Effectiveness of participatory community solutions strategy on improving household and provider health care behaviors and practices: A mixed-method evaluation

Barriers to and enablers of quality improvement in primary health care in low- and middle-income countries: A systematic review

The quality of health care remains generally poor across primary health care settings, especially in low- and middle-income countries where tertiary care tends to take up much of the limited resources despite primary health care being the first (and often the only) point of contact with the health system for nearly 80 per cent of people in these countries. Evidence is needed on barriers and enablers of quality improvement initiatives. This systematic review sought to answer the question: What are the enablers of and barriers to quality improvement in primary health care in low- and middle-income countries? It adopted an integrative review approach with narrative evidence synthesis, which combined qualitative and mixed methods research studies systematically. Using a customized geographic search filter for LMICs developed by the Cochrane Collaboration, Scopus, Academic Search Ultimate, MEDLINE, CINAHL, PSYCHINFO, EMBASE, ProQuest Dissertations and Overton.io (a new database for LMIC literature) were searched in January and February 2023, as were selected websites and journals. 7,077 reports were retrieved. After removing duplicates, reviewers independently screened titles, abstracts and full texts, performed quality appraisal and data extraction, followed by analysis and synthesis. 50 reports from 47 studies were included, covering 52 LMIC settings. Six themes related to barriers and enablers of quality improvement were identified and organized using the model for understanding success in quality (MUSIQ) and the consolidated framework for implementation research (CFIR). These were: microsystem of quality improvement, intervention attributes, implementing organization and team, health systems support and capacity, external environment and structural factors, and execution. Decision makers, practitioners, funders, implementers, and other stakeholders can use the evidence from this systematic review to minimize barriers and amplify enablers to better the chances that quality improvement initiatives will be successful in resource-limited settings. PROSPERO registration: CRD42023395166.

Community engagement initiatives in primary health care to achieve universal health coverage: A realist synthesis of scoping review

BACKGROUND

Community engagement (CE) is an essential component in a primary health care (PHC) and there have been growing calls for service providers to seek greater CE in the planning, design, delivery and evaluation of PHC services. This scoping review aimed to explore the underlying attributes, contexts and mechanisms in which community engagement initiatives contribute to improved PHC service delivery and the realisation of UHC.

METHODS

PubMed, PsycINFO, CINAHL, Cochrane Library, EMBASE and Google Scholar were searched from the inception of each database until May 2022 for studies that described the structure, process, and outcomes of CE interventions implemented in PHC settings. We included qualitative and quantitative studies, process evaluations and systematic or scoping reviews. Data were extracted using a predefined extraction sheet, and the quality of reporting of included studies was assessed using the Mixed Methods Appraisal Tool. The Donabedian's model for quality of healthcare was used to categorise attributes of CE into "structure", "process" and "outcome".

RESULTS

Themes related to the structural aspects of CE initiatives included the methodological approaches (i.e., format and composition), levels of CE (i.e., extent, time, and timing of engagement) and the support processes and strategies (i.e., skills and capacity) that are put in place to enable both communities and service providers to undertake successful CE. Process aspects of CE initiatives discussed in the literature included: i) the role of the community in defining priorities and setting objectives for CE, ii) types and dynamics of the broad range of engagement approaches and activities, and iii) presence of an on-going communication and two-way information sharing. Key CE components and contextual factors that affected the impact of CE initiatives included the wider socio-economic context, power dynamics and representation of communities and their voices, and cultural and organisational issues.

CONCLUSIONS

Our review highlighted the potential role of CE initiatives in improving decision making process and improving overall health outcomes, and identified several organisational, cultural, political, and contextual factors that affect the success of CE initiatives in PHC settings. Awareness of and responding to the contextual factors will increase the chances of successful CE initiatives.

