Strengthening the Health System as a Strategy to Achieving a Universal Health Coverage in Underprivileged Communities in Africa: A Scoping Review

Care seeking for childhood illnesses in rural Mtwara, south-east Tanzania: a mixed methods study

BACKGROUND

Care seeking was assessed in preparation for a study of the health impact of novel design houses in rural Mtwara, Tanzania.

METHODS

A total of 578 residents of 60 villages participated in this mixed-methods study from April to August 2020. Among them, 550 participated in a healthcare-seeking survey, 17 in in-depth interviews and 28 in key informant interviews.

RESULTS

The decision to seek care was based on symptom severity (95.4% [370]). Caregivers first visited non-allopathic healthcare providers or were treated at home, which led to delays in seeking care at healthcare facilities. More than one-third (36.0% [140]) of respondents took >12 h seeking care at healthcare facilities. The majority (73.0% [282]) visited healthcare facilities, whereas around one-fifth (21.0% [80]) sought care at drug stores. Treatment costs deterred respondents from visiting healthcare facilities (61.4% [338]). Only 10 (3.6%) of the households surveyed reported that they were covered by health insurance.

CONCLUSIONS

Quality of care, related to institutional factors, impacts timely care seeking for childhood illnesses in Mtwara, Tanzania. Ensuring accessibility of facilities is therefore not sufficient.

Identifying and costing common gaps in Central and West Africa pharmaceutical regulation

Background

Regulatory systems strengthening is crucial for catalyzing access to safe and effective medical products and health technologies (MPHT) for all. Identifying and addressing common regulatory gaps through regional approaches could be instrumental for the newly incepted African Medicine Agency.

Aims

This original study sheds light on common gaps among 10 national regulatory authorities (NRAs) and ways to address them regionally.

Objectives

The study used NRA self-assessment outcomes to identify common gaps in four critical regulatory pillars and estimate the cost of addressing them from regional perspectives that aimed at raising the maturity level of regulatory institutions.

Methods

A cross-sectional study, using the WHO Global Benchmarking Tool (GBT), was conducted between 2020 and 2021 with five NRAs from ECCAS and ECOWAS member states that use French and Spanish as lingua franca.

Results

The 10 NRAs operated in a non-formal-to-reactive approach (ML1-2), which hinders their ability to ensure the quality of MPHT and respond appropriately to public health emergencies. Common gaps were identified in four critical regulatory pillars-good regulatory practices, preparedness for public health emergencies, quality management systems, and substandard and falsified medical products-with overall cost to address gaps estimated at US$3.3 million.

Contribution

We elaborated a reproducible method to strengthen regulatory systems at a regional level to improve equitable access to assured-quality MPHT. Our bottom-up approach could be utilized by RECs to address common gaps through common efforts.

Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.

Advancement and the existing landscape of forensic medicine in Africa: A comparison with developed countries

This article explores the development and challenges of forensic medicine in Africa, comparing it to developed countries. It addresses limited resources, funding, and a shortage of trained professionals. The growth of forensic investigation capabilities and the challenges of funding and technology access are discussed. Training and education have improved, but disparities remain. Partnerships with developed countries and international organizations are crucial to bridge the gap. A comprehensive legal framework is important, but disparities exist among African countries. Harmonizing forensic laws would enhance cooperation. The role of forensic medicine in the criminal justice system is examined, emphasizing the need to build trust in forensic evidence. International collaboration and capacity building are key to advancing forensic medicine in Africa. Investments in infrastructure, funding, training, and legal frameworks are required. By leveraging partnerships, Africa can develop its forensic medicine capabilities for a fair and effective criminal justice system.

Acceptance of the Advocacy Core Group approach in promoting integrated social and behaviour change for MNCH+N in Nigeria: a qualitative study

OBJECTIVE

This paper examines the acceptance of the Advocacy Core Group (ACG) programme, a social and behaviour change intervention addressing maternal, newborn, child health and nutrition (MNCH+N) in Bauchi and Sokoto states, with an additional focus on the perceived endorsement of health behaviours by social networks as a potential factor influencing acceptance.

DESIGN

This study used the qualitative social network analysis approach and used in-depth interviews to collect data from 36 participants across Bauchi and Sokoto states.

SETTING

This study was conducted in selected communities across Bauchi and Sokoto states.

PARTICIPANTS

A purposive sample of 36 participants comprised of men and women aged 15-49 years who have been exposed to the ACG programme.

RESULTS

Programme beneficiaries actively engaged in various ACG-related activities, including health messaging delivered through religious houses, social gatherings, home visits, community meetings and the media. As a result, they reported a perceived change in behaviour regarding exclusive breast feeding, antenatal care visits, family planning and malaria prevention. Our findings indicated consistent discussions on health behaviours between programme beneficiaries and their network partners (NPs), with a perceived endorsement of these behaviours by the NPs. However, a potential negative factor emerged, whereby NPs exhibited perceived disapproval of key behaviours, which poses a threat to behaviour adoption and, consequently, the success of the ACG model.

CONCLUSIONS

While findings suggest the successful implementation and acceptance of the model, it is important to address possible barriers and to further explore the socially determined acceptance of MNCH+N behaviours by NPs. Interventions such as the ACG model should mobilise the networks of programme participants, particularly those with decision-making power, to improve the uptake of health behaviours.

