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Mianda S, Todowede O, Schneider H. Service delivery interventions to improve maternal and newborn health in low- and middle-income countries: scoping review of quality improvement, implementation research and health system strengthening approaches. BMC Health Serv Res 2023; 23:1223. [PMID: 37940974 PMCID: PMC10634015 DOI: 10.1186/s12913-023-10202-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
INTRODUCTION This review explores the characteristics of service delivery-related interventions to improve maternal and newborn health (MNH) in low-and middle-income countries (LMICs) over the last two decades, comparing three common framings of these interventions, namely, quality improvement (QI), implementation science/research (IS/IR), and health system strengthening (HSS). METHODS The review followed the staged scoping review methodology proposed by Levac et al. (2010). We developed and piloted a systematic search strategy, limited to English language peer-reviewed articles published on LMICs between 2000 and March 2022. Analysis was conducted in two-quantitative and qualitative-phases. In the quantitative phase, we counted the year of publication, country(-ies) of origin, and the presence of the terms 'quality improvement', 'health system strengthening' or 'implementation science'/ 'implementation research' in titles, abstracts and key words. From this analysis, a subset of papers referred to as 'archetypes' (terms appearing in two or more of titles, abstract and key words) was analysed qualitatively, to draw out key concepts/theories and underlying mechanisms of change associated with each approach. RESULTS The searches from different databases resulted in a total of 3,323 hits. After removal of duplicates and screening, a total of 231 relevant articles remained for data extraction. These were distributed across the globe; more than half (n = 134) were published since 2017. Fifty-five (55) articles representing archetypes of the approach (30 QI, 16 IS/IR, 9 HSS) were analysed qualitatively. As anticipated, we identified distinct patterns in each approach. QI archetypes tended towards defined process interventions (most typically, plan-do-study-act cycles); IS/IR archetypes reported a wide variety of interventions, but had in common evaluation methodologies and explanatory theories; and HSS archetypes adopted systemic perspectives. Despite their distinctiveness, there was also overlap and fluidity between approaches, with papers often referencing more than one approach. Recognising the complexity of improving MNH services, there was an increased orientation towards participatory, context-specific designs in all three approaches. CONCLUSIONS Programmes to improve MNH outcomes will benefit from a better appreciation of the distinctiveness and relatedness of different approaches to service delivery strengthening, how these have evolved and how they can be combined.
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Affiliation(s)
- Solange Mianda
- School of Public Health & SAMRC Health Services to Systems Research Unit, University of the Western Cape, Private Bag X17, Bellville, 7535, Cape Town, South Africa.
| | - Olamide Todowede
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Helen Schneider
- School of Public Health & SAMRC Health Services to Systems Research Unit, University of the Western Cape, Private Bag X17, Bellville, 7535, Cape Town, South Africa
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Wakida EK, Obua C, Haberer JE, Bartels SJ. Enhancing the Capacity of Providers in Mental Health Integration (ECaP-MHI) in Rural Uganda: The Adaptation Process. J Multidiscip Healthc 2023; 16:387-396. [PMID: 36816613 PMCID: PMC9930675 DOI: 10.2147/jmdh.s401495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/02/2023] [Indexed: 02/12/2023] Open
Abstract
Purpose Uganda adopted the World Health Organization (WHO) model of creating district health management teams (DHMT) comprised of public health officials and administrators to supervise health service delivery at the community level. The purpose of this study was to characterize the perspectives of the DMHT in providing support supervision to primary health-care providers implementing mental health integration using the pre-recorded material. Our aim was to identify barriers to individual uptake and contextual fit, and to solicit solutions for co-designed improvements. Methods We conducted a qualitative exploratory study using one-on-one interviews informed by the Practical Robust Implementation and Sustainability Model. Results Members of the DHMT identified a systemic gap in supporting mental health integration into primary care, and reported limited knowledge in how to supervise mental health integration and lacked data on mental health delivery and outcomes. They recommended training of the DHMT in supervising mental health integration supported by standard outcome reports, pre-recorded instructional material by psychiatrists, checklists to help guide and standardize the process, and use of visual aids illustrating mental disorders and treatments for low-health literacy populations. Conclusion Implementing integrated mental health care using the WHO model of DHMTs as external facilitators and supervisors of primary health-care providers is potentially feasible and scalable, provided that substantial reforms occur such as training in how to provide supervision, standard collection of outcome reports, and practical tools to help guide and facilitate the process.
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Affiliation(s)
- Edith K Wakida
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda,Correspondence: Edith K Wakida, Email
| | - Celestino Obua
- Office of Research Administration, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jessica E Haberer
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen J Bartels
- Mongan Institute, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Kruk ME, Lewis TP, Arsenault C, Bhutta ZA, Irimu G, Jeong J, Lassi ZS, Sawyer SM, Vaivada T, Waiswa P, Yousafzai AK. Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services. Lancet 2022; 399:1830-1844. [PMID: 35489361 PMCID: PMC9077444 DOI: 10.1016/s0140-6736(21)02532-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/10/2021] [Accepted: 11/11/2021] [Indexed: 12/25/2022]
Abstract
Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.
