Towards leaving no one behind in North Macedonia: a mixed methods assessment of barriers to effective coverage with health services

BACKGROUND

The Government of North Macedonia's Primary Health Care reform is committed to leaving no one behind on the path to Universal health Coverage (UHC). During mid-2022 to March 2023, the World Health Organization (WHO) collaborated with the Government and other national stakeholders for an assessment of barriers to effective coverage with health services experienced by adult citizens, with a specific focus on rural areas and subpopulations in situations of vulnerability.

METHODS

This study constituted the piloting of a draft forthcoming WHO handbook on assessing barriers for health services, grounded in the Tanahashi framework for effective coverage with health services. In North Macedonia, the convergent parallel mixed methods study involved four sources. These were: a nationally representative Computer Assisted Telephone Interview Survey (1,139 respondents); 24 key informant interviews with representatives from government, professional associations, non-governmental and civil society organizations, and development partners; 12 focus groups in four regions with adults from vulnerable/high risk groups in rural areas and small urban settlements and an additional focus group with persons with disabilities; and a literature review. Instrument design was underpinned by the Tanahashi framework, which also orientated data triangulation and deductive analysis. The research team synergistically incorporated emerging themes in an inductive way. A key component of the assessment was participatory design of the study protocol with inputs from national stakeholders as well as participatory deliberation of the results and the ways forward.

RESULTS

Despite considerable progress towards UHC in North Macedonia, the assessment elucidated remaining challenges. These included: insufficient numbers of health workers, in general and particularly in the more disadvantaged regions of the country; inadequate number of outpatient medicines covered by health insurance; distance and transportation obstacles, including indirect travel costs, particularly in rural areas; adverse gender norms and relations for both women and men inhibiting timely treatment seeking; perceived discrimination by providers on multiple grounds; bottlenecks including waiting times to get appointments for specialist referrals; and lack of patient adherence, due several factors including costs of medicines and health products.

CONCLUSIONS

The outputs from this study of barriers to effective coverage with health services for adult citizens of North Macedonia are feeding into the ongoing Primary Health Care reform, and provide evidence for equity-related actions in the forthcoming National Development Strategy.

Disproportionate infection, hospitalisation and death from COVID-19 in ethnic minority groups and Indigenous Peoples: an application of the Priority Public Health Conditions analytical framework

The COVID-19 pandemic has resulted in disproportionate consequences for ethnic minority groups and Indigenous Peoples. We present an application of the Priority Public Health Conditions (PPHC) framework from the World Health Organisation (WHO), to explicitly address COVID-19 and other respiratory viruses of pandemic potential. This application is supported by evidence that ethnic minority groups were more likely to be infected, implying differential exposure (PPHC level two), be more vulnerable to severe disease once infected (PPHC level three) and have poorer health outcomes following infection (PPHC level four). These inequities are driven by various interconnected dimensions of racism, that compounds with socioeconomic context and position (PPHC level one). We show that, for respiratory viruses, it is important to stratify levels of the PPHC framework by infection status and by societal, community, and individual factors to develop optimal interventions to reduce inequity from COVID-19 and future infectious diseases outbreaks.

COVID-19 preparedness and response in rural and remote areas: A scoping review

This scoping review used the Arksey and O'Malley approach to explore COVID-19 preparedness and response in rural and remote areas to identify lessons to inform future health preparedness and response planning. A search of scientific and grey literature for rural COVID-19 preparedness and responses identified 5 668 articles published between 2019 and early 2022. A total of 293 articles were included, of which 160 (54.5%) were from high income countries and 106 (36.2%) from middle income countries. Studies focused mostly on the Maintenance of Essential Health Services (63; 21.5%), Surveillance, epidemiological investigation, contact tracing and adjustment of public health and social measures (60; 20.5%), Coordination and Planning (32; 10.9%); Case Management (30; 10.2%), Social Determinants of Health (29; 10%) and Risk Communication (22; 7.5%). Rural health systems were less prepared and national COVID-19 responses were often not adequately tailored to rural areas. Promising COVID-19 responses involved local leaders and communities, were collaborative and multisectoral, and engaged local cultures. Non-pharmaceutical interventions were applied less, support for access to water and sanitation at scale was weak, and more targeted approaches to the isolation of cases and quarantine of contacts were preferable to blanket lockdowns. Rural pharmacists, community health workers and agricultural extension workers assisted in overcoming shortages of health professionals. Vaccination coverage was hindered by weaker rural health systems. Digital technology enabled better coordination, communication, and access to health services, yet for some was inaccessible. Rural livelihoods and food security were affected through disruptions to local labour markets, farm produce markets and input supply chains. Important lessons include the need for rural proofing national health preparedness and response and optimizing synergies between top-down planning with localised planning and coordination. Equity-oriented rural health systems strengthening and action on rural social determinants is essential to better prepare for and respond to future outbreaks.

