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Abdul-Samed AB, Peprah EB, Jahan Y, Reichenberger V, Balabanova D, Mirzoev T, Lawson H, Odei E, Antwi E, Agyepong I. Exploring the path to optimal diabetes care by unravelling the contextual factors affecting access, utilisation, and quality of primary health care in West Africa: A scoping review protocol. PLoS One 2024; 19:e0294917. [PMID: 38768121 PMCID: PMC11104679 DOI: 10.1371/journal.pone.0294917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/13/2023] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The prevalence of diabetes in West Africa is increasing, posing a major public health threat. An estimated 24 million Africans have diabetes, with rates in West Africa around 2-6% and projected to rise 129% by 2045 according to the WHO. Over 90% of cases are Type 2 diabetes (IDF, World Bank). As diabetes is ambulatory care sensitive, good primary care is crucial to reduce complications and mortality. However, research on factors influencing diabetes primary care access, utilisation and quality in West Africa remains limited despite growing disease burden. While research has emphasised diabetes prevalence and risk factors in West Africa, there remains limited evidence on contextual influences on primary care. This scoping review aims to address these evidence gaps. METHODS AND ANALYSIS Using the established methodology by Arksey and O'Malley, this scoping review will undergo six stages. The review will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Review (PRISMA-ScR) guidelines to ensure methodological rigour. We will search four electronic databases and search through grey literature sources to thoroughly explore the topic. The identified articles will undergo thorough screening. We will collect data using a standardised data extraction form that covers study characteristics, population demographics, and study methods. The study will identify key themes and sub-themes related to primary healthcare access, utilisation, and quality. We will then analyse and summarise the data using a narrative synthesis approach. RESULTS The findings and conclusive report will be finished and sent to a peer-reviewed publication within six months. CONCLUSION This review protocol aims to systematically examine and assess the factors that impact the access, utilisation, and standard of primary healthcare services for diabetes in West Africa.
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Affiliation(s)
| | | | - Yasmin Jahan
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Dina Balabanova
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Tolib Mirzoev
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Henry Lawson
- Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Eric Odei
- Korle Bu Teaching Hospital, Accra, Ghana
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Sahani MK, Maat H, Balabanova D, Woldie M, Richards P, Mayhew S. Engaging communities as partners in health crisis response: a realist-informed scoping review for research and policy. Health Res Policy Syst 2024; 22:56. [PMID: 38711067 PMCID: PMC11075189 DOI: 10.1186/s12961-024-01139-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Accepted: 03/30/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Health is increasingly affected by multiple types of crises. Community engagement is recognised as being a critical element in successful crisis response, and a number of conceptual frameworks and global guideline documents have been produced. However, little is known about the usefulness of such documents and whether they contain sufficient information to guide effective community engagement in crisis response. We undertake a scoping review to examine the usefulness of conceptual literature and official guidelines on community engagement in crisis response using a realist-informed analysis [exploring contexts, mechanisms, and outcomes(CMOs)]. Specifically, we assess the extent to which sufficient detail is provided on specific health crisis contexts, the range of mechanisms (actions) that are developed and employed to engage communities in crisis response and the outcomes achieved. We also consider the extent of analysis of interactions between the mechanisms and contexts which can explain whether successful outcomes are achieved or not. SCOPE AND FINDINGS We retained 30 documents from a total of 10,780 initially identified. Our analysis found that available evidence on context, mechanism and outcomes on community engagement in crisis response, or some of their elements, was promising, but few documents provided details on all three and even fewer were able to show evidence of the interactions between these categories, thus leaving gaps in understanding how to successfully engage communities in crisis response to secure impactful outcomes. There is evidence that involving community members in all the steps of response increases community resilience and helps to build trust. Consistent communication with the communities in time of crisis is the key for effective responses and helps to improve health indicators by avoiding preventable deaths. CONCLUSIONS Our analysis confirms the complexity of successful community engagement and the need for strategies that help to deal with this complexity to achieve good health outcomes. Further primary research is needed to answer questions of how and why specific mechanisms, in particular contexts, can lead to positive outcomes, including what works and what does not work and how to measure these processes.
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Affiliation(s)
- Mateus Kambale Sahani
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Harro Maat
- Knowledge, Technology, and Innovation Group, Department of Social Sciences, Wageningen University, Wageningen, The Netherlands
| | - Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mirkuzie Woldie
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
| | - Paul Richards
- School of Environmental Sciences, Njala University, Freetown, Sierra Leone
| | - Susannah Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Hutchinson E, Kiwanuka S, Muhindo R, Nimwesiga C, Balabanova D, McKee M, Kitutu FE. The paradoxical surplus of health workers in Africa: The need for research and policy engagement. Int J Health Plann Manage 2024; 39:956-962. [PMID: 38193753 DOI: 10.1002/hpm.3745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 01/10/2024] Open
Abstract
In many countries in Africa, there is a 'paradoxical surplus' of under and unemployed nurses, midwives, doctors and pharmacists which exists amidst a shortage of staff within the formal health system. By 2030, the World Health Organisation Africa Region may find itself with a shortage of 6.1 million health workers alongside 700,000 un- or underemployed health staff. The emphasis in policy debates about human resources for health at most national and global levels is on staff shortage and the need to train more health workers. In contrast, these 'surplus' health workers are both understudied and underacknowledged. Little time is given over to understand the economic, political and social factors that have driven their emergence; the ways in which they seek to make a living; the governance challenges that they raise; nor potential interventions that could be implemented to improve employment rates and leverage their expertise. This short communication reflects on current research findings and calls for improved quantitative and qualitative research to support policy engagement at national, regional and global levels.
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Affiliation(s)
- Eleanor Hutchinson
- Department of Global Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Suzanne Kiwanuka
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Richard Muhindo
- Department of Nursing, Makerere University School of Health Sciences, Kampala, Uganda
| | | | - Dina Balabanova
- Department of Global Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Freddy Eric Kitutu
- Department of Pharmacy, Makerere University School of Health Sciences, Kampala, Uganda
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Islam MR, Angell B, Naher N, Islam BZ, Khan MH, McKee M, Hutchinson E, Balabanova D, Ahmed SM. Who is absent and why? Factors affecting doctor absenteeism in Bangladesh. PLOS Glob Public Health 2024; 4:e0003040. [PMID: 38574057 PMCID: PMC10994372 DOI: 10.1371/journal.pgph.0003040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 02/27/2024] [Indexed: 04/06/2024]
Abstract
Absenteeism by doctors in public healthcare facilities in rural Bangladesh is a form of chronic rule-breaking and is recognised as a critical problem by the government. We explored the factors underlying this phenomenon from doctors' perspectives. We conducted a facility-based cross-sectional survey in four government hospitals in Dhaka, Bangladesh. Junior doctors with experience in rural postings were interviewed to collect data on socio-demographic characteristics, work and living experience at the rural facilities, and associations with professional and social networks. Multiple logistic regression was used to determine the factors associated with rural retention. Of 308 respondents, 74% reported having served each term of their rural postings without interruptions. The main reasons for absenteeism reported by those who interrupted rural postings were formal training opportunities (65%), family commitments (41%), and a miscellaneous group of others (17%). Almost half of the respondents reported unmanageable workloads. Most (96%) faced challenges in their last rural posting, such as physically unsafe environments (70%), verbally abusive behaviour by patients/caregivers (67%) and absenteeism by colleagues that impacted them (48%). Respondents who did not serve their entire rural posting were less likely to report an unmanageable workload than respondents who did (AOR 0.39, 95% CI 0.22-0.70). Respondents with connections to influential people in the local community had a 2.4 times higher chance of serving in rural facilities without interruption than others (AOR 2.40, 95% CI 1.26-4.57). Our findings demonstrate that absenteeism is not universal and depends upon doctors' socio-political networks. Policy interventions rarely target unsupportive or threatening behaviour by caregivers and community members, a pivotal disincentive to doctors' willingness to work in underserved rural areas. Policy responses must promote opportunities for doctors with weak networks who are willing to attend work with appropriate support.
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Affiliation(s)
- Mir Raihanul Islam
- Poverty, Gender and Inclusion Division, International Food Policy Research Institute, Dhaka, Bangladesh
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
| | - Nahitun Naher
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Bushra Zarin Islam
- School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, Massachusetts, United States of America
| | - Mushtaq Husain Khan
- School of Oriental and African Studies (SOAS), University of London, London, England
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Eleanor Hutchinson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Syed Masud Ahmed
- BRAC James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
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Agwu P, Onwujekwe O, Obi U, McKee M, Odii A, Orjiakor C, Hutchinson E, Balabanova D. Targeting systems not individuals: Institutional and structural drivers of absenteeism among primary healthcare workers in Nigeria. Int J Health Plann Manage 2024; 39:417-431. [PMID: 37947450 DOI: 10.1002/hpm.3736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/12/2023] Open
Abstract
Universal Health Coverage (UHC) can only be achieved if people receive good quality care from health workers, yet in Nigeria, as in many other low- and middle-income countries (LMICs), many health workers are absent from work. Absenteeism is a well-known phenomenon but is often considered as the self-serving behaviour of individuals, independent from the characteristics of health systems structures and processes and the broader contexts that enable it. We undertook a qualitative inquiry among 40 key informants, comprising health facility heads and workers, community leaders and state-level health policymakers in Nigeria. We employed a phenomenology approach to examine their lived experiences and grouped findings into thematic clusters. Absenteeism by health workers was found to be a response to structural problems at two levels -midstream (facility-level) and upstream (government level) - rather than being a result of moral failure of individuals. The problems at midstream level pointed to an inconsistent and unfair application of rules and regulations in facilities and ineffective management, while the upstream drivers relate mainly to political interference and suboptimal health system leadership. Reducing absenteeism requires two-pronged interventions that tackle defects in the upstream and midstream rather than just focusing on sanctioning deviant staff (downstream).
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Affiliation(s)
- Prince Agwu
- Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Social Work, University of Nigeria, Nsukka, Nigeria
- School of Humanities, Social Sciences, and Law, University of Dundee, Dundee, UK
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Health Administration and Management, University of Nigeria, Enugu, Nigeria
| | - Uche Obi
- Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Community Medicine, University of Nigeria, Nsukka, Nigeria
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
| | - Aloysius Odii
- Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Sociology & Anthropology, University of Nigeria, Nsukka, Nigeria
| | - Charles Orjiakor
- Department of Pharmacology and Therapeutics, Health Policy Research Group, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Psychology, University of Nigeria, Nsukka, Nigeria
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Onwujekwe O, Agwu P, Roy P, Hutchinson E, Orjiakor C, McKee M, Odii A, Nwokolo C, Khan M, Mayhew S, Balabanova D. The Promise of Grassroots Approaches to Solving Absenteeism in Primary Health-Care Facilities in Nigeria: Evidence from a Qualitative Study. Health Syst Reform 2023; 9:2199515. [PMID: 37105904 DOI: 10.1080/23288604.2023.2199515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Absenteeism among primary health-care (PHC) workers in Nigeria is widespread and is a major obstacle to achieving Universal Health Coverage (UHC). There is increasing research on the forms it takes and what drives them, but limited evidence on how to address it. The dominant approach has involved government-led topdown solutions (vertical approach). However, these have rarely been successful in countries such as Nigeria. This paper explores alternative approaches based on grassroots (horizontal) approaches. Data collected from interviews with 40 PHC stakeholders in Enugu, Nigeria, were organized in thematic clusters that explored the contribution of horizontal interventions to solving absenteeism in primary health-care facilities. We applied phenomenology to analyze the lived (practical) experiences of respondents. Absenteeism by PHC workers was prevalent and is encouraged by the complex configuration of the PHC system and its operating environment, which constrains topdown interventions. We identified several horizontal approaches that may create effective incentives and compulsions to reduce absenteeism, which include leveraging community resources to improve security of facilities, tapping the resources of philanthropic individuals and organizations to provide accommodation for health workers, and engaging trained health workers as volunteers or placeholders to address shortages of health-care staff. Nevertheless, a holistic response to absenteeism must complement horizontal approaches with vertical measures, with the government supporting and encouraging the health system to develop self-enforcing mechanisms to tackle absenteeism.