Improving public health sector service delivery in the Free State, South Africa: development of a provincial intervention model

Background

Public health sector service delivery challenges leading to poor population health outcomes have been observed in the Free State province of South Africa for the past decade. A multi-method situation appraisal of the different functional domains revealed serious health system deficiencies and operational defects, notably fragmentation of healthcare programmes and frontline services, as well as challenges related to governance, accountability and human resources for health. It was therefore necessary to develop a system-wide intervention to comprehensively address defects in the operation of the public health system and its major components.

Methods

This study describes the development of the ‘Health Systems Governance & Accountability’ (HSGA) intervention model by the Free State Department of Health (FSDoH) in collaboration with the community and other stakeholders following a participatory action approach. Documented information collected during routine management processes were reviewed for this paper. Starting in March 2013, the development of the HSGA intervention model and the concomitant application of Kaplan and Norton’s (1992) Balanced Scorecard performance measurement tool was informed by the World Health Organization’s (2007) conceptual framework for health system strengthening and reform comprised of six health system ‘building blocks.’ The multiple and overlapping processes and actions to develop the intervention are described according to the four steps in Kaplan et al.’s (2013) systems approach to health systems strengthening: (i) problem identification, (ii) description, (iii) alteration and (iv) implementation.

Results

The finalisation of the HSGA intervention model before end-2013 was a prelude to the development of the FSDoH’s Strategic Transformation Plan 2015–2030. The HSGA intervention model was used as a tool to implement and integrate the Plan’s programmes moving forward with a consistent focus on the six building blocks for health systems strengthening and the all-important linkages between them.

Conclusion

The model was developed to address fragmentation and improve public health service delivery by the provincial health department. In January 2016, the intervention model became an official departmental policy, meaning that it was approved for implementation, compliance, monitoring and reporting, and became the guiding framework for health systems strengthening and transform in the Free State.

Predictors of maternal and newborn health service utilization across the continuum of care in Ethiopia: A multilevel analysis

Background

The continuum of care for maternal and newborn health is a systematic approach for delivery of an integrated effective package of life-saving interventions throughout pregnancy, childbirth, and postpartum as well as across levels of service delivery to women and newborns. Nonetheless, in low-income countries, coverage of these interventions across the life cycle continuum is low. This study examined the predictors of utilization of maternal and newborn health care services along the continuum of care in Ethiopia.

Methods

This was a cross-sectional population-based study. We measured maternal and newborn health care utilization practices among women who had live births in the last 12 months preceding the survey in Amhara, Oromia, SNNP, and Tigray regions of Ethiopia. We fitted multilevel random-effects logistic regression models to examine the predictors of the continuum of care accounting for the survey design, and individual, and contextual characteristics of the respondents.

Results

Our analysis revealed that only one-fifth of women utilized maternal and newborn health services across the antepartum, intrapartum, and postpartum continuum; most women discontinued at the postpartum stage. Continued use of services varied significantly across wealth, model family, prenatal stay at maternity waiting homes, antenatal care in the first trimester, complete antenatal care service, and the administrative region at all antepartum, intrapartum, and postpartum stages. Moreover, family conversation during pregnancy [AOR: 2.12; 95% CI: 1.56–2.88], delivery by cesarean [AOR: 2.70; 95% CI: 1.82–4.02] and birth notified to health extension workers [AOR: 1.95; 95% CI: 1.56–2.43] were found to be predictors of the continuum of care at the postpartum stage.

Conclusion

In Ethiopia, despite good access to antepartum care, compliance with continuity of care across the pathway decreased with significant inequitable distributions, the poorest segment of the population being at most disadvantage. The main modifiable program factors connected to the continued uptake of maternal health services include family conversation, pregnant women conference, complete antenatal care, antenatal care in the first trimester, and birth notification.

Evaluation of the Direct Health Facility Financing Program in Improving Maternal Health Services in Pangani District, Tanzania

BACKGROUND

Maternal morbidity and mortality remain significant public health concerns globally, with Tanzania reporting 398 deaths per 100,000 live births annually. While national level data provide some insights into the issue, a focus on sub-national levels is required because of differences in contexts such as rural-urban disparities in maternal mortality. This study examined Direct Health Facility Financing (DHFF) and its effects on the quality of maternal health services in Pangani, a rural district in Tanzania.