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Affiliation(s)
- Margaret E Kruk
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Catherine Arsenault
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Center of Excellence in Women and Child Health and Institute for Global Health and Development, Aga Khan University, Karachi, Pakistan
| | - Grace Irimu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Joshua Jeong
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Zohra S Lassi
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Susan M Sawyer
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Centre for Adolescent Health, Royal Children's Hospital, Parkville, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Waiswa
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Aisha K Yousafzai
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
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Nelson E, Waiswa P, Coelho VS, Sarriot E. Social accountability and health systems' change, beyond the shock of Covid-19: drawing on histories of technical and activist approaches to rethink a shared code of practice. Int J Equity Health 2022; 21:41. [PMID: 35331257 PMCID: PMC8948032 DOI: 10.1186/s12939-022-01645-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recognition of the value of "social accountability" to improve health systems performance and to address health inequities, has increased over the last decades, with different schools of thought engaging in robust dialogue. This article explores the tensions between health policy and systems research and practice on the one hand, and health equity-focussed activism on the other, as distinct yet interacting processes that have both been impacted by the shock effects of the Covid-19 pandemic. This extended commentary brings multidisciplinary voices seeking to look back at health systems history and fundamental social-institutional systems' behaviors in order to contextualize these current debates over how best to push social accountability efforts forward. ANALYSIS There is a documented history of tension between long and short processes of international health cooperation and intervention. Social accountability approaches, as a more recent strategy to improve health systems performance, intersect with this overarching history of negotiation between differently situated actors both global and local on whether to pursue sustained, slow, often community-driven change or to focus on rapid, measurable, often top-down interventions. Covid-19, as a global public health emergency, resulted in calls for urgent action which have unsurprisingly displaced some of the energy and aspiration for systemic transformation processes. A combination of accountability approaches and mechanisms have their own legitimacy in fostering health systems change, demanding collaboration between those that move both fast and slow, top-down and bottom-up. CONCLUSION We argue that social accountability, much like all efforts to strengthen health systems, is "everybody's business" and that we must understand better the historical processes that have shaped the field of practice over time to move forward. These differences of perspective, knowledge-base and positioning vis-a-vis interventions or longer-term political commitment should not drive a conflict of legitimacy but instead be named, subsequently enabling the development of a shared code of conduct that applies to the breadth of actors involved in social accountability work. If we are concerned about the state of/status of social accountability within the context of "building back better" we must approach collaboration with a willingness to create dialogue across distinct disciplinary, technical and politically-informed ways of working.
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Affiliation(s)
- Erica Nelson
- The Institute of Development Studies, Health and Nutrition Cluster, Brighton, UK
| | - Peter Waiswa
- Makerere University School of Public Health, Kampala, Uganda
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Lowe D, Ryan R, Schonfeld L, Merner B, Walsh L, Graham-Wisener L, Hill S. Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation. Cochrane Database Syst Rev 2021; 9:CD013373. [PMID: 34523117 PMCID: PMC8440158 DOI: 10.1002/14651858.cd013373.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis. OBJECTIVES To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s). DATA COLLECTION AND ANALYSIS Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events. MAIN RESULTS We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies. AUTHORS' CONCLUSIONS The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.
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Affiliation(s)
- Dianne Lowe
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Rebecca Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Bronwen Merner
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Louisa Walsh
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | | | - Sophie Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
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Waiswa P, Mpanga F, Bagenda D, Kananura RM, O'Connell T, Henriksson DK, Diaz T, Ayebare F, Katahoire AR, Ssegujja E, Mbonye A, Peterson SS. Child health and the implementation of Community and District-management Empowerment for Scale-up (CODES) in Uganda: a randomised controlled trial. BMJ Glob Health 2021; 6:bmjgh-2021-006084. [PMID: 34103326 PMCID: PMC8189926 DOI: 10.1136/bmjgh-2021-006084] [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: 04/26/2021] [Accepted: 05/21/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction Uganda’s district-level administrative units buttress the public healthcare system. In many districts, however, local capacity is incommensurate with that required to plan and implement quality health interventions. This study investigates how a district management strategy informed by local data and community dialogue influences health services. Methods A 3-year randomised controlled trial (RCT) comprised of 16 Ugandan districts tested a management approach, Community and District-management Empowerment for Scale-up (CODES). Eight districts were randomly selected for each of the intervention and comparison areas. The approach relies on a customised set of data-driven diagnostic tools to identify and resolve health system bottlenecks. Using a difference-in-differences approach, the authors performed an intention-to-treat analysis of protective, preventive and curative practices for malaria, pneumonia and diarrhoea among children aged 5 and younger. Results Intervention districts reported significant net increases in the treatment of malaria (+23%), pneumonia (+19%) and diarrhoea (+13%) and improved stool disposal (+10%). Coverage rates for immunisation and vitamin A consumption saw similar improvements. By engaging communities and district managers in a common quest to solve local bottlenecks, CODES fostered demand for health services. However, limited fiscal space-constrained district managers’ ability to implement solutions identified through CODES. Conclusion Data-driven district management interventions can positively impact child health outcomes, with clinically significant improvements in the treatment of malaria, pneumonia and diarrhoea as well as stool disposal. The findings recommend the model’s suitability for health systems strengthening in Uganda and other decentralised contexts. Trial registration number ISRCTN15705788.
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Affiliation(s)
- Peter Waiswa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda .,Makerere University Centre of Excellence for Maternal Newborn & Child Health, Makerere University School of Public Health, Kampala, Uganda.,Global Public Health, Karolinska Institute, Stockholm, Sweden.,Busoga Health Forum, Jinja, Uganda
| | | | - Danstan Bagenda
- University of Nebraska Medical Center, College of Medicine, Omaha, Nebraska, USA
| | - Rornald Muhumuza Kananura
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.,Makerere University Centre of Excellence for Maternal Newborn & Child Health, Makerere University School of Public Health, Kampala, Uganda.,Department of International Development, London School of Economics and Political Science, London, UK
| | | | | | - Theresa Diaz
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organizations, Geneva, Switzerland
| | - Florence Ayebare
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | | | - Eric Ssegujja
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Anthony Mbonye
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Stefan Swartling Peterson
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda.,Global Public Health, Karolinska Institute, Stockholm, Sweden.,Programme Division, Health Section, United Nations Children's Fund, New York, New York, USA
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Mianda S, Todowede OO, Schneider H. Scoping review protocol of service delivery-related interventions to improve maternal and newborn health in low-income and middle-income countries. BMJ Open 2021; 11:e042952. [PMID: 33762232 PMCID: PMC7993309 DOI: 10.1136/bmjopen-2020-042952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION This review will explore the characteristics of service delivery-related interventions to improve maternal and newborn health in low-income and middle-income countries, comparing three common framing approaches of these interventions (referred to as archetypes), namely, quality improvement (QI), health system strengthening (HSS) and implementation science (IS), over the last 20 years. METHODS AND ANALYSIS This study will review the literature on health service interventions from 2000 to 2020. This will be achieved by searching for English peer-reviewed articles in the following electronic databases EBSCOhost, PubMed, Web of Science, MASCOT/Wotro Map of Maternal Health Research and Google scholar. We will develop a systematic search strategy using a combination of keywords and Boolean operators AND/OR. Eligibility screening and data extraction will be conducted by two independent reviewers, and disagreements resolved by a third independent reviewer. Analyses will be conducted in two steps, a quantitative and a qualitative phase. The quantitative phase will provide a descriptive profile of papers, including the category (QI, HSS, IS, mixed or other) of papers. In the follow-up qualitative phase, all three reviewers will independently code for key concepts in a subset of papers, jointly selected as representing each archetype, and analysed in batches until concept saturation is achieved. ETHICS AND DISSEMINATION This review does not require ethical approval. The results will be published as an article in a peer-reviewed journal and presented to stakeholders involved in implementing health system interventions in maternal and newborn.