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Affiliation(s)
- Obinna Onwujekwe
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Health Administration and Management, University of Nigeria, Enugu, Nigeria
| | - Prince Agwu
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Social Work, University of Nigeria, Nsukka, Nigeria
| | - Pallavi Roy
- Department of Global Health and Development, School of Oriental and African Studies (SOAS), London, UK
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Charles Orjiakor
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Psychology, University of Nigeria, Nsukka, Nigeria
| | - Martin McKee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Aloysius Odii
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Sociology, University of Nigeria, Nsukka, Nigeria
| | - Chukwudi Nwokolo
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Economics, University of Nigeria, Nsukka, Nigeria
| | - Mushtaq Khan
- Department of Global Health and Development, School of Oriental and African Studies (SOAS), London, UK
| | - Susannah Mayhew
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Allen LN, Pettigrew LM, Exley J, Nugent R, Balabanova D, Villar-Uribe M, Baatiema L, Shubber Z, Mugambi J, Kidd M, Zewdie A, Padula I, Abimbola S. The role of Primary Health Care, primary care and hospitals in advancing Universal Health Coverage. BMJ Glob Health 2023; 8:e014442. [PMID: 38084496 PMCID: PMC10711840 DOI: 10.1136/bmjgh-2023-014442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/19/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Luke N Allen
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Josephine Exley
- Department of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Rachel Nugent
- Department of Global Health, University of Washington, Washington, DC, USA
| | | | - Manuela Villar-Uribe
- Health Nutrition and Population, World Bank Group, Washington, District of Columbia, USA
| | | | - Zara Shubber
- World Bank Group, Washington, District of Columbia, USA
| | - Joy Mugambi
- Kenya Association Family Physicians, Nakuru, Kenya
| | | | - Anteneh Zewdie
- International Institute for Primary Health Care, Addis, Ethiopia
| | - Inez Padula
- Department of Family and Community Medicine, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - Seye Abimbola
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Erlangga D, Powell-Jackson T, Balabanova D, Hanson K. Determinants of government spending on primary healthcare: a global data analysis. BMJ Glob Health 2023; 8:e012562. [PMID: 38035736 PMCID: PMC10689394 DOI: 10.1136/bmjgh-2023-012562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 10/16/2023] [Indexed: 12/02/2023] Open
Abstract
In 2018 global leaders renewed their political commitment to primary healthcare (PHC) ratifying the Declaration of Astana emphasising the importance of building a sustainable PHC system based on accessible and affordable delivery models strengthened by community empowerment. Yet, PHC often remains underfunded, of poor quality, unreliable and not accountable to users which further deprives PHC of funding. This paper analyses the determinants of PHC expenditure in 102 countries, and quantitatively tests the influence of a set of economic, social and political determinants of government expenditure on PHC. The analysis is focused on the determinants of PHC funding from government sources as the government is in a position to make decisions in relation to this expenditure as opposed to out-of-pocket spending which is not in their direct control. Multivariate regression analysis was done to determine statistically significant predictors.Our analysis found that some economic factors-namely Gross Domestic Product (GDP) per capita, government commitment to health and tax revenue raising capacity-were strongly associated with per capita government spending on PHC. We also found that control of corruption was strongly associated with the level of total spending on PHC, while voice and accountability were positively associated with greater government commitment to PHC as measured by government spending on PHC as a share of total government health spending.Our analysis takes a step towards understanding of the drivers of PHC expenditure beyond the level of national income. Some of these drivers may be beyond the remit of health policy decision makers and relate to broader governance arrangements and political forces in societies. Thus, efforts to prioritise PHC in the health agenda and increase PHC expenditure should recognise the constraints within the political landscapes and engage with a wide range of actors who influence decisions affecting the health sector.
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Affiliation(s)
- Darius Erlangga
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Kara Hanson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Boland ST, Balabanova D, Mayhew S. Examining the militarised hierarchy of Sierra Leone's Ebola response and implications for decision making during public health emergencies. Global Health 2023; 19:89. [PMID: 37993942 PMCID: PMC10664671 DOI: 10.1186/s12992-023-00995-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
BACKGROUND In September, 2014, Médecins Sans Frontières (MSF) called for militarised assistance in response to the rapidly escalating West Africa Ebola Epidemic. Soon after, the United Kingdom deployed its military to Sierra Leone, which (among other contributions) helped to support the establishment of novel and military-led Ebola Virus Disease (Ebola) response centres throughout the country. To examine these civil-military structures and their effects, 110 semi-structured interviews with civilian and military Ebola Response Workers (ERWs) were conducted and analysed using neo-Durkheimian theory. RESULTS The hierarchical Ebola response centres were found to be spaces of 'conflict attenuation' for their use of 'rule-bound niches', 'neutral zones', 'co-dependence', and 'hybridity', thereby not only easing civil-military relationships (CMRel), but also increasing the efficiency of their application to Ebola response interventions. Furthermore, the hierarchical response centres were also found to be inclusive spaces that further increased efficiency through the decentralisation and localisation of these interventions and daily decision making, albeit for mostly privileged groups and in limited ways. CONCLUSIONS This demonstrates how hierarchy and localisation can (and perhaps should) go hand-in-hand during future public health emergency responses as a strategy for more robustly including typically marginalised local actors, while also improving necessary efficiency-in other words, an 'inclusive hierarchical coordination' that is both operationally viable and an ethical imperative.
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Affiliation(s)
- Samuel T Boland
- Centre for Universal Health, Chatham House, 10 St James's Square, London, SW1Y 4LE, UK.
| | - Dina Balabanova
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Square, London, WC1H 9SH, UK
| | - Susannah Mayhew
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Square, London, WC1H 9SH, UK
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Chilumpha M, Chatha G, Umar E, McKee M, Scott K, Hutchinson E, Balabanova D. 'We stay silent and keep it in our hearts': a qualitative study of failure of complaints mechanisms in Malawi's health system. Health Policy Plan 2023; 38:ii14-ii24. [PMID: 37995264 PMCID: PMC10666912 DOI: 10.1093/heapol/czad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/10/2023] [Accepted: 07/02/2023] [Indexed: 11/25/2023] Open
Abstract
A responsive health system must have mechanisms in place that ensure it is accountable to those it serves. Patients in Malawi have to overcome many barriers to obtain care. Many of these barriers reflect weak accountability. There are at least 30 mechanisms through which Malawian patients in the public sector can assert their rights, yet few function well and, as a consequence, they are underused. Our aim was to identify the various channels for complaints and why patients are reluctant to use them when they experience poor quality or inappropriate care, as well as the institutional, social and political factors that give rise to these problems. The study was set in the Blantyre district. We used qualitative methods, including ethnographic observations, focus group discussions, document analysis and interviews with stakeholders involved in complaint handling both in Blantyre and in the capital, Lilongwe. We found that complaints mechanisms and redress procedures are underutilized because of lack of trust, geographical inaccessibility and lack of visibility leading to limited awareness of their existence. Drawing on these results, we propose a series of recommendations for the way forward.
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Affiliation(s)
- Maryam Chilumpha
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre, Malawi
| | - Gertrude Chatha
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre, Malawi
| | - Eric Umar
- Department of Health Systems and Policy, Kamuzu University of Health Sciences, Private Bag 360, Chichiri, Blantyre, Malawi
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, United Kingdom
| | - Kerry Scott
- Johns Hopkins School of Public Health, Canada
| | | | - Dina Balabanova
- London School of Hygiene and Tropical Medicine, United Kingdom
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Ogbozor PA, Hutchinson E, Goodman C, McKee M, Onwujekwe O, Balabanova D. The nature, drivers and equity consequences of informal payments for maternal and child health care in primary health centres in Enugu, Nigeria. Health Policy Plan 2023; 38:ii62-ii71. [PMID: 37995265 PMCID: PMC10666910 DOI: 10.1093/heapol/czad048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 11/25/2023] Open
Abstract
In Nigeria, most basic maternal and child health services in public primary health-care facilities should be either free of charge or subsidized. In practice, additional informal payments made in cash or in kind are common. We examined the nature, drivers and equity consequences of informal payments in primary health centres (PHC) in Enugu State. We used three interlinked qualitative methods: participant observation in six PHC facilities and two local government area (LGA) headquarters; in-depth interviews with frontline health workers (n = 19), managers (n = 4) and policy makers (n = 10); and focus group discussions (n = 2) with female service users. Data were analysed thematically using NVivo 12. Across all groups, informal payments were described as routine for immunization, deliveries, family planning consultations and birth certificate registration. Health workers, managers and policy makers identified limited supervision, insufficient financing of facilities, and lack of receipts for formal payments as enabling this practice. Informal payments were seen by managers and health workers as a mechanism to generate discretionary revenue to cover operational costs of the facility but, in practice, were frequently taken as extra income by health workers. Health workers rationalized informal payments as being of small value, and not a burden to users. However, informal payments were reported to be inequitable and exclusionary. Although they tended to be lower in rural PHCs than in wealthier urban facilities, participant observation revealed how, within a PHC, the lowest earners paid the same as others and were often left unattended if they failed to pay. Some female patients reported that extra payments excluded them from services, driving them to seek help from retail outlets or unlicensed health providers. As a result, informal payments reduced equity of access to essential services. Targeted policies are needed to improve financial risk protection for the poorest groups and address drivers of informal payments and unfairness in the health system.
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Affiliation(s)
- Pamela Adaobi Ogbozor
- Department of Psychology, Enugu State University of Science and Technology, PMB 01600, Agbani, Enugu, Nigeria
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, PMB 01129, Enugu, Nigeria
| | - Eleanor Hutchinson
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Catherine Goodman
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Enugu Campus, PMB 01129, Enugu, Nigeria
- Department of Health Administration and Management, University of Nigeria, Enugu Campus, PMB 410001, Enugu, Nigeria
| | - Dina Balabanova
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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Onwujekwe O, Orjiakor C, Ogbozor P, Agu I, Agwu P, Wright T, Balabanova D, Kohler J. Examining corruption risks in the procurement and distribution of COVID-19 vaccines in select states in Nigeria. J Pharm Policy Pract 2023; 16:141. [PMID: 37957711 PMCID: PMC10641993 DOI: 10.1186/s40545-023-00649-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/04/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Public health emergencies raise significant concerns about corruption and accountability; however, these concerns can manifest in different ways across diverse locations. For instance, more developed countries with a stronger rule of law may experience more corruption in vaccine procurement, whereas developing countries may experience more corruption at the point of distribution and delivery to end users. This research focuses on corruption concerns in Nigeria, specifically examining the procurement and distribution of COVID-19 vaccines. METHODS This paper utilizes a scoping review and a qualitative research approach. Key informants (n = 40) involved in the procurement and distribution of COVID-19 vaccines across two states in Nigeria were interviewed. Findings from the scoping review were summarized, and collected data were inductively coded and analysed in themes, revealing clear examples of implementation irregularities and corruption in the country's COVID-19 vaccination processes. RESULTS Vaccination programme budgeting processes were unclear, and payment irregularities were frequently observed, resulting in vaccinators soliciting informal payments while in the field. Recruitment and engagement of vaccination personnel was opaque, while target vaccination rates incentivized data falsification during periods of vaccine hesitancy. Accountability mechanisms, such as health worker supervision, vaccination data review, and additional technical support provided by donors were implemented but not effective at preventing corruption among frontline workers. CONCLUSIONS Future accountability measures should be evidence-driven based on findings from this research. Personnel recruitment, contracting, budgeting, and remuneration should focus on transparency and accountability.
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Affiliation(s)
- Obinna Onwujekwe
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Health Administration and Management, University of Nigeria, Enugu, Nigeria
| | - Charles Orjiakor
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Psychology, University of Nigeria, Nsukka, Nigeria
- Department of Psychology, University of Toronto, Scarborough, Canada
| | - Pamela Ogbozor
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Psychology, Enugu State University of Science and Technology, Enugu, Nigeria
| | - Ifunanya Agu
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Prince Agwu
- Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria, Enugu, Nigeria
- Department of Social Work, University of Nigeria, Nsukka, Nsukka, Nigeria
| | - Tom Wright
- Transparency International Global Health Programme, Transparency International, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Jillian Kohler
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.
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Boland ST, Balabanova D, Mayhew S. The political economy of expedience: examining perspectives on military support to Sierra Leone's Ebola response. Confl Health 2023; 17:53. [PMID: 37932772 PMCID: PMC10626636 DOI: 10.1186/s13031-023-00553-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/01/2023] [Indexed: 11/08/2023] Open
Abstract
The 2013-2016 West Africa Ebola Epidemic is the largest outbreak of Ebola in history. By September, 2014 the outbreak was worsening significantly, and the international president of Médecins Sans Frontières called for military assistance. In Sierra Leone, the British and Sierra Leonean militaries intervened. They quickly established a National Ebola Response Centre and a constituent network of District Ebola Response Centres. Thereafter, these inherently militarised centres are where almost all Ebola response activities were coordinated. In order to examine perspectives on the nature of the militaries' intervention, 110 semi-structured qualitative interviews were conducted and analysed. Military support to Sierra Leone's Ebola response was felt by most respondents to be a valuable contribution to the overall effort to contain the outbreak, especially in light of the perceived weakness of the Ministry of Health and Sanitation to effectively do so. However, a smaller number of respondents emphasised that the military deployments facilitated various structural harms, including for how the perceived exclusion of public institutions (as above) and other local actors from Ebola response decision making was felt to prevent capacity building, and in turn, to limit resilience to future crises. The concurrent provision of life-saving assistance and rendering of structural harm resulting from the militaries' intervention is ultimately found to be part of a vicious cycle, which this article conceptualises as the 'political economy of expedience', a paradox that should be considered inherent in any militarised intervention during humanitarian and public health crises.
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Affiliation(s)
- Samuel T Boland
- Centre for Universal Health, Chatham House, 10 St James's Square, London, SW1Y 4LE, UK.
