioners sought to please patients instead of giving medically appropriate care. The BMA considered it would be dangerous to attempt to train and register unqualified practitioners. Conclusions The continuing dissatisfaction of health workers may have undermined the effectiveness of the HPSP. Presenting the views of the public and service users to health managers helped to focus discussions about quality of services. It is important to involve health workers in health services reforms.
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Andersson N. Building the community voice into planning: 25 years of methods development in social audit. BMC Health Serv Res 2011; 11 Suppl 2:S1. [PMID: 22376121 PMCID: PMC3397387 DOI: 10.1186/1472-6963-11-s2-s1] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Health planners and managers make decisions based on their appreciation of causality. Social audits question the assumptions behind this and try to improve quality of available evidence. The method has its origin in the follow-up of Bhopal survivors in the 1980s, where "cluster cohorts" tracked health events over time. In social audit, a representative panel of sentinel sites are the framework to follow the impact of health programmes or reforms. The epidemiological backbone of social audit tackles causality in a calculated way, balancing computational aspects with appreciation of the limits of the science.Social audits share findings with planners at policy level, health services providers, and users in the household, where final decisions about use of public services rest. Sharing survey results with sample communities and service workers generates a second order of results through structured discussions. Aggregation of these evidence-based community-led solutions across a representative sample provides a rich substrate for decisions. This socialising of evidence for participatory action (SEPA) involves a different skill set but quality control and rigour are still important.Early social audits addressed settings without accepted sample frames, the fundamentals of reproducible questionnaires, and the logistics of data turnaround. Feedback of results to stakeholders was at CIET insistence--and at CIET expense. Later social audits included strong SEPA components. Recent and current social audits are institutionalising high level research methods in planning, incorporating randomisation and experimental designs in a rigorous approach to causality.The 25 years have provided a number of lessons. Social audit reduces the arbitrariness of planning decisions, and reduces the wastage of simply allocating resources the way they were in past years. But too much evidence easily exceeds the uptake capacity of decision takers. Political will of governments often did not match those of donors with interest conditioned by political cycles. Some reforms have a longer turnaround than the political cycle; short turnaround interventions can develop momentum. Experience and specialisation made social audit seem more simple than it is. The core of social audit, its mystique, is not easily taught or transferred. Yet teams in Mexico, Nicaragua, Canada, southern Africa, and Pakistan all have more than a decade of experience in social audit, their in-service training supported by a customised Masters programme.
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Affiliation(s)
- Neil Andersson
- Centro de Investigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero, Calle Pino, El Roble, Acapulco, Mexico.
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Ansari U, Cockcroft A, Omer K, Ansari NMD, Khan A, Chaudhry UU, Andersson N. Devolution and public perceptions and experience of health services in Pakistan: linked cross sectional surveys in 2002 and 2004. BMC Health Serv Res 2011; 11 Suppl 2:S4. [PMID: 22375682 PMCID: PMC3332563 DOI: 10.1186/1472-6963-11-s2-s4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The government of Pakistan introduced devolution in 2001. Responsibility for delivery of most health services passed from provincial to district governments. Two national surveys examined public opinions, use, and experience of health services in 2001 and 2004, to assess the impact of devolution on these services from the point of view of the public. METHODS A stratified random cluster sample drawn in 2001 and revisited in 2004 included households in all districts. Field teams administered a questionnaire covering views about available health services, use of government and private health services, and experience and satisfaction with the service. Focus groups in each community discussed reasons behind the findings, and district nazims (elected mayors) and administrators commented about implementation of devolution. Multivariate analysis, with an adjustment for clustering, examined changes over time, and associations with use and satisfaction with services in 2004. RESULTS Few of 57,321 households interviewed in 2002 were satisfied with available government health services (23%), with a similar satisfaction (27%) among 53,960 households in 2004. Less households used government health services in 2004 (24%) than in 2002 (29%); the decrease was significant in the most populous province. In 2004, households were more likely to use government services if they were satisfied with the services, poorer, or less educated. The majority of users of government health services were satisfied; the increase from 63% to 67% between 2002 and 2004 was significant in two provinces. Satisfaction in 2004 was higher among users of private services (87%) or private unqualified practitioners (78%). Users of government services who received all medicines from the facility or who were given an explanation of their condition were more likely to be satisfied. Focus groups explained that people avoid government health services particularly because of bad treatment from staff, and unavailable or poor quality medicines. District nazims and administrators cited problems with implementation of devolution, especially with transfer of funds. CONCLUSIONS Under devolution, the public did not experience improved government health services, but devolution was not fully implemented as intended. An ongoing social audit process could provide a basis for local and national accountability of health services.
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Affiliation(s)
- Umaira Ansari
- CIET Trust Botswana, PO Box 1240, Gaborone, Botswana
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