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Affiliation(s)
- Solange Mianda
- School of Public, University of the Western Cape, Cape Town, South Africa
| | - Olamide O Todowede
- Department of Health Science Mental Health and Addiction Research Group (MHARG), University of York, York, North Yorkshire, UK
| | - Helen Schneider
- School of Public, University of the Western Cape, Cape Town, South Africa
- South African Medical research Council (SAMRC) Service to System Extramural research Unit, Cape Town, South Africa
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Sheff MC, Bawah AA, Asuming PO, Kyei P, Kushitor M, Phillips JF, Kachur SP. Evaluating health service coverage in Ghana's Volta Region using a modified Tanahashi model. Glob Health Action 2021; 13:1732664. [PMID: 32174254 PMCID: PMC7144185 DOI: 10.1080/16549716.2020.1732664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The United Nations 2030 Sustainable Development Goals have reaffirmed the international community’s commitment to maternal, newborn, and child health, with further investments in achieving quality essential service coverage and financial protection for all. Objective: Using a modified version of the 1978 Tanahashi model as an analytical framework for measuring and assessing health service coverage, this paper aims to examine the system of care at the community level in Ghana’s Volta Region to highlight the continued reforms needed to achieve Universal Health Coverage. Methods: The Tanahashi model evaluates health system coverage through five key measures that reflect different stages along the service provision continuum: availability of services; accessibility; initial contact with the health system; continued utilization; and quality coverage. Data from cross-sectional household and health facility surveys were used in this study. Immunization and antenatal care services were selected as tracer interventions to serve as proxies to assess systems bottlenecks. Results: Financial access and quality coverage were identified as the biggest bottlenecks for both tracer indicators. Financial accessibility, measured by enrollment in Ghana’s National Health Insurance Scheme was poor with 16.94% presenting valid membership cards. Childhood immunization was high but dropped modestly from 93.8% at initial contact to 76.7% quality coverage. For antenatal care, estimates ranged from 65.9% at initial visit to 25.1% quality coverage. Conclusion: Results highlight the difficulty in achieving high levels of quality service coverage and the large variations that exist within services provided at the primary care level. While vertical investments have been prioritized to benefit specific health services, a comprehensive systems approach to primary health care needs to be further strengthened to reach Ghana’s Universal Health Coverage objectives.
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Affiliation(s)
- Mallory C Sheff
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Ayaga A Bawah
- Regional Institute for Population Studies, University of Ghana, Accra, Ghana
| | - Patrick O Asuming
- Department of Finance, University of Ghana Business School, Accra, Ghana
| | - Pearl Kyei
- Regional Institute for Population Studies, University of Ghana, Accra, Ghana
| | - Mawuli Kushitor
- Regional Institute for Population Studies, University of Ghana, Accra, Ghana
| | - James F Phillips
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - S Patrick Kachur
- Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
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Tibeihaho H, Nkolo C, Onzima RA, Ayebare F, Henriksson DK. Continuous quality improvement as a tool to implement evidence-informed problem solving: experiences from the district and health facility level in Uganda. BMC Health Serv Res 2021; 21:83. [PMID: 33482799 PMCID: PMC7825214 DOI: 10.1186/s12913-021-06061-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 01/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background Continuous quality improvement processes in health care were developed for use at health facility level, and that is where they have been used the most, often addressing defined care processes. However, in different settings different factors have been important to support institutionalization. This study explores how continuous quality improvement processes were institutionalized at the district level and at the health facility level in Uganda. Methods This qualitative study was carried out in seven districts in Uganda. Semi-structured interviews with key informants from the district health management teams and document review were conducted. Thematic analysis was used to analyze the data. Results All districts that participated in the study formed Continuous Quality Improvement (CQI) teams both at the district level and at the health facilities. The district CQI teams comprised of members from different departments within the district health office. District level CQI teams were mandated to take the lead in addressing management gaps and follow up CQI activities at the health facility level. Acceptability of quality improvement processes by the district leadership was identified across districts as supporting the successful implementation of CQI. However, high turnover of staff at health facility level was also reported as a detrimental to the successful implementation of quality improvement processes. Also the district health management teams did not engage much in addressing their own roles using continuous quality improvement. Conclusion The leadership and management provided by the district health management team was an important factor for the use of Continuous Quality Improvement principles within the district. The key roles of the district health team revolved around the institutionalisation of CQI at different levels of the health system, monitoring results of continuous quality improvement implementation, mobilising resources and health care delivery hence promoting the culture of quality, direct implementation of CQI, and creating an enabling environment for the lower-level health facilities to engage in CQI. High turnover of staff at health facility level was also reported as one of the challenges to the successful implementation of continuous quality improvement. The DHT did not engage much in addressing gaps in their own roles using continuous quality improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06061-8.
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Affiliation(s)
| | - Charles Nkolo
- Liverpool School of Tropical Medicine, Liverpool, Uganda
| | | | - Florence Ayebare
- Makerere University College of Health Sciences, School of Public Health, Makerere, Uganda
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Schneider H, George A, Mukinda F, Tabana H. District Governance and Improved Maternal, Neonatal and Child Health in South Africa: Pathways of Change. Health Syst Reform 2020; 6:e1669943. [PMID: 32040355 DOI: 10.1080/23288604.2019.1669943] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
District-level initiatives to improve maternal, neonatal and child health (MNCH) generally do not take governance as their primary lens on health system strengthening. This paper is a case study of a district and sub-district governance mechanism, the Monitoring and Response Unit (MRU), which aimed to improve MNCH outcomes in two districts of South Africa. The MRU was introduced as a decision-making and accountability structure, and constituted of a "triangle" of managers, clinicians and information officers. An independent evaluation of the MRU initiative was conducted, three years after establishment, involving interviews with 89 district actors. Interviewees reported extensive changes in the scope, quality and organization of MNCH services, attributing these to the introduction of the MRU and enhanced support from district clinicians. We describe both the formal and informal aspects of the MRU as a governance mechanism, and then consider the pathways through which the MRU plausibly acted as a catalyst for change, using the institutional constructs of credible commitment, coordination and cooperation. In particular, the MRU promoted the formation of non-hierarchical collaborative networks; improved coordination between community, PHC and hospital services; and shaped collective sense-making in positive ways. We conclude that innovations in governance could add significant value to the district health system strengthening for improved MNCH. However, this requires a shift in focus from strengthening the front-line of service delivery, to change at the meso-level of sub-district and district decision-making; and from purely technical, data-driven to more holistic approaches that engage collective mindsets, widen participation in decision-making and nurture political leadership skills.