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Square, London, WC1H 9SH, UK
| | - Susannah Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Square, London, WC1H 9SH, UK
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Orjiakor CT, Onwujekwe O, McKee M, Hutchison E, Agwu P, Balabanova D. "I can't kill myself": Local narratives and meanings that foster absenteeism in Nigerian primary health centres. J Glob Health 2023; 13:04129. [PMID: 37861129 PMCID: PMC10588289 DOI: 10.7189/jogh.13.04129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
Background Absenteeism in the health sector is increasingly seen as a form of harmful rule-breaking, with health workers receiving a salary although they are not present to provide care. It is a barrier to achieving universal health coverage yet remains widespread in primary health centres (PHCs) in Nigeria and many other low-resource settings. Traditional approaches to combatting absenteeism have relied on anti-corruption measures such as promoting accountability and transparency. However, more needs to be understood about the social and cultural realities, including perceptions and norms enabling or constraining the application of such measures in Nigeria and in similar contexts. Methods We conducted 34 in-depth interviews (IDIs) with frontline health workers and their managers/supervisors and two focus group discussions (FDGs) with service users (n = 22) in Enugu State, South Eastern Nigeria. We discussed their experiences and views about absenteeism, allowing the respondents' framings to emerge. We adopted a mixed approach of narrative analysis and phenomenology to examine respondents' narratives - identifying the concepts and social constructs within the narratives that manifested through the language used. Results Stakeholders acknowledged the problem of absenteeism but had differing perspectives on its dynamics. Health workers distinguished two forms of absenteeism: one as a mundane, everyday response to the poorly funded health system; and the other, brazen and often politically enabled absenteeism, where health workers whom powerful politicians protect are absent without facing consequences. There is a general feeling of powerlessness among both health service providers and service users confronted by politically backed absentees as the power dynamics in the health sector resonate with experiences in other spheres of life in Nigeria. Health workers rationalised mundane, technical absenteeism, adjusted to it and felt it should be accommodated in the health system. Service users are often unsure about who is absent and why, but when they notice absenteeism, they often ascribe it to wider system malpractices that characterise public services. Conclusion Interventions to tackle absenteeism and other forms of health sector corruption should be sensitive to socio-cultural and political contexts that shape everyday lives in specific contexts. Challenging narratives/beliefs that normalise absenteeism should be part of reform plans.
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Affiliation(s)
- Charles T Orjiakor
- Department of Psychology, University of Nigeria, Nsukka, Nigeria
- Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria
- Department of Health Administration and Management, University of Nigeria, Nsukka, Nigeria
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, England, UK
| | - Eleanor Hutchison
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Prince Agwu
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
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Montel L, Coleman MP, Murphy T, Balabanova D, Ciula R, Evans DP, Lougarre C, Verhoeven D, Allemani C. Implementing and monitoring the right to health in breast cancer: selection of indicators using a Delphi process. Int J Equity Health 2023; 22:142. [PMID: 37507731 PMCID: PMC10386607 DOI: 10.1186/s12939-023-01964-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Women with breast cancer have different chances of surviving their disease, depending on where they live. Variations in survival may stem from unequal access to prompt diagnosis, treatment and care. Implementation of the right to health may help remedy such inequalities. The right to health is enshrined in international human rights law, notably Article 12 of the International Covenant on Economic, Social and Cultural Rights. A human rights-based approach to health requires a robust, just and efficient health system, with access to adequate health services and medicines on a non-discriminatory basis. However, it may prove challenging for health policymakers and cancer management specialists to implement and monitor this right in national health systems. METHOD This article presents the results of a Delphi study designed to select indicators of implementation of the right to health to inform breast cancer care and management. In a systematic process, 13 experts examined an initial list of 151 indicators. RESULTS After two rounds, 54 indicators were selected by consensus, three were rejected, three were added, and 97 remained open for debate. For breast cancer, right-to-health features selected as worth implementing and monitoring included the formal recognition of the right to health in breast cancer strategies; a population-based screening programme, prompt diagnosis, strong referral systems and limited waiting times; the provision of palliative, survivorship and end-of-life care; the availability, accessibility, acceptability and quality (AAAQ) of breast cancer services and medicines; the provision of a system of accountability; and the collection of anonymised individual data to target patterns of discrimination. CONCLUSION We propose a set of indicators as a guide for health policy experts seeking to design national cancer plans that are based on a human rights-based approach to health, and for cancer specialists aiming to implement principles of the right to health in their practice. The 54 indicators selected may be used in High-Income Countries, or member states of the OECD who also have signed the International Covenant on Economic, Social and Cultural Rights to monitor progress towards implementation of the right to health for women with breast cancer.
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Affiliation(s)
- Lisa Montel
- London School of Hygiene and Tropical Medicine, Cancer Survival Group, Faculty of Epidemiology and Population Health, Keppel Street, London, WC1E 7HT, UK.
| | - Michel P Coleman
- London School of Hygiene and Tropical Medicine, Cancer Survival Group, Faculty of Epidemiology and Population Health, Keppel Street, London, WC1E 7HT, UK
| | - Therese Murphy
- Queen's University Belfast, Belfast, UK
- Raoul Wallenberg Visiting Chair, Lund University, Lund, Sweden
| | - Dina Balabanova
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, London, UK
| | | | - Dabney P Evans
- Hubert Department of Global Health, Emory University, Atlanta, GA, USA
| | | | | | - Claudia Allemani
- London School of Hygiene and Tropical Medicine, Cancer Survival Group, Faculty of Epidemiology and Population Health, Keppel Street, London, WC1E 7HT, UK
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16
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Binyaruka P, Angell B, McKee M, Andreoni A, Mamdani M, Hutchinson E, Balabanova D. How can we elicit health workers' preferences for measures to reduce informal payments? A mixed methods approach to developing a discrete choice experiment in Tanzania. BMJ Open 2023; 13:e068781. [PMID: 37419635 PMCID: PMC10335481 DOI: 10.1136/bmjopen-2022-068781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 06/02/2023] [Indexed: 07/09/2023] Open
Abstract
OBJECTIVE While discrete choice experiments (DCEs) have been used in other fields as a means of eliciting respondent preferences, these remain relatively new in studying corrupt practices in the health sector. This study documents and discusses the process of developing a DCE to inform policy measures aimed at addressing informal payments for healthcare in Tanzania. DESIGN A mixed methods design was used to systematically develop attributes for the DCE. It involved five stages: a scoping literature review, qualitative interviews, a workshop with health providers and managers, expert review and a pilot study. SETTING Dar es Salaam and Pwani regions in Tanzania. PARTICIPANTS Health workers and health managers. RESULTS A large number of factors were identified as driving informal payments in Tanzania and thus represent potential areas for policy intervention. Through iterative process involving different methods (qualitative and quantitative) and seeking consensus views by diverse actors, we derived six attributes for a DCE: mode of payment, supervision at the facility level, opportunity for private practice, awareness and monitoring, disciplinary measures against informal payments and incentive payment for staff if a facility has less informal payments. 12 choice sets were generated and piloted with 15 health workers from 9 health facilities. The pilot study revealed that respondents could easily understand the attributes and levels, answered all the choice sets and appeared to be trading between the attributes. The results from the pilot study had expected signs for all attributes. CONCLUSIONS We elicited attributes and levels for a DCE to identify the acceptability and preferences of potential policy interventions to address informal payments in Tanzania through a mixed-methods approach. We argue that more attention is needed to the process of defining attributes for the DCE, which needs to be rigorous and transparent in order to derive reliable and policy-relevant findings.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Tanzania
| | - Blake Angell
- University of New South Wales Sydney, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Martin McKee
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Antonio Andreoni
- Department of Economics, SOAS University of London, London, UK
- College of Business and Economics, University of Johannesburg, South African Chair in Industrial Development, Auckland Park, Gauteng, South Africa
| | - Masuma Mamdani
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Ifakara, Tanzania
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Sureshkumar S, Mustapha F, Yusoff H, Mwangi KJ, Marcus K, Kohlbrenner B, Issom D, Benissa MR, Aebischer-Perone S, Braha N, Candela E, Chhabra KG, Desikachari BR, Dondi A, Etchebehere M, Gathecha G, Kengne AP, Missoni E, Palafox B, Pati S, Madhu PP, Peer N, Quint J, Tabrizi R, Oris M, Beran D, Balabanova D, Etter JF. An Online Survey of the Perceptions of Clinical and Non-Clinical Professionals on Healthcare for Non-Communicable Diseases and COVID-19 Measures During the Pandemic in Malaysia. Int J Public Health 2023; 68:1605861. [PMID: 37304500 PMCID: PMC10247991 DOI: 10.3389/ijph.2023.1605861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/15/2023] [Indexed: 06/13/2023] Open
Abstract
Objectives: This study assesses the opinions of health professionals in Malaysia on the disruption of non-communicable disease (NCD) services during the COVID-19 pandemic from March 2020 to January 2022. Methods: We conducted a cross-sectional online survey with 191 non-clinical public health workers and clinical health service workers in Malaysia from November 2021 to January 2022. Participants were recruited by the Malaysian Ministry of Health using major networks including key experts and practitioners. Secondary respondents were subsequently enrolled through snowballing. Results: The most notable issues raised by the survey participants relate to NCD service disruption, the redirection of NCD care resources, and NCD care being overburdened post-pandemic. Respondents also reported accounts of resilience and prompt reaction from the healthcare system, as well as calls for innovation. Conclusion: Most respondents perceived that the challenges arising from COVID-19 were mostly managed well by the healthcare system, which was able to provide the necessary services to NCD patients during this health emergency. However, the study identifies gaps in the health system response and preparedness capacity, and highlights solutions for strengthening NCD services.
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Affiliation(s)
| | - Feisul Mustapha
- Disease Control Division, Ministry of Health (Malaysia), Putrajaya, Malaysia
| | - Haironi Yusoff
- Department of Medicine and Public Health, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Kibachio Joseph Mwangi
- Institute of Global Health, University of Geneva, Geneva, Switzerland
- Department of Non-Communicable Diseases, Ministry of Health (Kenya), Nairobi, Kenya
| | - Kailing Marcus
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | - David Issom
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | | | | | | | - Egidio Candela
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy
| | | | | | - Arianna Dondi
- IRCCS Azienda Ospedaliero, Universitaria di Bologna, Bologna, Italy
| | - Marina Etchebehere
- Faculty of Health Sciences (FICSAE), Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Gladwell Gathecha
- Department of Non-Communicable Diseases, Ministry of Health (Kenya), Nairobi, Kenya
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Benjamin Palafox
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | | | | | - Nasheeta Peer
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Reza Tabrizi
- Noncommunicable Diseases Research Centre, Fasa University of Medical Sciences, Fasa, Iran
| | - Michel Oris
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - David Beran
- University Hospitals of Geneva, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dina Balabanova
- London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
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Sureshkumar S, Mwangi KJ, Gathecha G, Marcus K, Kohlbrenner B, Issom D, Benissa MR, Aebischer-Perone S, Braha N, Candela E, Chhabra KG, Desikachari BR, Dondi A, Etchebehere M, Kengne AP, Missoni E, Mustapha F, Palafox B, Pati S, Madhu PP, Peer N, Quint J, Tabrizi R, Yusoff H, Oris M, Beran DH, Balabanova D, Etter JF. Exploring key-stakeholder perceptions on non-communicable disease care during the COVID-19 pandemic in Kenya. Pan Afr Med J 2023; 44:153. [PMID: 37455892 PMCID: PMC10349631 DOI: 10.11604/pamj.2023.44.153.38616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 03/14/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction over one third of total Disability-Adjusted-Life-Years lost in Kenya are due to non-communicable diseases (NCD). In response, the Government declared significant commitment towards improving NCD care. The COVID-19 pandemic increased the burden on the already overstretched health systems in Kenya. The aims of this study are to assess whether health care providers perceived NCD care to be optimal during the pandemic and explore how to improve responses to future emergencies. Methods this cross-sectional online survey included healthcare personnel with non-clinical roles (public health workers and policy-makers) and those delivering health care (doctors and nurses). Respondents were recruited between May and September 2021 by random sampling, completed by snowball sampling. Results among 236 participants (42% in clinical, 58% in non-clinical roles) there was an overall consensus between respondents on NCD care being disrupted and compromised during the pandemic in Kenya. Detracted supplies, funding, and technical resources affected the continuity of NCDs' response, despite government efforts. Respondents agreed that the enhanced personnel capacity and competencies to manage COVID-19 patients were positive, but noted a lack of guidance for redirecting care for chronic diseases, and advocated for digital innovation as a solution. Conclusion this paper explores the perceptions of key stakeholders involved in the management of NCDs in Kenya to improve planning for future emergency responses. Gaps were identified in health system response and preparedness capacity during the pandemic including the perceived need to strengthen NCD services, with solutions offered to guide resilience efforts to protect the health system from disruption.