Exploring the ideas of young healthcare professionals from selected countries regarding rural proofing

INTRODUCTION

Globally, most countries struggle to meet the health needs of rural communities. This has resulted in rural areas performing poorly when compared to urban areas in terms of a range of health indicators. There have been few coherent or systematic strategies that target rural communities and address their needs within the rural context. Rural proofing, defined as the systematic application of a rural lens across policies and guidelines to ensure that they speak to these health needs, seeks to address this gap. The healthcare professionals (HCPs) who will be called upon to advocate for and lead the implementation of rural proofing efforts are those currently in training or early career stages. We thus sought to understand the perspectives of young HCPs regarding the concept of rural proofing.

METHODS

The study adopted an interpretivist paradigm. Data were collected using semi-structured individual interviews and focus group discussions (FGDs). Selected HCPs who are in leadership in Rural Seeds, a movement for young HCPs, participated in the study. FGDs in the form of Rural Cafés were led by some Rural Seeds leaders who participated in the interviews and who showed interest in organising the discussions. Eleven exploratory interviews and six FGDs were conducted using Zoom. HCPs were from Australia, Europe, Africa, North America, South America, and Asia. Interviews and FGDs were conducted in English, recorded, and transcribed verbatim. Thematic analysis was then undertaken.

RESULTS

Participants perceived the state of rural healthcare globally to be problematic. Access to care was seen as the most significant issue in rural health care, associated with the challenges of lack of equity in access, and limited funding and support for healthcare professionals and their career pathways. Despite varying understanding of the concept, rural proofing was seen to be of great value in improving rural health care. A number of ideas for applying rural proofing, with examples, were proposed from their perspectives as frontline healthcare providers. They particularly recognised the importance of addressing the local needs of rural communities and the needs of present and future HCPs. Implementation of rural proofing was seen to require the involvement of key stakeholders from a range of sectors at multiple levels.

CONCLUSION

Given the state of rural health, young rural HCPs suggest that rural proofing strategies are needed as they have the potential to bring about equity in the delivery of health care in rural and remote communities. These strategies will assist in creating a more positive future for rural health care worldwide and motivate young HCPs to become involved in rural health care, as well as to increase their motivation to take an interest in health policy development. These strategies need to be applied at multiple levels, from national government to local contexts. It is also seen to be critically important to involve multiple levels of stakeholders, from politicians to healthcare providers and community members, in the process of rural proofing.

Primary health care as a platform for addressing racial discrimination to "leave no one behind" and reduce health inequities

The health inequities faced by populations experiencing racial discrimination, including indigenous peoples and people of African descent, Roma, and other ethnic minorities, are an issue of global concern. Health systems have an important role to play in tackling these health inequities. Health systems based on comprehensive Primary Health Care (PHC) are best placed to tackle health inequities because PHC encompasses a whole-of-society approach to health. PHC includes actions to address the wider social determinants of health, multisectoral policy and action, intercultural and integrated healthcare services, community empowerment, and a focus on addressing health inequities. PHC can also serve as a platform for introducing specific actions to tackle racial discrimination and can act to drive wider societal change for tackling racial and ethnic health inequities.