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Affiliation(s)
- Helen Schneider
- School of Public and SAMRC Health Services to Systems Research Unit, University of the Western Cape, Cape Town, South Africa
| | - Asha George
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Fidele Mukinda
- School of Public Health, University of the Western Cape, Cape Town, South Africa
| | - Hanani Tabana
- School of Public Health, University of the Western Cape, Cape Town, South Africa
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11
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Martin Hilber A, Doherty P, Nove A, Cullen R, Segun T, Bandali S. The development of a new accountability measurement framework and tool for global health initiatives. Health Policy Plan 2020; 35:765-774. [PMID: 32494815 PMCID: PMC7487333 DOI: 10.1093/heapol/czz170] [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] [Accepted: 11/28/2019] [Indexed: 11/16/2022] Open
Abstract
The Global Strategy for Women’s Children’s and Adolescents’ Health emphasizes accountability as essential to ensure that decision-makers have the information required to meet the health needs of their populations and stresses the importance of tracking resources, results, and rights to see ‘what works, what needs improvement and what requires increased attention’. However, results from accountability initiatives are mixed and there is a lack of broadly applicable, validated tools for planning, monitoring and evaluating accountability interventions. This article documents an effort to transform accountability markers—including political will, leadership and the monitor–review–act cycle—into a measurement tool that can be used prospectively or retrospectively to plan, monitor and evaluate accountability initiatives. It describes the development process behind the tool including the literature review, framework development and subsequent building of the measurement tool itself. It also examines feedback on the tool from a panel of global experts and the results of a pilot test conducted in Bauchi and Gombe states in Nigeria. The results demonstrate that the tool is an effective aid for accountability initiatives to reflect on their own progress and provides a useful structure for future planning, monitoring and evaluation. The tool can be applied and adapted to other accountability mechanisms working in global health.
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Affiliation(s)
- Adriane Martin Hilber
- Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box. 4002 Basel, Switzerland
- University of Basel, Petersplatz 1, 4001 Basel, Switzerland
- Novametrics Ltd, Duffield, Belper, Derbyshire, England DE56 4HQ, UK
| | - Patricia Doherty
- Options Consultancy Services Ltd, St Magnus House, 3 Lower Thames Street, London EC3R 6HD, UK
| | - Andrea Nove
- Novametrics Ltd, Duffield, Belper, Derbyshire, England DE56 4HQ, UK
| | - Rachel Cullen
- Marie Stopes International, 1 Conway Street, London W1T 6LP, UK
| | - Tunde Segun
- Options Consultancy Services Ltd, St Magnus House, 3 Lower Thames Street, London EC3R 6HD, UK
| | - Sarah Bandali
- Options Consultancy Services Ltd, St Magnus House, 3 Lower Thames Street, London EC3R 6HD, UK
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Bulthuis SE, Kok MC, Amon S, Agyemang SA, Nsabagasani X, Sanudi L, Raven J, Finn M, Gerold J, Tulloch O, Dieleman MA. How district health decision-making is shaped within decentralised contexts: A qualitative research in Malawi, Uganda and Ghana. Glob Public Health 2020; 16:120-135. [DOI: 10.1080/17441692.2020.1791213] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Susan E. Bulthuis
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
| | - Maryse C. Kok
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Samuel Amon
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Samuel Agyei Agyemang
- Department of Health Policy, Planning & Management, School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | | | - Lifah Sanudi
- Research for Equity and Community Health (REACH) Trust, Lilongwe, Malawi
| | - Joanna Raven
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Mairead Finn
- Trinity Centre for Global Health, the University of Dublin, Trinity College, Dublin, Ireland
- Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jana Gerold
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Marjolein A. Dieleman
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
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Waiswa P. Institutionalization of Projects Into Districts in Low- and Middle-Income Countries Needs Stewardship, Autonomy, and Resources. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:144-146. [PMID: 32614779 PMCID: PMC7326513 DOI: 10.9745/ghsp-d-20-00170] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 04/29/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Peter Waiswa
- Maternal, Newborn, and Child Health Centre of Excellence, Makerere University School of Public Health, Kampala, Uganda. .,Department of Global Public Health, Karolinska Institutet, Solna, Sweden
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Heerdegen ACS, Aikins M, Amon S, Agyemang SA, Wyss K. Managerial capacity among district health managers and its association with district performance: A comparative descriptive study of six districts in the Eastern Region of Ghana. PLoS One 2020; 15:e0227974. [PMID: 31968010 PMCID: PMC6975551 DOI: 10.1371/journal.pone.0227974] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION District health managers play a pivotal role in the delivery of basic health services in many countries, including Ghana, as they are responsible for converting inputs and resources such as, staff, supplies and equipment into effective services that are responsive to population needs. Weak management capacity among local health managers has been suggested as a major obstacle for responsive health service delivery. However, evidence on district health managers' competencies and its association with health system performance is scarce. AIM To examine managerial capacity among district health managers and its association with health system performance in six districts in the Eastern Region of Ghana. METHODS Fifty-nine district health managers' in six different performing districts in the Eastern Region of Ghana completed a self-administered questionnaire measuring their management competencies and skills. In addition, the participants provided information on their socio-demographic background; previous management experience and training; the extent of available management support systems, and the dynamics within their district health management teams. A non-parametric one-way analysis was applied to test the association between management capacity and district performance, which was measured by 17 health indicators. RESULTS Shortcomings within different aspects of district management were identified, however there were no significant differences observed in the availability of support systems, characteristics and qualifications of district health managers across the different performing districts. Overall management capacity among district health managers were significantly higher in high performing districts compared with lower performing districts (p = 0.02). Furthermore, district health managers in better performing districts reported a higher extent of teamwork (p = 0.02), communication within their teams (p<0.01) and organizational commitment (p<0.01) compared with lower performing districts. CONCLUSION The findings demonstrate individual and institutional capacity needs, and highlights the importance of developing management competencies and skills as well as positive team dynamics among health managers at district level.