METHODS

This study was conducted in Pangani district of Tanga region in Tanzania. The study used both qualitative and quantitative methods, including 16 in-depth interviews with the council health management teams, facility in charges, maternity nurse in charge, and 5 focus group discussions with community health governing committee members. The number of deliveries that occurred in health facilities, as well as medical supplies, equipment, and reagents purchased by the facilities, were compared using descriptive statistics before and after the DHFF implementation.

RESULTS

Direct disbursement of funds from the central government through the Ministry of Finance and Planning to the primary health facilities reduced delays in procurement, improved community outreach services, and improved community leaders' engagements. Deliveries occurring at health facilities increased by 33.6% (p < 0.001) one year after the HDFF implementation. Various medicines, delivery kits, and some reagents increased significantly (p < 0.05). However, the lack of computers and poor internet connectivity, an insufficient supply of medical equipment and unstable stock of the Medical Stores Department increased the difficulty of obtaining the missed items from the selected prime vendor.

CONCLUSION

Overall, this study shows a positive impact of the DHFF on maternal health service delivery in Pangani district. Specifically, an increase in the number of medical supplies, equipment, and reagents necessary to provide maternal health services contributed to the observed increase in facility deliveries by 33.6%. Moreover, the system minimizes unnecessary delays in the procurement processes of required drugs, supplies, and other facility reagents. To maximize the impact of the HDFF system, lack of computers, unstable internet, limited knowledge of the staff about the system, and inadequate health workforce should be addressed. Therefore, strengthening the DHFF system and staff training in-service and on the job is essential for smooth implementation.

Determinants of postnatal care utilization in Ethiopia: a multilevel analysis

BACKGROUND

The expansion of primary health care services in Ethiopia made basic health services available and accessible. The Last Ten Kilometers (L10K) project has strengthened the primary health care system through implementing innovative strategies to engage local communities to improve maternal and newborn health care behavior and practices in Amhara, Oromia, Southern Nations, Nationalities and Peoples [SNNP], and Tigray regions over a decade. Despite the efforts of the government and its partners to improve the use of maternal health services, the coverage of postnatal care is persistently low in the country. This study examined the individual and community level determinants for the persistently low uptake of postnatal care in the project areas.

METHODS

The study used a cross-sectional population-based survey that measured maternal and newborn health care practices among women who had live births in the last 12 months preceding the survey in Amhara, Oromia, SNNP, and Tigray regions. Multilevel random effects binary logistic regression analysis was used to assess the independent effects of community-and individual-level factors and moderating effects on the uptake of postnatal care.

RESULTS

This study identified region of residence, obstetric factors, and health service-related factors to be significant determinants for use of postnatal care. Obstetric factors include knowledge of obstetric danger signs (AOR: 1.30; 95% CI: 1.05-1.60), cesarean section mode of delivery (AOR: 1.96; 95% CI: 1.28-3.00), and institutional delivery (AOR: 10.29; 95% CI: 7.57-13.98). While the health service-related factors include attended family conversation during pregnancy (AOR: 1.48; 95% CI: 1.04-2.12), birth notification (AOR: 2.66; 95% CI: 2.15-3.29), home visits by community health workers (AOR: 1.98; 95% CI: 1.58-2.50), and being recognized as a model family (AOR: 1.27; 95% CI: 1.03-1.57).

CONCLUSION

This study demonstrated that community-level interactions and promotive health services including antepartum home visits by community health workers, family conversation, birth notification, and model family, are important determinants to seek postnatal care. The findings also highlight the need for expansion of health facilities or design appropriate strategies to reach the disadvantaged communities. Program managers are recommended to strengthen community-based interventions to improve postnatal care utilization.