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Affiliation(s)
- Sugitha Sureshkumar
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kibachio Joseph Mwangi
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
| | - Gladwell Gathecha
- Department of Non-Communicable Diseases, Ministry of Health, Nairobi, Kenya
| | - Kailing Marcus
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bogomil Kohlbrenner
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - David Issom
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | | | - Nirit Braha
- Royal Free Hospitals, National Health Service, London, United Kingdom
| | - Egidio Candela
- RCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Kumar Gaurav Chhabra
- Department of Public Health Dentistry, Nims Dental College and Hospital, Nims University, Rajasthan, India
| | | | - Arianna Dondi
- RCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marina Etchebehere
- Faculdade Israelita de Ciencias da Saude Albert Einstein, Sao Paulo, Brazil
| | - Andre Pascal Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Eduardo Missoni
- Center for Research on Health and Social Care Management - CERGAS, SDA Bocconi Management School, Milan, Italy
| | - Feisul Mustapha
- Disease Control Division, Ministry of Health, Putrajaya, Malaysia
| | - Benjamin Palafox
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Priyanka Paul Madhu
- Department of Public Health Dentistry, Sharad Pawar Dental College and Hospital, Wardha, India
| | - Nasheeta Peer
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Reza Tabrizi
- Non-Communicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Haironi Yusoff
- Department of Public Health, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Sarawak, Malaysia
| | - Michel Oris
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - David Henry Beran
- Division of Tropical and Humanitarian Medicine, Faculty of Medicine, University of Geneva, Geneva University Hospitals, Geneva, Switzerland
| | - Dina Balabanova
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jean-François Etter
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Hutchinson E, Hansen KS, Sanyu J, Amonya LP, Mundua S, Balabanova D, Clarke SE, Kitutu FE. Is it possible for drug shops to abide by the formal rules? The structural determinants of community medicine sales in Uganda. BMJ Glob Health 2023; 8:bmjgh-2022-011097. [PMID: 36822666 PMCID: PMC9950907 DOI: 10.1136/bmjgh-2022-011097] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/05/2023] [Indexed: 02/25/2023] Open
Abstract
The medicines retail sector is an essential element of many health systems in Africa and Asia, but it is also well known for poor practice. In the literature, it is recognised that improvements in the sector can only be made if more effective forms of governance and regulation can be identified. Recent debate suggests that interventions responsive to structural constraints that shape and underpin poor practice is a useful way forward. This paper presents data from a mixed-methods study conducted to explore regulation and the professional, economic and social constraints that shape rule breaking among drug shops in one district in Uganda. Our findings show that regulatory systems are undermined by frequent informal payments, and that although drug shops are often run by qualified staff, many are unlicensed and sell medicines beyond their legal permits. Most shops have either a small profit or a loss and rely on family and friends for additional resources as they compete in a highly saturated market. We argue that in the current context, drug shop vendors are survivalist entrepreneurs operating in a market in which it is extremely difficult to abide by policy, remain profitable and provide a service to the community. Structural changes in the medicines market, including removing unqualified sellers and making adjustments to policy are likely prerequisite if drug shops are to become places where individuals can earn a living, abide by the rules and facilitate access to medicines for people living in some of the world's poorest countries.
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Affiliation(s)
- Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Jacquellyn Sanyu
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
| | - Lydia Peace Amonya
- Infectious Diseases Research Collaboration, Kampala, Central Region, Uganda
| | - Sunday Mundua
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian E Clarke
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Freddy Eric Kitutu
- Makerere University College of Health Sciences, Kampala, Uganda
- Department of Pharmacy, Makerere University School of Health Sciences, Kampala, Uganda
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Hanson K, Balabanova D, Brikci N, Erlangga D, Powell-Jackson T. Financing primary health care in low- and middle-income countries: A research and policy agenda. J Health Serv Res Policy 2023; 28:1-3. [PMID: 36301630 DOI: 10.1177/13558196221135741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Kara Hanson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK
| | - Nouria Brikci
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK
| | - Darius Erlangga
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, UK
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21
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Odii A, Onwujekwe O, Hutchinson E, Agwu P, Orjiakor CT, Ogbozor P, Roy P, McKee M, Balabanova D. Absenteeism in primary health centres in Nigeria: leveraging power, politics and kinship. BMJ Glob Health 2022; 7:bmjgh-2022-010542. [PMID: 36593645 PMCID: PMC9730370 DOI: 10.1136/bmjgh-2022-010542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Primary health centres (PHCs) in Nigeria suffer critical shortages of health workers, aggravated by chronic absenteeism that has been attributed to insufficient resources to govern the system and adequately meet their welfare needs. However, the political drivers of this phenomenon are rarely considered. We have asked how political power and networks influence absenteeism in the Nigerian health sector, information that can inform the development of holistic solutions. METHODS Data were obtained from in-depth interviews with three health administrators, 30 health workers and 6 health facility committee chairmen in 15 PHCs in Enugu State, Nigeria. Our analysis explored how political configurations and the resulting distribution of power influence absenteeism in Nigeria's health systems. RESULTS We found that health workers leverage social networks with powerful and politically connected individuals to be absent from duty and escape sanctions. This reflects the dominant political settlement. Thus, the formal governance structures that are meant to regulate the operations of the health system are weak, thereby allowing powerful individuals to exert influence using informal means. As a result, health managers do not confront absentees who have a relationship with political actors for fear of repercussions, including retaliation through informal pressure. In addition, we found that while health system structures cannot effectively handle widespread absenteeism, networks of local actors, when interested and involved, could address absenteeism by enabling health managers to call politically connected staff to order. CONCLUSION The formal governance mechanisms to reduce absenteeism are insufficient, and building alliances (often informal) with local elites interested in improving service delivery locally may help to reduce interference by other powerful actors.
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Affiliation(s)
- Aloysius Odii
- Sociology/Anthropology, University of Nigeria, Nsukka, Nigeria
| | - Obinna Onwujekwe
- Health Administration & Management and Pharmacology and Therapeutics, University of Nigeria - Enugu Campus, Enugu, Nigeria
| | - Eleanor Hutchinson
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Prince Agwu
- Social Work, University of Nigeria, Nsukka, Nigeria
| | | | - Pamela Ogbozor
- Psychology, Enugu State University of Science and Technology, Enugu, Nigeria
| | - Pallavi Roy
- Centre for International Studies and Diplomacy, SOAS, London, UK
| | - Martin McKee
- Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Dina Balabanova
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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22
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Binyaruka P, Andreoni A, Balabanova D, McKee M, Hutchinson E, Angell B. Re-aligning Incentives to Address Informal Payments in Tanzania Public Health Facilities: A Discrete Choice Experiment. Int J Health Policy Manag 2022; 12:6877. [PMID: 37579473 PMCID: PMC10125169 DOI: 10.34172/ijhpm.2022.6877] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 10/24/2022] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Informal payments for healthcare are typically regressive and limit access to quality healthcare while increasing risk of catastrophic health expenditure, especially in developing countries. Different responses have been proposed, but little is known about how they influence the incentives driving this behaviour. We therefore identified providers' preferences for policy interventions to overcome informal payments in Tanzania. METHODS We undertook a discrete choice experiment (DCE) to elicit preferences over various policy options with 432 health providers in 42 public health facilities in Pwani and Dar es Salaam region. DCE attributes were derived from a multi-stage process including a literature review, qualitative interviews with key informants, a workshop with health stakeholders, expert opinions, and a pilot test. Each respondent received 12 unlabelled choice sets describing two hypothetical job-settings that varied across 6-attributes: mode of payment, supervision at facility, opportunity for private practice, awareness and monitoring, measures against informal payments, and incentive payments to encourage noninfraction. Mixed multinomial logit (MMNL) models were used for estimation. RESULTS All attributes, apart from supervision at facility, significantly influenced providers' choices (P<.001). Health providers strongly and significantly preferred incentive payments for non-infraction and opportunities for private practice, but significantly disliked disciplinary measures at district level. Preferences varied across the sample, although all groups significantly preferred the opportunity to practice privately and cashless payment. Disciplinary measures at district level were significantly disliked by unit in-charges, those who never engaged in informal payments, and who were not absent from work for official trip. 10% salary top-up were preferred incentive by all, except those who engaged in informal payments and absent from work for official trip. CONCLUSION Better working conditions, with improved earnings and career paths, were strongly preferred by all, different respondents groups had distinct preferences according to their characteristics, suggesting the need for adoption of tailored packages of interventions.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Antonio Andreoni
- Department of Economics, SOAS University of London, London, UK
- South African Research Chair in Industrial Development, University of Johannesburg, Johannesburg, South Africa
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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23
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Seguin M, Mendoza J, Lasco G, Palileo-Villanueva LM, Palafox B, Renedo A, McKee M, Balabanova D. Strong structuration analysis of patterns of adherence to hypertension medication. SSM Qual Res Health 2022; 2:None. [PMID: 36531298 PMCID: PMC9748305 DOI: 10.1016/j.ssmqr.2022.100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/29/2022] [Accepted: 05/12/2022] [Indexed: 10/18/2022]
Abstract
Achieving blood pressure control is among the highest priorities for reducing the burden of cardiovascular diseases globally. Control is poor in the Philippines, especially in socioeconomically marginalised communities. This paper explores long-term adherence to anti-hypertensive medication in these communities, identifying 4 distinct medication adherence patterns. We draw on Strong Structuration Theory to explore motivations of action for those who are consistently adherent, consistently non-adherent, and those who became more or less adherent over time. We employ longitudinal qualitative methods comprising repeat interviews and digital diaries collected over 12 months by 34 participants. Twelve participants were consistently adherent, 9 consistently non-adherent, 9 increasingly adherent, and 4 increasingly non-adherent. For the consistently adherent, positive views about prescribed medication and family support encouraged adherence. Conversely, negative views of medication and lack of family support were notable amongst the consistently non-adherent, along with resistance to accepting a 'sick' label. A shift toward positive views of medication was detected amongst those whose adherence improved, along with worsening health and increased family support. A decrease in financial resources drove some participants to become less adherent, especially if they already held negative views toward medication. This study sheds light on the variety of medication adherence patterns among poor people with hypertension in the Philippines, as well as the complex web of elements influencing their treatment choices. The results point to the potential for measures that address concerns about medicines and increase family support.
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Affiliation(s)
- Maureen Seguin
- The Centre for Global Chronic Conditions, The London School of Hygiene and Tropical Medicine, UK
| | - Jhaki Mendoza
- College of Medicine, University of the Philippines Manila, Philippines
| | - Gideon Lasco
- Development Studies Program, Ateneo de Manila University, Philippines.,Department of Anthropology, University of the Philippines Diliman, Philippines
| | | | - Benjamin Palafox
- The Centre for Global Chronic Conditions, The London School of Hygiene and Tropical Medicine, UK
| | - Alicia Renedo
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, UK
| | - Martin McKee
- The Centre for Global Chronic Conditions, The London School of Hygiene and Tropical Medicine, UK
| | - Dina Balabanova
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, UK
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24
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Thompson N, McKee M, Balabanova D. The PPE procurement scandal-who pays and who profits? BMJ 2022; 379:o2495. [PMID: 36257678 DOI: 10.1136/bmj.o2495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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25
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Palileo-Villanueva LM, Palafox B, Amit AML, Pepito VCF, Ab-Majid F, Ariffin F, Balabanova D, Isa MR, Mat-Nasir N, My M, Renedo A, Seguin ML, Yusoff K, Dans AL, Mckee M. Prevalence, determinants and outcomes of traditional, complementary and alternative medicine use for hypertension among low-income households in Malaysia and the Philippines. BMC Complement Med Ther 2022; 22:252. [PMID: 36180884 PMCID: PMC9526286 DOI: 10.1186/s12906-022-03730-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 09/19/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Traditional, complementary and alternative medicine (TCAM) is used to treat a broad range of conditions. In low- and middle-income countries (LMICs), TCAM use is particularly common among those with low socio-economic status. To better understand the patterns and impact of TCAM use on the management of non-communicable diseases in these populations, this study examines the prevalence and characteristics of TCAM use for hypertension, its determinants, and its association with hypertension management outcomes and wellbeing among low-income adults in two Southeast Asian countries at different levels of economic and health system development, Malaysia and the Philippines. METHODS We analysed cross-sectional data from 946 randomly selected adults diagnosed with hypertension from low-income rural and urban communities in Malaysia (n = 495) and the Philippines (n = 451). We compared the prevalence, characteristics and household expenditure on TCAM use between countries and used multi-level, mixed-effects regression to estimate associations between TCAM use and its determinants, and five hypertension management outcomes and wellbeing. RESULTS The prevalence of TCAM use to manage hypertension was higher in the Philippines than in Malaysia (18.8% vs 8.8%, p < 0.001). Biologically-based modalities, e.g. herbal remedies, were the most common type of TCAM used in both countries, mainly as a complement, rather than an alternative to conventional treatment. Households allocated around 10% of health spending to TCAM in both countries. Belief that TCAM is effective for hypertension was a positive predictor of TCAM use, while belief in conventional medicine was a negative predictor. TCAM use was not strongly associated with current use of medications for hypertension, self-reported medication adherence, blood pressure level and control, or wellbeing in either country. CONCLUSIONS A small, but significant, proportion of individuals living in low-income communities in Malaysia and the Philippines use TCAM to manage their hypertension, despite a general lack of evidence on efficacy and safety of commonly used TCAM modalities. Recognising that their patients may be using TCAM to manage hypertension will enable health care providers to deliver safer, more patient-centred care.