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Affiliation(s)
- Anne Christine Stender Heerdegen
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Samuel Amon
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Samuel Agyei Agyemang
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Kaspar Wyss
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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15
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Lowe D, Merner B, Graham-Wisener L, Walsh L, Hill S. The effects of consumers and health providers working in partnership as an intervention for the promotion of person-centred health services. Hippokratia 2019. [DOI: 10.1002/14651858.cd013373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Dianne Lowe
- La Trobe University; Centre for Health Communication and Participation, School of Psychology and Public Health; Bundoora VIC Australia 3086
| | - Bronwen Merner
- La Trobe University; Centre for Health Communication and Participation, School of Psychology and Public Health; Bundoora VIC Australia 3086
| | | | - Louisa Walsh
- La Trobe University; Centre for Health Communication and Participation, School of Psychology and Public Health; Bundoora VIC Australia 3086
| | - Sophie Hill
- La Trobe University; Centre for Health Communication and Participation, School of Psychology and Public Health; Bundoora VIC Australia 3086
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16
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Henriksson DK, Peterson SS, Waiswa P, Fredriksson M. Decision-making in district health planning in Uganda: does use of district-specific evidence matter? Health Res Policy Syst 2019; 17:57. [PMID: 31170988 PMCID: PMC6554923 DOI: 10.1186/s12961-019-0458-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 04/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In a decentralised health system, district health managers are tasked with planning for health service delivery, which should be evidence based. However, planning in low-income countries such as Uganda has been described as ad hoc. A systematic approach to the planning process using district-specific evidence was introduced to district health managers in Uganda. However, little is known about how the use of district-specific evidence informs the planning process. In this study, we investigate how the use of this evidence affects decision-making in the planning process and how stakeholders in the planning process perceived the use of evidence. METHODS A convergent parallel mixed-methods study design was used, where quantitative data was collected from district health annual work plans for the financial years 2012/2013, 2013/2014, 2014/2015 and 2015/2016 as well as from bottleneck analysis reports for 2012, 2013, 2014 and 2015. Qualitative data was collected through semi-structured interviews with key informants from the two study districts. RESULTS District managers reported that they were able to produce more robust district annual work plans when they used the systematic approach of using district-specific evidence. Approximately half of the prioritised activities in the annual work plans were evidence based. Procurement and logistics, training, and support supervision activities were the most prioritised activities. Between 4% and 5.5% of the total planned expenditure was for child survival, of which 47% to 94% was from donor and other partner contributions. CONCLUSION District-specific evidence and a structured process for its use to prioritise activities and make decisions in the planning process at the district level helped systematise the planning process. However, the reported limited decision and fiscal space, inadequate funding and high dependency on donor funding did not always allow for the use of district-specific evidence in the planning process.
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Affiliation(s)
| | - Stefan Swartling Peterson
- United Nations Children's Fund, New York, Karolinska Institutet, Stockholm, Uppsala University, Uppsala, Sweden
| | - Peter Waiswa
- School of Public Health, Kampala and Karolinska Institutet, Makerere University College of Health Sciences, Stockholm, Sweden
| | - Mio Fredriksson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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Muhwezi WW, Palchik EA, Kiwanuka DH, Mpanga F, Mukundane M, Nanungi A, Bataringaya D, Ssesanga P, Aryaija-Karemani A. Community participation to improve health services for children: a methodology for a community dialogue intervention in Uganda. Afr Health Sci 2019; 19:1574-1581. [PMID: 31148986 PMCID: PMC6531984 DOI: 10.4314/ahs.v19i1.32] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Like other developing countries, Uganda still struggles to meaningfully reduce child mortality. A strategy of giving information to communities to spark interest in improving child survival through inducing responsibility and social sanctioning in the health workforce was postulated. By focusing on diarrhea, pneumonia and malaria, a Community and District Empowerment for Scale up (CODES) undertaking used "community dialogues" to arm communities with health system performance information. This empowered them to monitor health service provision and demand for quality child-health services. METHODS We describe a process of community dialoguing through use of citizen report cards, short-text-messages, media and post-dialogue monitoring. Each community dialogue assembled 70-100 members including health workers and community leaders. After each community dialogue, participants implemented activities outlined in generated community contracts. Radio messages promoted demand for child-health services and elicited support to implement accepted activities. CONCLUSION The perception that community dialoging is "a lot of talk" that never advances meaningful action was debunked since participant-initiated actions were conceived and implemented. Potential for use of electronic communication in real-time feedback and stimulating discussion proved viable. Post-dialogue monitoring captured in community contracts facilitated process evaluation and added plausibility for observed effects. Capacitated organizations during post-dialogue monitoring guaranteed sustainability.