Exploring the potential for a new measure of socioeconomic deprivation status to monitor health inequality

BACKGROUND

Monitoring health inequalities is an important task for health research and policy, to uncover who is being left behind - and where - and to inform effective and equitable policies and programmes to tackle existing inequities. The choice of which measure to use to monitor and analyse health inequalities is thereby not trivial. This article explores a new measure of socioeconomic deprivation status (SDS) to monitor health inequalities.

METHODS

The SDS measure was constructed using the Alkire-Foster method. It includes eight indicators across two equally weighted dimensions (education and living standards) and specifies a four-level gradient of socioeconomic deprivation at the household-level. We conducted four exercises to examine the value-added of the proposed SDS measure, using Demographic and Health Surveys data. First, we examined the discriminatory power of the new measure when applied to outcomes in four select reproductive, maternal, neonatal, and child health (RMNCH) indicators across six countries: skilled birth attendance, stunting, U5MR, and DTP3 immunisation. Then, we analysed the behaviour and association of the new SDS measure vis-à-vis the DHS Wealth Index, including chi-squared test and Pearson correlation coefficient. Third, we analysed the robustness of the SDS measure results to changes in its structure, using pairwise comparisons and Kendal Tau-b rank correlation. Finally, we illustrated some of the advantageous properties of the new measure, disaggregation and decomposition, on Haitian data.

RESULTS

1) Higher levels of socioeconomic deprivation are generally consistently associated with lower levels of achievements in the RMNCH indicators across countries. 2) 87% of all pairwise rank comparisons across a range of SDS measure structures were robust. 3) SDS and DHS Wealth Index are associated, but with considerable cross-country variation, highlighting their complementarity. 4) Haitian households in rural areas experienced, on average, more severe socioeconomic deprivation as well as lower levels of RMNCH achievement than urban households.

CONCLUSIONS

The proposed SDS measure adds analytical possibilities to the health inequality monitoring literature, in line with ethically and conceptually well-founded notions of absolute, multidimensional disadvantage. In addition, it allows for breakdown by its dimensions and components, which may facilitate nuanced analyses of health inequality, its correlates, and determinants.

Assessing Barriers to Effective Coverage of Health Services for Adolescents in Low- and Middle-Income Countries: A Scoping Review

PURPOSE

Understanding barriers to health services, as experienced by adolescents, is important to expand effective and equitable coverage; however, there is limited discussion on methods for conducting barrier assessments and translating findings into action.

METHODS

We conducted a scoping review of literature published between 2005 and 2019 on barriers to health services for adolescents in low- and middle-income countries. The review was guided by a framework that conceptualized barriers across multiple dimensions of access (availability, geographic accessibility, affordability, and acceptability), utilization, and effective coverage.

RESULTS

We identified 339 studies that assessed barriers related to at least one dimension of the operational framework. Acceptability (93%) and availability (88%) of health services were the most frequently studied access dimensions; affordability (45%) and geographic access (32%) were studied less frequently. Less than half (40%) of the studies evaluated utilization, and none of the 339 studies assessed effective coverage. Attention to equity stratifiers (e.g., income, disability) was limited. Topics studied reflected only a subset of the major causes of adolescent death and disability.

CONCLUSIONS

Holistic, equity-oriented approaches are needed to better understand barriers across multiple dimensions that together determine whether health services are accessible, used, and effectively meet the needs of different adolescent groups.

Building capacity for health equity analysis in the WHO South-East Asia Region

"Leaving no one behind" is at the heart of the agenda of the Sustainable Development Goals, requiring that health systems be vigilant to how interventions can be accessed equitably by all, including population subgroups that face exclusion. In the World Health Organization (WHO) South-East Asia Region, inequalities can be found across and within countries but there has been a growing commitment to examining and starting to tackle them. Over the past decade in particular, WHO has been developing an armamentarium of tools to enable analysis of health inequalities and action on health equity. Tools include the Health Equity Assessment Toolkit in built-in database and upload database editions, as well as the Innov8 tool for reorientation of national health programmes. Countries across the region have engaged meaningfully in the development and application of these tools, in many cases aligning them with, or including them as part of, ongoing efforts to examine inequities in population subgroups domestically. This paper reflects on these experiences in Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, where efforts have ranged from workshops to programme reorientation; the creation of assemblies and conferences; and collation of evidence through collaborative research, reviews/synthesis and conferences. This promising start must be maintained and expanded, with greater emphasis on building capacity for interpretation and use of evidence on inequalities in policy-making. This may be further enhanced by the use of innovative mixed methodologies and interdisciplinary approaches to refine and contextualize evidence, with a concomitant shift in attention, developing solutions to redress inequities and anchor health reform within communities. There are many lessons to be learnt in this region, as well as mounting political and popular will for change.