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Affiliation(s)
| | - Benjamin Palafox
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Centre for Global Chronic Conditions, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Arianna Maever L Amit
- College of Medicine, University of the Philippines Manila, Manila, Philippines.,School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
| | - Veincent Christian F Pepito
- College of Medicine, University of the Philippines Manila, Manila, Philippines.,School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
| | - Fadhlina Ab-Majid
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Farnaza Ariffin
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Dina Balabanova
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Centre for Global Chronic Conditions, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Mohamad-Rodi Isa
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Nafiza Mat-Nasir
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Mazapuspavina My
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
| | - Alicia Renedo
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Centre for Global Chronic Conditions, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Maureen L Seguin
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Centre for Global Chronic Conditions, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Khalid Yusoff
- Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia.,Faculty of Medicine and Health Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Antonio L Dans
- College of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Martin Mckee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Centre for Global Chronic Conditions, 15-17 Tavistock Place, London, WC1H 9SH, UK
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26
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Campbell F, Sein TT, Htoo TS, Khine WYK, Howard N, Balabanova D. Policy space and pro-health equity national policymaking: a case study of Myanmar during political transition (2006-16). Health Policy Plan 2022; 38:170-180. [PMID: 36083012 PMCID: PMC9494378 DOI: 10.1093/heapol/czac076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/17/2022] [Accepted: 10/04/2022] [Indexed: 11/14/2022] Open
Abstract
Health equity is central to achieving sustainable development goals and COVID-19 has emphasized its importance. Ensuring health equity is prominent in policy discussions and decision-making is a critical challenge in all countries. Understanding the policy space for actors to promote health equity in the policy process may help to strengthen prioritization of equity in policy and programme discussions and decisions. Authors developed a conceptual framework for policy space based on a narrative literature review. This comprised five key elements and their associated factors, i.e. context, policy circumstances, policy characteristics, actor engagement and policy spaces. Authors then applied it in Myanmar during a period of political transition, using a qualitative case study design. Findings showed that political transition provided an important 'policy window' to develop more equitable health policy in Myanmar. Changing policy circumstances offered opportunities for advancing pro-equity policy. However, lack of visibility of health equity and long-standing inequalities were important challenges to policy space. Within a changing context, actors at individual and organizational levels used a range of policy spaces to advance pro-equity health policy. Learning from using the framework in Myanmar was incorporated into a revised framework. Application of this revised framework could provide valuable insights into the opportunities to promote a pro-health equity approach across policy and programme discussions and decision-making for actors trying to promote equity in other transition and non-transition contexts.
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Affiliation(s)
- Fiona Campbell
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
| | - Than Tun Sein
- Department of Medical Research, Formerly Ministry of Health, No. 5 Ziwaka Road, Yangon 11191, Myanmar
| | - Thant Sin Htoo
- Ministry of Health and Sports, Minister’s Office, No. 249 Theinbyu Road, Mingalar Taung Nyunt Township, Yangon, Myanmar
| | | | - Natasha Howard
- *Corresponding author. Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549, Singapore. E-mail:
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, United Kingdom
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27
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Hanson K, Balabanova D, Powell-Jackson T, Brikci N, Erlangga D. Primary health care is not just a service delivery platform – Authors' reply. The Lancet Global Health 2022; 10:e1094. [DOI: 10.1016/s2214-109x(22)00282-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 10/17/2022] Open
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Ogbozor P, Onwujekwe O, Balabanova D, Odii A, Agwu P, McKee M, Obi U, Orjiakor CT, Hutchinson E. The Gendered Drivers of Absenteeism in the Nigerian Health System. Health Policy Plan 2022; 37:1267-1277. [PMID: 35801868 DOI: 10.1093/heapol/czac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/03/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
The ability to deliver primary care in Nigeria is undermined by chronic absenteeism but an understanding of its drivers is needed if effective responses are to be developed. While there is a small but growing body of relevant research, the gendered dynamics of absenteeism remain largely unexplored. We apply a gendered perspective to understanding absenteeism and propose targeted strategies that appear likely to reduce it. We did so by means of a qualitative study that was part of a larger project examining corruption within the health system in six primary healthcare facilities across rural and urban regions in Enugu State, south-east Nigeria. We conducted thirty in-depth interviews with frontline health workers, healthcare managers, and community members of the health facility committee. Six Focus Group Discussions were held with male and female service users. Data were analysed using thematic analysis. Participants described markedly gendered differences in the factors contributing to health worker absenteeism that were related to gender norms. Absence by female health workers was attributed to domestic and caregiving responsibilities, including housekeeping, childcare, cooking, washing, and non-commercial farming used to support their families. Male health workers were most often absent to fulfil expectations related to their role as breadwinners, with dual practice and work in other sectors to generate additional income generation as their formal salaries were considered irregular and poor. Demands arising from sociocultural and religious events affected the attendance of both male and female health workers. Both men and women were subject to sanctions, but managers and facility chairs were more lenient with women when absence was due to caregiving and other domestic responsibilities. In summary, gender roles influence absenteeism amongst primary healthcare workers in Nigeria and thus should be taken into account in developing nuanced responses that take account of the social, economic, and cultural factors that underpin these roles.
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Affiliation(s)
- Pamela Ogbozor
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.,Department of Psychology, Enugu State University of Science and Technology, Enugu, Nigeria
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.,Department of Health Administration and Management, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | | | - Aloysius Odii
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.,Department of Sociology and Anthropology, University of Nigeria, Nsukka, Nigeria
| | - Prince Agwu
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.,Department of Social Work, University of Nigeria, Nsukka, Nigeria
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
| | - Uche Obi
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.,Department of Community Medicine, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Charles Tochukwu Orjiakor
- Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria.,Department of Psychology, University of Nigeria, Nsukka, Nigeria
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Schleiff MJ, Rangnekar A, Oviedo Gomez F, Teddy G, Peters DH, Balabanova D. Towards Core Competencies for Health Policy and Systems Research (HPSR) Training: Results From a Global Mapping and Consensus-Building Process. Int J Health Policy Manag 2022; 11:1058-1068. [PMID: 33590742 PMCID: PMC9808165 DOI: 10.34172/ijhpm.2020.258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/14/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND As the field of health policy and systems research (HPSR) continues to grow, there is a recognition of the need for training in HPSR. This aspiration has translated into a multitude of teaching programmes of variable scope and quality, reflecting a lack of consensus on the skills and practices required for rigorous HPSR. The purpose of this paper is to identify an agreed set of core competencies for HPSR researchers, building on the previous work by the Health Systems Global (HSG) Thematic Working Group on Teaching & Learning. METHODS Our methods involved an iterative approach of four phases including a literature review, key informant interviews and group discussions with HPSR educators, and webinars with pre-post surveys capturing views among the global HPSR community. The phased discussions and consensus-building contributed to the evolution of the HPSR competency domains and competencies framework. RESULTS Emerging domains included understanding health systems complexity, assessing policies and programs, appraising data and evidence, ethical reasoning and practice, leading and mentoring, building partnerships, and translating and utilizing knowledge and HPSR evidence. The development of competencies and their application were often seen as a continuous process spanning evidence generation, partnering, communicating and helping to identify new critical health systems questions. CONCLUSION The HPSR competency set can be seen as a useful reference point in the teaching and practice of high-quality HPSR and can be adapted based on national priorities, the particularities of local contexts, and the needs of stakeholders (HPSR researchers and educators), as well as practitioners and policy-makers. Further research is needed in using the core competency set to design national training programmes, develop locally relevant benchmarks and assessment methods, and evaluate their use in different settings.
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Affiliation(s)
- Meike J. Schleiff
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Francisco Oviedo Gomez
- Ministry of Health, San José, Costa Rica
- School of Public Health, University of Costa Rica, San José, Costa Rica
| | - Gina Teddy
- Center for Health Systems and Policy Research at GIMPA, Accra, Ghana
| | - David H. Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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30
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Lasco G, Renedo A, Mendoza J, Seguin ML, Palafox B, Palileo‐Villanueva LM, Balabanova D, McKee M. 'Doing' hypertension: Experiential knowledge and practice in the self-management of 'high blood' in the Philippines. Sociol Health Illn 2022; 44:1167-1181. [PMID: 35929521 PMCID: PMC9540552 DOI: 10.1111/1467-9566.13503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 05/15/2022] [Indexed: 05/15/2023]
Abstract
Patients' embodied experiences do not always correspond to the biomedical concepts of particular diseases. Drawing from year-long fieldwork in the Philippines that involved semi-structured interviews, focus group discussions and digital diaries, we examine how individuals 'do' hypertension through their embodied experiences and the knowledge and practice that emerge from them. Drawing inspiration from Annemarie Mol's work on the notion of 'multiplicity' of disease, our analysis was informed by a commitment to privileging patients' embodied experiences and the multiple ontologies of hypertension. We find that for patients diagnosed with hypertension in the Philippines, symptoms enact illness; patients rely on their own embodied knowledge to define their illness' nature (e.g., diagnosis), experience (e.g., frequency of symptoms and non-chronicity) and praxis (e.g., self-care practices). We show how this knowledge gained from having embodied experiences of living with the disease interacts in various ways with biomedical knowledge, other diagnostic labels and clinical practices, to shape how hypertension manifests and is managed by patients. Beyond interrogating the relationship between what counts as a 'disease' and what is considered a 'symptom', our findings underscore the need to pay attention instead to the mutually co-constitutive processes of embodied experiences and disease categories in co-producing patient knowledge.
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Affiliation(s)
- Gideon Lasco
- Department of AnthropologyUniversity of the Philippines DilimanQuezon CityPhilippines
- Development Studies ProgramAteneo de Manila UniversityQuezon CityPhilippines
| | - Alicia Renedo
- Department of Global Health & DevelopmentLondon School of Hygiene and Tropical MedicineLondonUK
| | - Jhaki Mendoza
- College of MedicineUniversity of the Philippines ManilaManilaPhilippines
| | - Maureen L. Seguin
- Centre for Global Chronic ConditionsLondon School of Hygiene and Tropical MedicineLondonUK
| | - Benjamin Palafox
- Centre for Global Chronic ConditionsLondon School of Hygiene and Tropical MedicineLondonUK
| | | | - Dina Balabanova
- Department of Social and Environmental Health ResearchLondon School of Hygiene and Tropical MedicineLondonUK
| | - Martin McKee
- Centre for Global Chronic ConditionsLondon School of Hygiene and Tropical MedicineLondonUK
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31
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Hanson K, Brikci N, Erlangga D, Alebachew A, De Allegri M, Balabanova D, Blecher M, Cashin C, Esperato A, Hipgrave D, Kalisa I, Kurowski C, Meng Q, Morgan D, Mtei G, Nolte E, Onoka C, Powell-Jackson T, Roland M, Sadanandan R, Stenberg K, Vega Morales J, Wang H, Wurie H. The Lancet Global Health Commission on financing primary health care: putting people at the centre. Lancet Glob Health 2022; 10:e715-e772. [PMID: 35390342 PMCID: PMC9005653 DOI: 10.1016/s2214-109x(22)00005-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Kara Hanson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK.
| | - Nouria Brikci
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Darius Erlangga
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Abebe Alebachew
- Breakthrough International Consultancy, Addis Ababa, Ethiopia
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Ina Kalisa
- World Health Organization, Kigali, Rwanda
| | | | - Qingyue Meng
- China Center for Health Development Studies, Peking University, Beijing, China
| | - David Morgan
- Health Division, The Organisation for Economic Co-operation and Development, Paris, France
| | | | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Chima Onoka
- Department of Community Medicine, University of Nigeria, Enugu, Nigeria
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, UK
| | | | | | | | - Hong Wang
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Haja Wurie
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
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32
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Lotfizadeh A, Palafox B, Takallou A, Balabanova D, McKee M, Murphy A. Factors associated with the availability and affordability of essential cardiovascular disease medicines in low- and middle-income countries: A systematic review. PLOS Glob Public Health 2022; 2:e0000072. [PMID: 36962256 PMCID: PMC10021589 DOI: 10.1371/journal.pgph.0000072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/24/2021] [Indexed: 11/19/2022]
Abstract
Despite their potential to prevent or delay the onset and progression of cardiovascular disease (CVD), medicines for CVD remain unavailable and unaffordable to many in low- and middle-income countries (LMICs). We systematically reviewed the literature to identify factors associated with availability and affordability of CVD medicines in LMICs. A protocol for this study was registered on the PROSPERO register of systematic reviews (CRD42019135393). We searched Medline, EMBASE, Global Health, Cumulative Index to Nursing and Allied Health Literature, EconLit, Social Policy and Practice, and Africa Wide Information for studies analyzing factors associated with the presence of medicines (availability) or the price of these medicines as it relates to ability to pay (affordability) in LMICs. We performed a narrative synthesis of the results using an access to medicines framework that examines influences at different levels of the health system. We did not conduct a meta-analysis because of the differences in analytic approaches and outcome measures in different studies. The search was conducted in accordance with PRISMA guidelines. Of 43 studies meeting inclusion criteria, 41 were cross-sectional. Availability and affordability were defined and measured in different ways. A range of factors such as sociodemographic characteristics, facility tier, presence of medicines on national essential medicine lists, and international subsidy programs were examined. The studies had variable quality and findings were often inconsistent. We find gaps in the literature on factors associated with availability and affordability of CVD medicines, particularly at the health program level. We conclude that there is a need for experimental and quasi-experimental studies that could identify causal factors and effective responses. Such studies would help further our understanding of how complex multifactorial influences impact these outcomes, which could inform policy decisions. Along with this, greater standardization of definitions and measurement approaches of availability and affordability are needed to allow for more effective comparisons.