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Affiliation(s)
- Wilson Winstons Muhwezi
- Makerere University College of Health Sciences, Psychiatry
- Advocates Coalition for Development and Environment (ACODE), Uganda
| | | | | | | | - Moses Mukundane
- Advocates Coalition for Development and Environment (ACODE), Uganda
| | - Annet Nanungi
- Advocates Coalition for Development and Environment (ACODE), Uganda
| | | | - Patrick Ssesanga
- Advocates Coalition for Development and Environment (ACODE), Uganda
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18
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Yaya S, Uthman OA, Ekholuenetale M, Bishwajit G. Women empowerment as an enabling factor of contraceptive use in sub-Saharan Africa: a multilevel analysis of cross-sectional surveys of 32 countries. Reprod Health 2018; 15:214. [PMID: 30572927 PMCID: PMC6302468 DOI: 10.1186/s12978-018-0658-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Women's empowerment has a direct impact on maternal and child health care service utilization. Large scope measurement of contraceptive use in several dimensions is paramount, considering the nature of empowerment processes as it relates to improvements in maternal health status. However, multicountry and multilevel analysis of the measurement of women's empowerment indicators and their associations with contraceptive use is vital to make a substantial intervention in the Sub-Saharan Africa context. Therefore, we investigated the impact of women's empowerment on contraceptive use among women in sub-Saharan Africa countries. METHODS Secondary data involving 474,622 women of reproductive age (15-49 years) from the current Demographic and Health Survey (DHS) in 32 Sub-Saharan Africa region was used in this study. Contraceptive use was the primary outcome variable. Multilevel analysis was conducted to examine the impact of women's empowerment on contraceptive use. Percentages were conducted in univariate analysis. Furthermore, multilevel logistic regression models were used to analyze the association between individual, compositional and contextual factors of contraceptive use. RESULTS Results showed large disparities in the number of women who reportedly ever use contraceptive methods; this range from as low as 6.7% in Chad and as much as 72% in Namibia. More than one-third of the respondents had no formal education and more than half were active labor force. Contraceptive use was significantly more common among respondents from the richest households (28.5% versus 18.9%). Various components of women's empowerment were positively significantly associated with contraceptive use after adjusting for demographic and socioeconomic factors. There was a significant variation in the odds of contraceptive use across the 32 countries (σ2= 1.12, 95% CrI 0.67 to 1.87) and across the neighbourhoods (σ2= 0.95, 95% CrI 0.92 to 0.98). CONCLUSIONS Our findings suggest that an increase in contraceptive use and by better extension maternal health care services utilization can be achieved by enhancing women's empowerment. Also, an increase in decision-making autonomy by women, their participation in labour force, reduction in abuse and violence and improved knowledge level are all key issues to be considered. Health-related policies should address inequalities in women's empowerment, education and economic status which would yield benefits to individuals, families, and societies in general.
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Affiliation(s)
- Sanni Yaya
- School of International Development and Global Studies, 120 University Private, University of Ottawa, Ottawa, ON K1N 6N5 Canada
| | - Olalekan A. Uthman
- Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, CV4 7AL UK
| | - Michael Ekholuenetale
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Ghose Bishwajit
- School of International Development and Global Studies, 120 University Private, University of Ottawa, Ottawa, ON K1N 6N5 Canada
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Jannati A, Sadeghi V, Imani A, Saadati M. Effective coverage as a new approach to health system performance assessment: a scoping review. BMC Health Serv Res 2018; 18:886. [PMID: 30470214 PMCID: PMC6251131 DOI: 10.1186/s12913-018-3692-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 11/07/2018] [Indexed: 11/29/2022] Open
Abstract
Background Delivering interventions is the main task of health systems whose accurate measurement is an essential input into tracking performance. Recently, the concept of effective coverage was introduced by World Health Organization to incorporate into health system performance assessment. The aim of present scoping review was mapping the key elements and steps of effective coverage assessment in practical efforts including kinds of interventions, criteria for selecting them and the need, use and quality estimation approaches and strategies of each intervention. Methods We conducted a scoping review of health system/program assessments which assessed effective coverage till May 2017. Seven databases were systematically searched with no time and language restriction through applying combined keyword of “effective coverage”. Results Eighteen studies contributed findings on monitoring effective coverage of health interventions and they all were included in the review. Only 4 contributed findings on health system and the others were related to specific intervention(s) assessment. The interventions monitored by effective coverage were mainly in child health, prenatal and antenatal care and delivery, and chronic conditions areas. Potential impact on the burden of disease, leading causes of mortality and morbidity, and high occurrence and prevalence rate were among the main intervention selection criteria. Availability of data was the critical prerequisite, especially, in all of the studies applied ex post approach in estimating effective coverage. Estimation based on a norm, self- reporting from surveys and biomarkers were the main strategies and methods of need, utilization and quality measurement, respectively. Conclusions More studies are needed to contribute to the ongoing improvement in the development of effective coverage concept and increasing practical efforts, especially through defining prospective approaches and strategies into estimation of composite measures based on the effective coverage framework. Also, further attention needs to be paid to quality measures of effective coverage in a manner that better conceptualizes and measures the connection between coverage rates and interventions’ effectiveness. At the administrative system level, more innovation is needed to develop data systems in order to enhance capacity of routine health service information. Electronic supplementary material The online version of this article (10.1186/s12913-018-3692-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ali Jannati
- Health Services Management, Iranian Center of Excellence in Health Management, Health Services Management Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahideh Sadeghi
- Health Services Management, Health Services Management Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, University Street, next to Shahid Madani hospital, Tabriz, 5165665811, Iran.
| | - Ali Imani
- Pharmacoeconomics and Pharmaceutical Management, Tabriz Health Services Management Research center, Health Economics Department, School of Management and Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Saadati
- Health Services Management, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Kiwanuka Henriksson D, Fredriksson M, Waiswa P, Selling K, Swartling Peterson S. Bottleneck analysis at district level to illustrate gaps within the district health system in Uganda. Glob Health Action 2018; 10:1327256. [PMID: 28581379 PMCID: PMC5496050 DOI: 10.1080/16549716.2017.1327256] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Poor quality of care and access to effective and affordable interventions have been attributed to constraints and bottlenecks within and outside the health system. However, there is limited understanding of health system barriers to utilization and delivery of appropriate, high-impact, and cost-effective interventions at the point of service delivery in districts and sub-districts in low-income countries. In this study we illustrate the use of the bottleneck analysis approach, which could be used to identify bottlenecks in service delivery within the district health system. Methods: A modified Tanahashi model with six determinants for effective coverage was used to determine bottlenecks in service provision for maternal and newborn care. The following interventions provided during antenatal care were used as tracer interventions: use of iron and folic acid, intermittent presumptive treatment for malaria, HIV counseling and testing, and syphilis testing. Data from cross-sectional household and health facility surveys in Mayuge and Namayingo districts in Uganda were used in this study. Results: Effective coverage and human resource gaps were identified as the biggest bottlenecks in both districts, with coverage ranging from 0% to 66% for effective coverage and from 46% to 58% for availability of health facility staff. Our findings revealed a similar pattern in bottlenecks in both districts for particular interventions although the districts are functionally independent. Conclusion: The modified Tanahashi model is an analysis tool that can be used to identify bottlenecks to effective coverage within the district health system, for instance, the effective coverage for maternal and newborn care interventions. However, the analysis is highly dependent on the availability of data to populate all six determinants and could benefit from further validation analysis for the causes of bottlenecks identified.