Applying the Innov8 approach for reviewing national health programmes to leave no one behind: lessons learnt from Indonesia

The World Health Organization's Innov8 Approach for Reviewing National Health Programmes to Leave No One Behind is an eight-step process that supports the operationalization of the Sustainable Development Goals' commitment to 'leave no one behind'. In 2014-2015, Innov8 was adapted and applied in Indonesia to review how the national neonatal and maternal health action plans could become more equity-oriented, rights-based and gender-responsive, and better address critical social determinants of health. The process was led by the Indonesian Ministry of Health, with the support of WHO. It involved a wide range of actors and aligned with/fed into the drafting of the maternal newborn health action plan and the implementation planning of the newborn action plan. Key activities included a sensitization meeting, diagnostic checklist, review workshop and in-country work by the review teams. This 'methods forum' article describes this adaptation and application process, the outcomes and lessons learnt. In conjunction with other sources, Innov8 findings and recommendations informed national and sub-national maternal and neonatal action plans and programming to strengthen a 'leave no one behind' approach. As follow-up during 2015-2017, components of the Innov8 methodology were integrated into district-level planning processes for maternal and newborn health, and Innov8 helped generate demand for health inequality monitoring and its use in planning. In Indonesia, Innov8 enhanced national capacity for equity-oriented, rights-based and gender-responsive approaches and addressing critical social determinants of health. Adaptation for the national planning context (e.g. decentralized structure) and linking with health inequality monitoring capacity building were important lessons learnt. The pilot of Innov8 in Indonesia suggests that this approach can help operationalize the SDGs' commitment to leave no one behind, in particular in relation to influencing programming and monitoring and evaluation.

Tools and approaches to operationalize the commitment to equity, gender and human rights: towards leaving no one behind in the Sustainable Development Goals

The objective of this article is to present specific resources developed by the World Health Organization on equity, gender and human rights in order to support Member States in operationalizing their commitment to leave no one behind in the health Sustainable Development Goals (SDGs), and other health-related goals and targets. The resources cover: (i) health inequality monitoring; (ii) barrier analysis using mixed methods; (iii) human rights monitoring; (iv) leaving no one behind in national and subnational health sector planning; and (v) equity, gender and human rights in national health programme reviews. Examples of the application of the tools in a range of country contexts are provided for each resource.

Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries

Many intrinsically related determinants of health and disease exist, including social and economic status, education, employment, housing, and physical and environmental exposures. These factors interact to cumulatively affect health and disease burden of individuals and populations, and to establish health inequities and disparities across and within countries. Biomedical models of health care decrease adverse consequences of disease, but are not enough to effectively improve individual and population health and advance health equity. Social determinants of health are especially important in Latin American countries, which are characterised by adverse colonial legacies, tremendous social injustice, huge socioeconomic disparities, and wide health inequities. Poverty and inequality worsened substantially in the 1980s, 1990s, and early 2000s in these countries. Many Latin American countries have introduced public policies that integrate health, social, and economic actions, and have sought to develop health systems that incorporate multisectoral interventions when introducing universal health coverage to improve health and its upstream determinants. We present case studies from four Latin American countries to show the design and implementation of health programmes underpinned by intersectoral action and social participation that have reached national scale to effectively address social determinants of health, improve health outcomes, and reduce health inequities. Investment in managerial and political capacity, strong political and managerial commitment, and state programmes, not just time-limited government actions, have been crucial in underpinning the success of these policies.