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Affiliation(s)
- Ali Lotfizadeh
- PASHA, Los Angeles, California, United States of America
- Department of Health Services Research and Policy, Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Benjamin Palafox
- Department of Health Services Research and Policy, Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Armin Takallou
- School of Medicine, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Dina Balabanova
- Department of Global Health and Development, Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Martin McKee
- Department of Health Services Research and Policy, Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Adrianna Murphy
- Department of Health Services Research and Policy, Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, United Kingdom
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33
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Liverani M, Por I, Perel P, Khan M, Balabanova D, Wiseman V. Assessing the Potential of Wearable Health Monitors for Health System Strengthening in Low- and Middle-Income Countries: A Prospective Study of Technology Adoption in Cambodia. Health Policy Plan 2022; 37:943-951. [PMID: 35262172 PMCID: PMC9469886 DOI: 10.1093/heapol/czac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/24/2022] [Accepted: 02/26/2022] [Indexed: 11/15/2022] Open
Abstract
Wearable health monitors are a rapidly evolving technology that may offer new opportunities for strengthening health system responses to cardiovascular and other non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). In light of this, we explored opportunities for, and potential challenges to, technology adoption in Cambodia, considering the complexity of contextual factors that may influence product uptake and sustainable health system integration. Data collection for this study involved in-depth interviews with national and international stakeholders and a literature review. The analytical approach was guided by concepts and categories derived from the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework—an evidence-based framework that was developed for studying health technology adoption and the challenges to scale-up, spread and sustainability of such technologies in health service organizations. Three potential applications of health wearables for the prevention and control of NCDs in Cambodia were identified: health promotion, follow-up and monitoring of patients and surveys of NCD risk factors. However, several challenges to technology adoption emerged across the research domains, associated with the intended adopters, the organization of the national health system, the wider infrastructure, the regulatory environment and the technology itself. Our findings indicate that, currently, wearables could be best used to conduct surveys of NCD risk factors in Cambodia and in other LMICs with similar health system profiles. In the future, a more integrated use of wearables to strengthen monitoring and management of patients could be envisaged, although this would require careful consideration of feasibility and organizational issues.
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Affiliation(s)
- Marco Liverani
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.,Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Ir Por
- The National Institute of Public Health, Phnom Penh, Cambodia
| | - Pablo Perel
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mishal Khan
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom.,The Kirby Institute, University of New South Wales, Sydney, Australia
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34
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Mendoza JA, Lasco G, Renedo A, Palileo-Villanueva L, Seguin M, Palafox B, Amit AML, Pepito V, McKee M, Balabanova D. (De)constructing 'therapeutic itineraries' of hypertension care: A qualitative study in the Philippines. Soc Sci Med 2021; 300:114570. [PMID: 34802782 PMCID: PMC7613024 DOI: 10.1016/j.socscimed.2021.114570] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 10/11/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
Hypertension, a major risk factor for non-communicable diseases, remains poorly controlled in many countries. In the Philippines, it is still one of the leading causes of preventable deaths despite the accessibility and availability of essential technologies and medicine to detect and treat hypertension. This paper characterizes the ‘therapeutic itineraries’ of people with hypertension from poor communities in rural and urban settings in the Philippines. We employ longitudinal qualitative methodology comprised of repeat interviews and digital diaries using mobile phones from 40 recruited participants in 12 months. Our findings demonstrate that therapeutic itineraries, rather than being organized according to categories that stem from the structure of the health system (i.e., diagnosis, treatment, follow-up, adherence), diverge from clinical pathways. Therapeutic itineraries begin at a stage we label as ‘pre-diagnosis’ (PD). Following this, itineraries diverge according to two possible entry points into the healthcare system: via incidental diagnosis (ID) whereby participants were diagnosed with hypertension without deliberately seeking care for hypertension-related symptoms and symptom-driven diagnosis (SD) whereby their diagnosis was obtained during a clinical encounter specifically prompted by hypertension-related symptoms. Participants whose itineraries follow the SD route typically oscillated between periods of regular and intermittent medical treatment, while participants who were diagnosed incidentally (ID) typically opted for self-care As we follow our participants’ therapeutic itineraries, we explore the confluence of factors informing their care journey, namely, their conceptions of hypertension, their social relationships, as well the choices and trade-offs they make. We conclude with policy implications from our findings, chief of which is our proposition that models of care based on mere access and availability of clinical interventions fail to reflect the complexity of people’s lay understanding and their lived experiences of hypertension and are thus ultimately unhelpful in improving its control.
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Affiliation(s)
- Jhaki A Mendoza
- College of Medicine, University of the Philippines Manila, Manila, 1000, Philippines.
| | - Gideon Lasco
- Department of Anthropology, University of the Philippines Diliman, Quezon City, 1111, Philippines
| | - Alicia Renedo
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | | | - Maureen Seguin
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Benjamin Palafox
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Arianna Maever L Amit
- College of Medicine, University of the Philippines Manila, Manila, Philippines; School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
| | - Veincent Pepito
- School of Medicine and Public Health, Ateneo de Manila University, Pasig City, Philippines
| | - Martin McKee
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Dina Balabanova
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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35
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Kabia E, Goodman C, Balabanova D, Muraya K, Molyneux S, Barasa E. The hidden financial burden of healthcare: a systematic literature review of informal payments in Sub-Saharan Africa. Wellcome Open Res 2021; 6:297. [PMID: 36199622 PMCID: PMC9513412 DOI: 10.12688/wellcomeopenres.17228.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Informal payments limit equitable access to healthcare. Despite being a common phenomenon, there is a need for an in-depth analysis of informal charging practices in the Sub-Saharan Africa (SSA) context. We conducted a systematic literature review to synthesize existing evidence on the prevalence, characteristics, associated factors, and impact of informal payments in SSA. Methods: We searched for literature on PubMed, African Index Medicus, Directory of Open Access Journals, and Google Scholar databases
and relevant organizational websites. We included empirical studies on informal payments conducted in SSA regardless of the study design and year of publication and excluded reviews, editorials, and conference presentations. Framework analysis was conducted, and the review findings were synthesized. Results: A total of 1700 articles were retrieved, of which 23 were included in the review. Several studies ranging from large-scale nationally representative surveys to in-depth qualitative studies have shown that informal payments are prevalent in SSA regardless of the health service, facility level, and sector. Informal payments were initiated mostly by health workers compared to patients and they were largely made in cash rather than in kind. Patients made informal payments to access services, skip queues, receive higher quality of care, and express gratitude.
The poor and people who were unaware of service charges, were more likely to pay informally. Supply-side factors associated with informal payments included low and irregular health worker salaries, weak accountability mechanisms, and perceptions of widespread corruption in the public sector. Informal payments limited access especially among the poor and the inability to pay was associated with delayed or forgone care and provision of lower-quality care. Conclusions: Addressing informal payments in SSA requires a multifaceted approach. Potential strategies include enhancing patient awareness of service fees, revisiting health worker incentives, strengthening accountability mechanisms, and increasing government spending on health.
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Affiliation(s)
- Evelyn Kabia
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Kui Muraya
- Health Systems & Research Ethics Department, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Sassy Molyneux
- Health Systems & Research Ethics Department, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
- Center for Tropical Medicine and Global Health,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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36
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Obodoechi DN, Onwujekwe O, McKee M, Angell B, Agwu P, Orjiakor C, Nwokolo C, Odii A, Hutchinson E, Balabanova D. Health Worker Absenteeism in Selected Health Facilities in Enugu State: Do Internal and External Supervision Matter? Front Public Health 2021; 9:752932. [PMID: 34708020 PMCID: PMC8542720 DOI: 10.3389/fpubh.2021.752932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Absenteeism is widespread in Nigerian health facilities and is a major barrier to achievement of effective Universal Health Coverage. We have examined the role of internal (by managerial staff within facilities) and external (by managers at a higher level) supervision arrangements on health worker absenteeism. Specifically, we sought to determine whether these forms of supervision have any role to play in reducing health worker absenteeism in health facilities in Enugu State Nigeria. Methods: We conducted interviews with 412 health workers in urban and rural areas of Enugu State, in South-Eastern Nigeria. We used binary logistic regression to estimate the role of different types of supervision on health worker absenteeism in selected health facilities in Enugu State. Results: Internal supervision arrangements significantly reduce health worker absenteeism (odds ratio = 0.516, p = 0.03). In contrast, existing external supervision arrangements were associated with a small but significant increase in absenteeism (OR = 1.02, 0.043). Those reporting a better financial situation were more likely to report being absent (OR = 1.36, p < 0.01) but there was no association with age and marital status of respondents. Our findings also pointed to the potential for alternative forms of supervision, provided in a supportive rather than punitive way, for example by community groups monitoring the activities of health workers but trying to understand what support these workers may need, within or beyond the work environment. Conclusion: The existing system of external supervision of absenteeism in health facilities in Nigeria is not working but alternatives that take a more holistic approach to the lived experiences of health workers might offer an alternative.
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Affiliation(s)
- Divine Ndubuisi Obodoechi
- Department of Economics, University of Nigeria, Nsukka, Nigeria.,Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Obinna Onwujekwe
- Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria.,Department of Health Admin and Management, University of Nigeria, Nsukka, Nigeria
| | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales (UNSW) Sydney, Sydney, NSW, Australia
| | - Prince Agwu
- Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria.,Department of Social Work, University of Nigeria, Nsukka, Nigeria.,School of Education and Social Work, University of Dundee, Dundee, United Kingdom
| | - Charles Orjiakor
- Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria.,Department of Psychology, University of Nigeria, Nsukka, Nigeria
| | - Chukwudi Nwokolo
- Department of Economics, University of Nigeria, Nsukka, Nigeria.,Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria
| | - Aloysius Odii
- Health Policy Research Group, College of Medicine, University of Nigeria, Nsukka, Nigeria.,Department of Sociology and Anthropology, University of Nigeria, Nsukka, Nigeria
| | | | - Dina Balabanova
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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37
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Rajan S, Santoso C, Abba-Aji M, Stuckler D, McKee M, Hutchinson E, Onwujekwe O, Balabanova D. Gender Differences in Informal Payments for Healthcare: Evidence from 36 African Countries. Health Policy Plan 2021; 37:132-139. [PMID: 34662388 DOI: 10.1093/heapol/czab123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 09/29/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Informal payments are widespread in many healthcare systems and can impede access to healthcare and thwart progress to achieving Universal Health Coverage, a major element of the health-related Sustainable Development Goals. Gender may be an important driver in determining who pays informally for care, but few studies have examined this, particularly in low- and middle-income countries. Our study aimed to examine gender disparities in paying informally for healthcare in Africa. We used Afrobarometer Round 7 survey data collected between September 2016 and August 2018 from 34 African countries. The final sample was 44 715 adults. We used multiple logistic regression to evaluate associations between gender and paying informally to obtain healthcare. Our results show that 12% of women and 14% of men reported paying informally for healthcare. Men were more likely to pay informally for healthcare than women in African countries (OR 1.22 [95% CI 1.13-1.31]), irrespective of age, residential location, educational attainment, employment status, occupation, and indicators of poverty. To make meaningful progress towards improving Universal Healthcare Coverage in African countries, we must improve our understanding of the gendered aspects of informal payments in healthcare, which can act as both a barrier to accessing care and a determinant of poor health.
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Affiliation(s)
- Selina Rajan
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Cornelia Santoso
- Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | | | | | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Eleanor Hutchinson
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, Health Policy Research Group, University of Nigeria Nsukka (Enugu campus), Enugu, Nigeria
| | - Dina Balabanova
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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38
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Jeemon P, Séverin T, Amodeo C, Balabanova D, Campbell NRC, Gaita D, Kario K, Khan T, Melifonwu R, Moran A, Ogola E, Ordunez P, Perel P, Piñeiro D, Pinto FJ, Schutte AE, Wyss FS, Yan LL, Poulter NR, Prabhakaran D. World Heart Federation Roadmap for Hypertension - A 2021 Update. Glob Heart 2021; 16:63. [PMID: 34692387 PMCID: PMC8447967 DOI: 10.5334/gh.1066] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 12/20/2022] Open
Abstract
The World Heart Federation (WHF) Roadmap series covers a large range of cardiovascular conditions. These Roadmaps identify potential roadblocks and their solutions to improve the prevention, detection and management of cardiovascular diseases and provide a generic global framework available for local adaptation. A first Roadmap on raised blood pressure was published in 2015. Since then, advances in hypertension have included the publication of new clinical guidelines (AHA/ACC; ESC; ESH/ISH); the launch of the WHO Global HEARTS Initiative in 2016 and the associated Resolve to Save Lives (RTSL) initiative in 2017; the inclusion of single-pill combinations on the WHO Essential Medicines' list as well as various advances in technology, in particular telemedicine and mobile health. Given the substantial benefit accrued from effective interventions in the management of hypertension and their potential for scalability in low and middle-income countries (LMICs), the WHF has now revisited and updated the 'Roadmap for raised BP' as 'Roadmap for hypertension' by incorporating new developments in science and policy. Even though cost-effective lifestyle and medical interventions to prevent and manage hypertension exist, uptake is still low, particularly in resource-poor areas. This Roadmap examined the roadblocks pertaining to both the demand side (demographic and socio-economic factors, knowledge and beliefs, social relations, norms, and traditions) and the supply side (health systems resources and processes) along the patient pathway to propose a range of possible solutions to overcoming them. Those include the development of population-wide prevention and control programmes; the implementation of opportunistic screening and of out-of-office blood pressure measurements; the strengthening of primary care and a greater focus on task sharing and team-based care; the delivery of people-centred care and stronger patient and carer education; and the facilitation of adherence to treatment. All of the above are dependent upon the availability and effective distribution of good quality, evidence-based, inexpensive BP-lowering agents.