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Affiliation(s)
- Dorcus Kiwanuka Henriksson
- a Institution of International Maternal and Child Health, Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden.,b Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden
| | - Mio Fredriksson
- c Department of Public Health and Caring Sciences , Uppsala University , Uppsala , Sweden
| | - Peter Waiswa
- b Department of Public Health Sciences , Karolinska Institutet , Stockholm , Sweden.,d Makerere University College of Health Sciences , School of Public Health , Kampala , Uganda
| | - Katarina Selling
- a Institution of International Maternal and Child Health, Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden
| | - Stefan Swartling Peterson
- a Institution of International Maternal and Child Health, Department of Women's and Children's Health , Uppsala University , Uppsala , Sweden.,d Makerere University College of Health Sciences , School of Public Health , Kampala , Uganda
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Garcia ER, Yim IS. A systematic review of concepts related to women's empowerment in the perinatal period and their associations with perinatal depressive symptoms and premature birth. BMC Pregnancy Childbirth 2017; 17:347. [PMID: 29143635 PMCID: PMC5688402 DOI: 10.1186/s12884-017-1495-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background The perinatal period, which we here define as pregnancy and the first year postpartum, is a time in women’s lives that involves significant physiological and psychosocial change and adjustment, including changes in their social status and decision-making power. Supporting women’s empowerment at this particular time in their lives may be an attractive opportunity to create benefits for maternal and infant health outcomes such as reductions in perinatal depressive symptoms and premature birth rates. Thus, we here systematically review and critically discuss the literature that investigates the effects of empowerment, empowerment-related concepts and empowerment interventions on reductions in perinatal depressive symptoms, preterm birth (PTB), and low birthweight (LBW). Methods For this systematic review, we conducted a literature search in PsychInfo, PubMed, and CINAHL without setting limits for date of publication, language, study design, or maternal age. The search resulted in 27 articles reporting on 25 independent studies including a total of 17,795 women. Results The majority of studies found that, for the most part, measures of empowerment and interventions supporting empowerment are associated with reduced perinatal depressive symptoms and PTB/LBW rates. However, findings are equivocal and a small portion of studies found no significant association between empowerment-related concepts and perinatal depressive symptoms and PTB or LBW. Conclusion This small body of work suggests, for the most part, that empowerment-related concepts may be protective for perinatal depressive symptoms and PTB/LBW. We recommend that future theory-driven and integrative work should include an assessment of different facets of empowerment, obtain direct measures of empowerment, and address the relevance of important confounders, including for example, ethnicity and socioeconomic status. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1495-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Esmeralda R Garcia
- Department of Psychology and Social Behavior, University of California, 4562 Social and Behavioral Sciences Gateway, Irvine, CA, 92697-7085, USA
| | - Ilona S Yim
- Department of Psychology and Social Behavior, University of California, 4562 Social and Behavioral Sciences Gateway, Irvine, CA, 92697-7085, USA.
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Allen EP, Muhwezi WW, Henriksson DK, Mbonye AK. Health facility management and access: a qualitative analysis of challenges to seeking healthcare for children under five in Uganda. Health Policy Plan 2017; 32:934-942. [PMID: 28881932 PMCID: PMC5886075 DOI: 10.1093/heapol/czw180] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 11/14/2022] Open
Abstract
While several studies have documented the various barriers that caretakers of children under five routinely confront when seeking healthcare in Uganda, few have sought to capture the ways in which caretakers themselves prioritize their own barriers to seeking services. To that end, we asked focus groups of caretakers to list their five greatest challenges to seeking care on behalf of children under five. Using qualitative content analysis, we grouped responses according to four categories: (1) geographical access barriers; (2) facility supplies, staffing, and infrastructural barriers; (3) facility management and administration barriers (e.g. health worker professionalism, absenteeism and customer care); and (4) household barriers related to financial circumstances, domestic conflicts with male partners and a stated lack of knowledge about health-related issues. Among all focus groups, caretakers mentioned supplies, staffing and infrastructure barriers most often and facility management and administration barriers the least. Caretakers living furthest from public facilities (8-10 km) more commonly mentioned geographical barriers to care and barriers related to financial and other personal circumstances. Caretakers who lived closest to health facilities mentioned facility management and administration barriers twice as often as those who lived further away. While targeting managerial barriers is vitally important-and increasingly popular among national planners and donors-it should be done while recognizing that alleviating such barriers may have a more muted effect on caretakers who are geographically harder to reach - and by extension, those whose children have an increased risk of mortality. In light of calls for greater equity in child survival programming - and given the limited resource envelopes that policymakers often have at their disposal - attention to the barriers considered most vital among caretakers in different settings should be weighed.
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Affiliation(s)
| | | | | | - Anthony Kabanza Mbonye
- Ministry of Health, Uganda and Makerere University College of Health Sciences, School of Public Health, Uganda
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23
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Henriksson DK, Ayebare F, Waiswa P, Peterson SS, Tumushabe EK, Fredriksson M. Enablers and barriers to evidence based planning in the district health system in Uganda; perceptions of district health managers. BMC Health Serv Res 2017; 17:103. [PMID: 28148251 PMCID: PMC5289024 DOI: 10.1186/s12913-017-2059-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 01/25/2017] [Indexed: 11/29/2022] Open
Abstract
Background The District Health System was endorsed as the key strategy to achieve ‘Health for all’ during the WHO organized inter-regional meeting in Harare in 1987. Many expectations were put upon the district health system, including planning. Although planning should be evidence based to prioritize activities, in Uganda it has been described as occurring more by chance than by choice. The role of planning is entrusted to the district health managers with support from the Ministry of Health and other stakeholders, but there is limited knowledge on the district health manager’s capacity to carry out evidence-based planning. The aim of this study was to determine the barriers and enablers to evidence-based planning at the district level. Methods This qualitative study collected data through key informant interviews with district managers from two purposefully selected districts in Uganda that have been implementing evidence-based planning. A deductive process of thematic analysis was used to classify responses within themes. Results There were considerable differences between the districts in regard to the barriers and enablers for evidence-based planning. Variations could be attributed to specific contextual and environmental differences such as human resource levels, date of establishment of the district, funding and the sociopolitical environment. The perceived lack of local decision space coupled with the perception that the politicians had all the power while having limited knowledge on evidence-based planning was considered an important barrier. Conclusion There is a need to review the mandate of the district managers to make decisions in the planning process and the range of decision space available within the district health system. Given the important role elected officials play in a decentralized system a concerted effort should be made to increase their knowledge on evidence-based planning and the district health system as a whole.