A New eHealth Investment Appraisal Framework for Africa: Validation

(1) Background: Decisions to use eHealth are complex and involve addressing a large opportunity cost. Sound choices are essential. Weighing up investment options is challenging in resource-constrained settings where there are frequently insufficient economics data and expertise to conduct adequate appraisals. To address this, a new eHealth Investment Appraisal Framework (eHIAF) for Africa has been designed and developed. The aim of this paper was to validate the new framework to consider whether it is fit for purpose and to refine it as needed. (2) Methods: An online survey of purposively selected eHealth experts was used to conduct a desktop validation of the proposed eHIAF for Africa. The survey covered the framework development process, structure, content, completeness, and utility. Expert opinions were charted, and a reflective and iterative process used to assess the tool and extract recommendations for refinement. (3) Results: Eleven eHealth experts who completed the survey had experience in African countries and elsewhere. The majority agreed with the eHIAF for Africa development approach and output. They provided valuable suggestions for minor refinements and felt that with these amendments, the eHIAF for Africa would be 'fit for purpose'. (4) Conclusions: The eHIAF for Africa is considered appropriate for use by policy- and decision-makers working in resource-constrained settings who face the task of selecting optimal eHealth investments. It has the potential for applicability beyond Africa and the framework should now be tested in African countries.

Determinants of Adherence to Antihypertension Medications Among Patients at a Tertiary Care Hospital in Islamabad, Pakistan, 2019

INTRODUCTION

Medication nonadherence leads to poor health outcomes, frequent complications, and high economic impact. Our objective was to assess the determinants of adherence to medication regimens among patients with hypertension.

METHODS

We conducted a cross-sectional study of patients with hypertension attending the cardiology clinic of a tertiary care hospital in Islamabad, Pakistan. Data were collected by using semistructured questionnaires. A score of 7 or 8 on the 8-item Morisky Medication Adherence Scale was classified as good adherence, 6 as moderate, and less than 6 as nonadherence. Logistic regression was performed to determine covariates associated with medication adherence.

RESULTS

We enrolled 450 patients with hypertension (mean age, 54.5 y; SD, 10.6). Medication adherence was good among 115 (25.6%) patients and moderate among 165 (36.7%); 170 (37.8%) patients were nonadherent. Most patients (72.7%) had uncontrolled hypertension. Nearly half (49.6%) were unable to afford monthly medication. In bivariate analysis, nonadherence was associated with female sex (odds ratio [OR], 1.44; P = .003) and long waiting times in the health care facility (OR, 2.93; P = .005); the presence of comorbidities (OR, 0.62; P = .01) was associated with good adherence. In multivariate analysis, nonadherence was associated with unaffordability of treatment (OR, 2.25; P = .002) and uncontrolled hypertension (OR, 3.16; P < .001). Good adherence determinants included adequate counseling (OR, 0.29; P < .001) and education (OR, 0.61; P = .02).

CONCLUSION

Addressing identified barriers, including medication affordability and patient counseling, should be included in Pakistan's national policy on noncommunicable disease.

Providing paediatric surgery in low-resource countries

Successful health systems comprise good outcomes, accessibility and availability. Surgery is the service that cuts across many treatment scenarios, yet in low- and middle-income countries 90% of people cannot access it. Estimates using most recent population data suggest that 1.75 billion children lack access to surgical care. Additionally, 30% of the global burden of disease is treatable with surgery, yet in LMICs as much as 87% of the surgical need remains unmet. Paediatric surgical services are not at the level they need to be, highlighting an increasing surgical burden on children’s health globally with a human cost of morbidity and mortality. Achieving Universal Health Coverage and the Sustainable Development Goals will fail if surgical systems are not strengthened in low resource settings. In 2018, global health charity Kids Operating Room was founded with a goal of ensuring every child has access to the surgery they need. The charity has a four-pillar approach to its work: provision of infrastructure and equipment, paediatric surgical workforce training, database development and research capacity strengthening, and advocating on behalf of children denied access to safe surgery. To ensure that paediatric surgical interventions produce real impact on service delivery, contextual understanding and needs assessment are key. The building of paediatric surgical capacity should align to countries’ priorities and wishes. Investing in local health workforce is essential to delivering quality services, supporting resilient health systems and provides integrated, people-centred health services. A competent surgical information system gives the local surgical workforce the tools needed to action evidence-driven decisions. Strengthening surgical services in a manner aligned to the WHO’s fundamental health system building blocks, allows for sustainable and long-lasting change. Confronting bottlenecks that exist in surgical services and establishing multi-faceted development, will allow global, national and local surgical targets to be met.

Equity in Scientific Publication

This editorial seeks to draw our attention to the central role of health research in identifying solutions to persistent challenges to meeting health goals, and as a core component of economic development, irrespective of the level of economic development of the country. As such, the 'leave no one behind' principle which underpins the sustainable development agenda applies to health research as well. Health Services Insights (HIS) contributes to meeting the need for equity in health research embracing a multidisciplinary approach to share comprehensive evidence.

A realist synthesis of staff-based primary health care interventions addressing universal health coverage

Background

Methods

Results

Conclusions