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Affiliation(s)
- Panniyammakal Jeemon
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandum, IN
| | | | - Celso Amodeo
- Universidade Federal de São Paulo (UNIFESP), São Paulo, BR
| | | | | | - Dan Gaita
- Universitatea de Medicina si Farmacie Victor Babes, Timisoara, RO
| | - Kazuomi Kario
- Jichi Medical University School of Medicine, Shimotsuke, Tochigi, JP
| | | | | | - Andrew Moran
- Columbia University and Resolve to Save Lives, New York, US
| | | | - Pedro Ordunez
- Pan American Health Organization, Washington, DC, US
| | - Pablo Perel
- London School of Hygiene & Tropical Medicine and World Heart Federation, Geneva, GB
| | | | - Fausto J. Pinto
- Santa Maria University Hospital (CHULN), CAML, CCUL, Lisboa, PT
| | - Aletta E. Schutte
- University of New South Wales; The George Institute for Global Health, Sydney, AU
| | - Fernando Stuardo Wyss
- Cardiovascular Technology and Services of Guatemala – CARDIOSOLUTIONS, Guatemala, GT
| | | | | | - Dorairaj Prabhakaran
- London School of Hygiene & Tropical Medicine, London, GB
- Public Health Foundation of India, Gurugram, IN
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39
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Binyaruka P, Balabanova D, McKee M, Hutchinson E, Andreoni A, Ramesh M, Angell B, Kapologwe NA, Mamdani M. Supply-side factors influencing informal payment for healthcare services in Tanzania. Health Policy Plan 2021; 36:1036-1044. [PMID: 34021334 PMCID: PMC8359751 DOI: 10.1093/heapol/czab034] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 01/30/2021] [Accepted: 02/25/2021] [Indexed: 11/13/2022] Open
Abstract
Informal payments for healthcare are widespread in sub-Saharan Africa. They are often regressive, potentially limiting access to quality healthcare, particularly for the most vulnerable, and can have catastrophic consequences for households. Yet there is little empirical research that uses theory-driven hypotheses to explore what influences informal payments and, especially, from health workers' perspectives. Consequently, we have explored the characteristics of health workers and facilities influencing informal payments in Tanzania, examining two hypotheses: health workers with power and position in the system are more likely to receive informal payments, and transparency and accountability measures can be bypassed by those who can game the system. We conducted a cross-sectional survey of 432 health workers from 42 public health facilities (hospitals and health centres) in 12 district councils from Pwani and Dar es Salam regions in Tanzania. Our dependent variable was whether the health worker has ever asked for or been given informal payments or bribes, while explanatory variables were measured at the individual and facility level. Given the hierarchical structure of the data, we used a multilevel mixed-effect logistic regression to explore the determinants. Twenty-seven percent of 432 health workers ever engaged in informal payment. This was more common amongst younger (<35 years) health workers and those higher in the hierarchy (specialists and heads of departments). Those receiving entitlements and benefits in a timely manner and who were subject to continued supervision were significantly less likely to receive informal payments. The likelihood of engaging in informal payments varied among health workers, consistent with our first hypothesis, but evidence on the second hypothesis remains mixed. Thus, policy responses should address both individual and system-level factors, including ensuring adequate and progressive health sector financing, better and timely remuneration of frontline public health providers, and enhanced governance and supervision.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Martin McKee
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Antonio Andreoni
- UCL Institute for Innovation and Public Purpose, 11 Montague Street, London WC1B 5BP, UK
| | - Mary Ramesh
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Blake Angell
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, Australia
- UCL Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK
| | - Ntuli A Kapologwe
- President’s Office—Regional Administration and Local Government (PO-RALG), Dodoma, Tanzania
| | - Masuma Mamdani
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
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Angell B, Khan M, Islam R, Mandeville K, Naher N, Hutchinson E, McKee M, Ahmed SM, Balabanova D. Incentivising doctor attendance in rural Bangladesh: a latent class analysis of a discrete choice experiment. BMJ Glob Health 2021; 6:bmjgh-2021-006001. [PMID: 34326070 PMCID: PMC8323362 DOI: 10.1136/bmjgh-2021-006001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/29/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Doctor absenteeism is widespread in Bangladesh, and the perspectives of the actors involved are insufficiently understood. This paper sought to elicit preferences of doctors over aspects of jobs in rural areas in Bangladesh that can help to inform the development of packages of policy interventions that may persuade them to stay at their posts. Methods We conducted a discrete choice experiment with 308 doctors across four hospitals in Dhaka, Bangladesh. Four attributes of rural postings were included based on a literature review, qualitative research and a consensus-building workshop with policymakers and key health-system stakeholders: relationship with the community, security measures, attendance-based policies and incentive payments. Respondents’ choices were analysed with mixed multinomial logistic and latent class models and were used to simulate the likely uptake of jobs under different policy packages. Results All attributes significantly impacted doctor choices (p<0.01). Doctors strongly preferred jobs at rural facilities where there was a supportive relationship with the community (β=0.93), considered good attendance in education and training (0.77) or promotion decisions (0.67), with functional security (0.67) and higher incentive payments (0.5 per 10% increase of base salary). Jobs with disciplinary action for poor attendance were disliked by respondents (−0.63). Latent class analysis identified three groups of doctors who differed in their uptake of jobs. Scenario modelling identified intervention packages that differentially impacted doctor behaviour and combinations that could feasibly improve doctors’ attendance. Conclusion Bangladeshi doctors have strong but varied preferences over interventions to overcome absenteeism. We generated evidence suggesting that interventions considering the perspective of the doctors themselves could result in substantial reductions in absenteeism. Designing policy packages that take account of the different situations facing doctors could begin to improve their ability and motivation to be present at their job and generate sustainable solutions to absenteeism in rural Bangladesh.
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Affiliation(s)
- Blake Angell
- Health Systems Science, The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia .,Institute for Global Health, University College London, London, UK
| | - Mushtaq Khan
- Economics and Head of Anti-Corruption Evidence Research Partnership Consortium (ACE), SOAS, London, UK
| | - Raihanul Islam
- Centre of Excellence for Health Systems and Universal Health Coverage, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Kate Mandeville
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Nahitun Naher
- Centre of Excellence for Health Systems and Universal Health Coverage, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Eleanor Hutchinson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Syed Masud Ahmed
- Centre of Excellence for Health Systems and Universal Health Coverage, James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Mayhew SH, Balabanova D, Vandi A, Mokuwa GA, Hanson T, Parker M, Richards P. (Re)arranging "systems of care" in the early Ebola response in Sierra Leone: An interdisciplinary analysis. Soc Sci Med 2021; 300:114209. [PMID: 34247897 PMCID: PMC9077326 DOI: 10.1016/j.socscimed.2021.114209] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/15/2021] [Accepted: 07/02/2021] [Indexed: 11/21/2022]
Abstract
Despite an expanding literature on Ebola-response, few studies detail or reflect on the responses of diverse systems of care. Little is known about how, why or in what ways, strategies of ill-health management were enacted locally, how health-systems power, authority and hierarchy were perceived and contested, or how other social systems, institutions and relationships shaped the response. This paper presents an interdisciplinary analysis of local responses in two early affected districts in Sierra Leone. Drawing on anthropological theories of social ordering and assemblage, we present an analysis of contrasting infection chains in three extended case studies from Bo and Moyamba districts. In contrast to previous scholarship which has understood local actions as being reactive (supporting or obstructing) to a national Ebola response, we show that local arrangements lead and shape responses. Our cases show how multiple, entangled, dynamic and co-existing systems of care influence these responses. Some individuals and communities collaborated with health authorities on measures like reporting and quarantine, others actively opposed them, or played an intermediary role. Collectively, formal health systems actors, local authorities and ordinary citizens negotiated and enacted new arrangements. These arrangements involved compromise and sometimes power was reconfigured. They were also shaped by wider political and historical contexts and by availability or absence of formal healthcare resources. Our research shows the critical importance of understanding how institutions and people involved in healthcare enact diverse “systems of care” and thereby shape Ebola response. Most importantly, our work underlines the need for alignment between formal health-systems and wider social, cultural, political and economic forms of organisation at family and community levels to improve crisis-response and promote sustainable care. In particular, health systems responders need to identify and engage with key brokers – or arrangers – in frontline care systems, with whom mutually acceptable, and effective, reconfigurations of care can be achieved. Multiple, dynamic, co-existing systems of care shaped Sierra Leone's Ebola response. Political/historic context, resources, conflict and compromise all shaped care systems. Diverse local actors negotiated relationships to reconfigure healthcare arrangements. It is local arrangements that lead and shape crisis-response at the decentralised level. Health systems need to engage with “arrangers” to reconfigure locally responsive care.
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Affiliation(s)
- Susannah H Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Ahmed Vandi
- School of Community Health Sciences, Njala University, Kowama, Bo, Sierra Leone
| | | | - Tommy Hanson
- School of Community Health Sciences, Njala University, Kowama, Bo, Sierra Leone
| | - Melissa Parker
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Paul Richards
- School of Environmental Sciences, Njala University, Mokonde, Sierra Leone
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Lasco G, Mendoza J, Renedo A, Seguin ML, Palafox B, Palileo-Villanueva LM, Amit AML, Dans AL, Balabanova D, McKee M. Nasa dugo ('It's in the blood'): lay conceptions of hypertension in the Philippines. BMJ Glob Health 2021; 5:bmjgh-2020-002295. [PMID: 32646854 PMCID: PMC7351273 DOI: 10.1136/bmjgh-2020-002295] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 05/04/2020] [Accepted: 05/15/2020] [Indexed: 12/15/2022] Open
Abstract
Introduction Understanding explanatory models is important for hypertension, a leading risk factor for cardiovascular disease and stroke. This article aims to determine what adult patients with hypertension in the Philippines attribute their condition to, how these views might be explained and what the implications are for hypertension management. Methods This is a qualitative study drawing on 71 semistructured interviews (40 initial and 31 follow-up) and four focus group discussions with patients diagnosed with hypertension. The setting was urban and rural low-income communities in the Philippines. Results Four prominent perceived causes were identified—genetics, heat, stress and diet—for what patients refer to as ‘high blood’. We propose a ‘folk physiology’ that rests on local understandings of blood and blood flow, draws from broader cultural notions of illness causation and accounts for a dynamic, non-chronic view of hypertension that in turn informs the health behaviours of those affected. Conclusions By understanding that hypertension is frequently seen not as a chronic constant condition but rather as an episodic one triggered by external influences, although in those genetically predisposed to it, it may be possible to address patient’s beliefs and thus adherence to treatment.
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Affiliation(s)
- Gideon Lasco
- Department of Anthropology, University of the Philippines Diliman, Quezon City, Metro Manila, Philippines .,Development Studies Program, Ateneo de Manila University, Quezon City, Philippines
| | - Jhaki Mendoza
- Department of Medicine, University of the Philippines Manila, Manila, Philippines
| | - Alicia Renedo
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | - Antonio L Dans
- Department of Medicine, University of the Philippines Manila, Manila, Philippines
| | | | - Martin McKee
- London School of Hygiene and Tropical Medicine, London, UK
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Hutchinson E, Naher N, Roy P, McKee M, Mayhew SH, Ahmed SM, Balabanova D. Targeting anticorruption interventions at the front line: developmental governance in health systems. BMJ Glob Health 2021; 5:bmjgh-2020-003092. [PMID: 33272939 PMCID: PMC7716661 DOI: 10.1136/bmjgh-2020-003092] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/30/2020] [Accepted: 10/06/2020] [Indexed: 11/12/2022] Open
Abstract
In 2008, Vian reported an increasing interest in understanding how corruption affects healthcare outcomes and asked what could be done to combat corruption in the health sector. Eleven years later, corruption is seen as a heterogeneous mix of activity, extensive and expensive in terms of loss of productivity, increasing inequity and costs, but with few examples of programmes that have successfully tackled corruption in low-income or middle-income countries. The commitment, by multilateral organisations and many governments to the Sustainable Development Goals and Universal Health Coverage has renewed an interest to find ways to tackle corruption within health systems. These efforts must, however, begin with a critical assessment of the existing theoretical models and approaches that have underpinned action in the health sector in the past and an assessment of the potential of innovations from anticorruption work developed in sectors other than health. To that end, this paper maps the key debates and theoretical frameworks that have dominated research on corruption in health. It examines their limitations, the blind spots that they create in terms of the questions asked, and the capacity for research to take account of contextual factors that drive practice. It draws on new work from heterodox economics which seeks to target anticorruption interventions at practices that have high impact and which are politically and economically feasible to address. We consider how such approaches can be adopted into health systems and what new questions need to be addressed by researchers to support the development of sustainable solutions to corruption. We present a short case study from Bangladesh to show how such an approach reveals new perspectives on actors and drivers of corruption practice. We conclude by considering the most important areas for research and policy.