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Affiliation(s)
| | - Florence Ayebare
- Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Peter Waiswa
- Karolinska Institutet, Stockholm, Sweden.,Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | - Stefan Swartling Peterson
- Uppsala University, Uppsala, Sweden.,Makerere University College of Health Sciences, School of Public Health, Kampala, Uganda
| | | | - Mio Fredriksson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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24
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Odaga J, Henriksson DK, Nkolo C, Tibeihaho H, Musabe R, Katusiime M, Sinabulya Z, Mucunguzi S, Mbonye AK, Valadez JJ. Empowering districts to target priorities for improving child health service in Uganda using change management and rapid assessment methods. Glob Health Action 2016; 9:30983. [PMID: 27225791 PMCID: PMC4880621 DOI: 10.3402/gha.v9.30983] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/23/2016] [Accepted: 04/13/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Local health system managers in low- and middle-income countries have the responsibility to set health priorities and allocate resources accordingly. Although tools exist to aid this process, they are not widely applied for various reasons including non-availability, poor knowledge of the tools, and poor adaptability into the local context. In Uganda, delivery of basic services is devolved to the District Local Governments through the District Health Teams (DHTs). The Community and District Empowerment for Scale-up (CODES) project aims to provide a set of management tools that aid contextualised priority setting, fund allocation, and problem-solving in a systematic way to improve effective coverage and quality of child survival interventions. DESIGN Although the various tools have previously been used at the national level, the project aims to combine them in an integral way for implementation at the district level. These tools include Lot Quality Assurance Sampling (LQAS) surveys to generate local evidence, Bottleneck analysis and Causal analysis as analytical tools, Continuous Quality Improvement, and Community Dialogues based on Citizen Report Cards and U reports. The tools enable identification of gaps, prioritisation of possible solutions, and allocation of resources accordingly. This paper presents some of the tools used by the project in five districts in Uganda during the proof-of-concept phase of the project. RESULTS All five districts were trained and participated in LQAS surveys and readily adopted the tools for priority setting and resource allocation. All districts developed health operational work plans, which were based on the evidence and each of the districts implemented more than three of the priority activities which were included in their work plans. CONCLUSIONS In the five districts, the CODES project demonstrated that DHTs can adopt and integrate these tools in the planning process by systematically identifying gaps and setting priority interventions for child survival.
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Affiliation(s)
- John Odaga
- Liverpool School of Tropical Medicine, Kampala, Uganda
| | - Dorcus K Henriksson
- Health Systems and Policy (HSP) Research Group, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.,International Maternal and Child Health Department, Uppsala University, Uppsala, Sweden;
| | - Charles Nkolo
- Liverpool School of Tropical Medicine, Kampala, Uganda
| | | | | | | | | | | | - Anthony K Mbonye
- Ministry of Health, Kampala, Uganda.,School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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25
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Katahoire AR, Henriksson DK, Ssegujja E, Waiswa P, Ayebare F, Bagenda D, Mbonye AK, Peterson SS. Improving child survival through a district management strengthening and community empowerment intervention: early implementation experiences from Uganda. BMC Public Health 2015; 15:797. [PMID: 26286146 PMCID: PMC4545317 DOI: 10.1186/s12889-015-2129-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 08/07/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The Community and District Empowerment for Scale-up (CODES) project pioneered the implementation of a comprehensive district management and community empowerment intervention in five districts in Uganda. In order to improve effective coverage and quality of child survival interventions CODES combines UNICEF tools designed to systematize priority setting, allocation of resources and problem solving with Community dialogues based on Citizen Report Cards and U-Reports used to engage and empower communities in monitoring health service provision and to demand for quality services. This paper presents early implementation experiences in five pilot districts and lessons learnt during the first 2 years of implementation. METHODS This qualitative study was comprised of 38 in-depth interviews with members of the District Health Teams (DHTs) and two implementing partners. These were supplemented by observations during implementation and documents review. Thematic analysis was used to distill early implementation experiences and lessons learnt from the process. RESULTS All five districts health teams with support from the implementing partners were able to adopt the UNICEF tools and to develop district health operational work plans that were evidence-based. Members of the DHTs described the approach introduced by the CODES project as a more systematic planning process and very much appreciated it. Districts were also able to implement some of the priority activities included in their work plans but limited financial resources and fiscal decision space constrained the implementation of some activities that were prioritized. Community dialogues based on Citizen Report Cards (CRC) increased community awareness of available health care services, their utilization and led to discussions on service delivery, barriers to service utilization and processes for improvement. Community dialogues were also instrumental in bringing together service users, providers and leaders to discuss problems and find solutions. The dialogues however are more likely to be sustainable if embedded in existing community structures and conducted by district based facilitators. U report as a community feedback mechanism registered a low response rate. CONCLUSION The UNICEF tools were adopted at district level and generally well perceived by the DHTs. The limited resources and fiscal decision space however can hinder implementation of prioritized activities. Community dialogues based on CRCs can bring service providers and the community together but need to be embedded in existing community structures for sustainability.
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Affiliation(s)
| | | | - Eric Ssegujja
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Peter Waiswa
- Karolinska Institutet, Solna, Sweden.
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Florence Ayebare
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Danstan Bagenda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
- College of Public Health, University of Nebraska Medical Center, Omaha, USA.
- Harvard T.H. Chan School of Public Health, Harvard University, Boston, USA.
| | - Anthony K Mbonye
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
- Ministry of Health, Kampala, Uganda.
| | - Stefan Swartling Peterson
- Karolinska Institutet, Solna, Sweden.
- Uppsala University, Uppsala, Sweden.
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.
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