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Affiliation(s)
- Eleanor Hutchinson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Nahitun Naher
- Centre of Excellence for Universal Health Coverage at Centre for Equity and Health Systems, James P. Grant School of Public Health, Brac University, Dhaka, Bangladesh
| | - Pallavi Roy
- Centre for International Studies and Diplomacy, Department of Politics and International Studies, SOAS University of London, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Susannah H Mayhew
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Syed Masud Ahmed
- Centre of Excellence for Universal Health Coverage at Centre for Equity and Health Systems, James P. Grant School of Public Health, Brac University, Dhaka, Bangladesh
| | - Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Mayhew SH, Kyamusugulwa PM, Kihangi Bindu K, Richards P, Kiyungu C, Balabanova D. Responding to the 2018-2020 Ebola Virus Outbreak in the Democratic Republic of the Congo: Rethinking Humanitarian Approaches. Risk Manag Healthc Policy 2021; 14:1731-1747. [PMID: 33953623 PMCID: PMC8092619 DOI: 10.2147/rmhp.s219295] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/20/2021] [Indexed: 11/23/2022] Open
Abstract
The Democratic Republic of Congo (DRC) presents a challenging context in which to respond to public health crises. Its 2018-2020 Ebola outbreak was the second largest in history. Lessons were known from the previous West African outbreak. Chief among these was the recognition that local action and involvement are key to establishing effective epidemic-response. It remains unclear whether and how this was achieved in DRC's Ebola response. Additionally, there is a lack of scholarship on how to build resilience (the ability to adapt or transform under pressure) in crisis-response. In this article, we critically review literature to examine evidence on whether and how communities were involved, trust built, and resilience strengthened through adaptation or transformation of DRC's 2018-2020 Ebola response measures. Overall, we found limited evidence that the response adapted to engage and involve local actors and institutions or respond to locally expressed concerns. When adaptations occurred, they were shaped by national and international actors rather than enabling local actors to develop locally trusted initiatives. Communities were "engaged" to understand their perceptions but were not involved in decision-making or shaping responses. Few studies documented how trust was built or analyzed power dynamics between different groups in DRC. Yet, both these elements appear to be critical in building effective, resilient responses. These failures occurred because there was no willingness by the national government or international agencies to concede decision-making power to local people. Emergency humanitarian response is entrenched in highly medicalized, military style command and control approaches which have no space for decentralizing decision-making to "non-experts". To transform humanitarian responses, international responders can no longer be regarded as "experts" who own the knowledge and control the response. To successfully tackle future humanitarian crises requires a transformation of international humanitarian and emergency response systems such that they are led, or shaped, through inclusive, equitable collaboration with local actors.
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Affiliation(s)
- Susannah H Mayhew
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Patrick Milabyo Kyamusugulwa
- Bukavu Medical University College/Institut Supérieur des Techniques Médicales de Bukavu (ISTM-Bukavu), Bukavu, Eastern Democratic Republic of Congo
| | - Kennedy Kihangi Bindu
- Centre de Recherche sur la Démocratie et le Développement en Afrique (CREDDA), Université Libre des Pays des Grands Lacs, Goma, Democratic Republic of Congo
| | - Paul Richards
- School of Environmental Sciences, Njala University, Freetown, Sierra Leone
| | - Cyrille Kiyungu
- Hygiene, State Administration, Kikwit, Democratic Republic of Congo
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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van Niekerk L, Manderson L, Balabanova D. The application of social innovation in healthcare: a scoping review. Infect Dis Poverty 2021; 10:26. [PMID: 33685487 PMCID: PMC7938294 DOI: 10.1186/s40249-021-00794-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/05/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Social innovation has been applied increasingly to achieve social goals, including improved healthcare delivery, despite a lack of conceptual clarity and consensus on its definition. Beyond its tangible artefacts to address societal and structural needs, social innovation can best be understood as innovation in social relations, in power dynamics and in governance transformations, and may include institutional and systems transformations. METHODS A scoping review was conducted of empirical studies published in the past 10 years, to identify how social innovation in healthcare has been applied, the enablers and barriers affecting its operation, and gaps in the current literature. A number of disciplinary databases were searched between April and June 2020, including Academic Source Complete, CIHAHL, Business Source Complete Psych INFO, PubMed and Global Health. A 10-year publication time frame was selected and articles limited to English text. Studies for final inclusion was based on a pre-defined criteria. RESULTS Of the 27 studies included in this review, the majority adopted a case research methodology. Half of these were from authors outside the health sector working in high-income countries (HIC). Social innovation was seen to provide creative solutions to address barriers associated with access and cost of care in both low- and middle-income countries and HIC settings in a variety of disease focus areas. Compared to studies in other disciplines, health researchers applied social innovation mainly from an instrumental and technocratic standpoint to foster greater patient and beneficiary participation in health programmes. No empirical evidence was presented on whether this process leads to empowerment, and social innovation was not presented as transformative. The studies provided practical insights on how implementing social innovation in health systems and practice can be enhanced. CONCLUSIONS Based on theoretical literature, social innovation has the potential to mobilise institutional and systems change, yet research in health has not yet fully explored this dimension. Thus far, social innovation has been applied to extend population and financial coverage, principles inherent in universal health coverage and central to SDG 3.8. However, limitations exist in conceptualising social innovation and applying its theoretical and multidisciplinary underpinnings in health research.
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Affiliation(s)
| | - Lenore Manderson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,School of Social Sciences, Monash University, Clayton, Australia
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Seguin M, Lasco G, Bin Idris K, Mendoza J, Mohd Kadri NH, Krauss S, D'Silva J, Shaffril HM, Fadzil MF, Palafox B, Renedo A, Nafiza MN, Majid F, Razak AA, Yusoff K, Palileo-Villanueva L, Dans A, Mallari E, Balabanova D, McKee M. Patient pathways for cardiovascular diseases in Malaysia and the Philippines: a systematic review. Wellcome Open Res 2021. [DOI: 10.12688/wellcomeopenres.16412.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Cardiovascular diseases (CVDs) are the leading cause of premature mortality in the world and are a growing public health concern in low- and middle-income countries (LMICs), including those in South East Asia. Their management requires coordinated responses by a range of healthcare providers, which should preferably be based on knowledge of the national context. We systematically review evidence on the pathways followed by patients with CVD in Malaysia and the Philippines to understand patient journeys, along with the barriers at each stage. Methods: We searched seven bibliographic databases and grey literature sources to identify material focused on the pathways followed by patients with CVD in Malaysia and the Philippines, and performed a narrative synthesis. Results: The search yielded 25 articles, 3 focused on the Philippines and 22 on Malaysia. Most articles were quantitative analyses that focused on hypertensive patients. Three examined secondary prevention post myocardial infarction, and one each examined acute myocardial infarction, heart failure, and atrial fibrillation. Reported barriers reflected capability (knowledge of behaviours to achieve control or the capacity to conduct these behaviours), intention (attitudes or motivations toward the behaviours to achieve control), and aspects of the health care system (availability, accessibility, affordability and acceptability of services). Conclusions: There are large gaps in our understanding of patient pathways in Malaysia and the Philippines that limit the development of evidence-based strategies to effectively address the CVD burden in South East Asian countries and in LMICs more broadly. Addressing these evidence gaps will require longitudinal mixed-methods studies following patients from initial diagnosis to long-term management.
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Abba-Aji M, Balabanova D, Hutchinson E, McKee M. How Do Nigerian Newspapers Report Corruption in the Health System? Int J Health Policy Manag 2021; 10:77-85. [PMID: 32610718 PMCID: PMC7947671 DOI: 10.34172/ijhpm.2020.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 03/03/2020] [Indexed: 11/29/2022] Open
Abstract
Background: Nigeria has a huge burden of corruption, with the health system especially vulnerable. The media can play a role in tackling it, by shaping the narrative around it. However, its influence depends on the extent and framing of its reporting on corruption. This paper reviews, for the first time, coverage of corruption in the health system in the Nigerian print media.
Methods: The top 10, by circulation, newspapers in Nigeria were selected and searched using the LexisNexis database for articles covering corruption in the health sector over a 2-year period (2016–2018). Two newspapers are not included in the database and were searched manually. 135 articles were identified and subject to content and framing analyses.
Results: The Punch newspaper had the highest number of publications focussed on corruption in the health sector. The National Health Insurance Scheme (NHIS) was the organization attracting most coverage, followed by the Federal Ministry of Health. Corruption in the health sector was predominantly framed as a political issue. Most coverage was episodic, focused on the details of the particular case, with much less thematic, delving into underlying causes. Corruption was most often attributed to a lack of accountability while enforcement was the most frequent solution proffered.
Conclusion: This study highlights the potential role of media analyses in helping to understand how newspapers cover corruption in the health sector in Nigeria. It argues that the media has the potential to act as an agent of change for tackling corruption within the health sector.
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Affiliation(s)
- Mohammed Abba-Aji
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Dina Balabanova
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Eleanor Hutchinson
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Martin McKee
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
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Palafox B, Renedo A, Lasco G, Palileo‐Villanueva L, Balabanova D, McKee M. Maintaining population health in low- and middle-income countries during the COVID-19 pandemic: Why we should be investing in Community Health Workers. Trop Med Int Health 2021; 26:20-22. [PMID: 32985024 PMCID: PMC7537160 DOI: 10.1111/tmi.13498] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Community health workers in low- and middle-income country primary health care systems are well suited to perform essential functions on the frontlines of Covid-19 pandemic responses. However, clear and coordinated guidance, updated infection control training, and reliable access to personal protective equipment must be ensured in order to deploy them safely and effectively. With these additional responsibilities, community health workers must also be supported to ensure that hard-fought gains in population health, including progress on non-communicable diseases, are sustained throughout the pandemic.
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Affiliation(s)
- Benjamin Palafox
- Faculty of Public Health & PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Alicia Renedo
- Faculty of Public Health & PolicyLondon School of Hygiene & Tropical MedicineLondonUK
| | - Gideon Lasco
- Department of AnthropologyUniversity of the Philippines DilimanQuezon CityPhilippines
| | | | - Dina Balabanova
- Department of Global Health & DevelopmentLondon School of Hygiene & Tropical MedicineLondonUK
| | - Martin McKee
- Faculty of Public Health & PolicyLondon School of Hygiene & Tropical MedicineLondonUK
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Naher N, Hoque R, Hassan MS, Balabanova D, Adams AM, Ahmed SM. Correction to: The influence of corruption and governance in the delivery of frontline health care services in the public sector: a scoping review of current and future prospects in low and middle-income countries of south and south-east Asia. BMC Public Health 2020; 20:1082. [PMID: 32646485 PMCID: PMC7350763 DOI: 10.1186/s12889-020-09197-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Balane MA, Palafox B, Palileo-Villanueva LM, McKee M, Balabanova D. Enhancing the use of stakeholder analysis for policy implementation research: towards a novel framing and operationalised measures. BMJ Glob Health 2020; 5:e002661. [PMID: 33158851 PMCID: PMC7651378 DOI: 10.1136/bmjgh-2020-002661] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Policy is shaped and influenced by a diverse set of stakeholders at the global, national and local levels. While stakeholder analysis is a recognised practical tool to assess the positions and engagement of actors relevant to policy, few empirical studies provide details of how complex concepts such as power, interest and position are operationalised and assessed in these types of analyses. This study aims to address this gap by reviewing conceptual approaches underlying stakeholder analyses and by developing a framework that can be applied to policy implementation in low-and-middle income countries. METHODS The framework was developed through a three-step process: a scoping review, peer review by health policy experts and the conduct of an analysis using key informant interviews and a consensus building exercise. Four characteristics were selected for inclusion: levels of knowledge, interest, power and position of stakeholders related to the policy. RESULT The framework development process highlighted the need to revisit how we assess the power of actors, a key issue in stakeholder analyses, and differentiate an actor's potential power, based on resources, and whether they exercise it, based on the actions they take for or against a policy. Exploration of the intersections between characteristics of actors and their level of knowledge can determine interest, which in turn can affect stakeholder position on a policy, showing the importance of analysing these characteristics together. Both top-down and bottom-up approaches in implementation must also be incorporated in the analysis of policy actors, as there are differences in the type of knowledge, interest and sources of power among national, local and frontline stakeholders. CONCLUSION The developed framework contributes to health policy research by offering a practical tool for analysing the characteristics of policy actors and tackling the intricacies of assessing complex concepts embedded in the conduct of stakeholder analyses.
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Affiliation(s)
| | - Benjamin Palafox
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Martin McKee
- Centre for Global Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, UK
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