Despite growing support for integration of frontline services, a lack of information about the pre-conditions necessary to integrate such services hampers the ability of policy makers and implementers to assess how feasible or worthwhile integration may be, especially in low- and middle-income countries (LMICs). The authors adopted a modified systematic review with aspects of realist review of quantitative and qualitative studies that incorporated assessment of health system preparedness for and capacity to implement integrated services. From an initial list of 10 550 articles, 206 were selected for full-text review by two reviewers who independently reviewed articles and inductively extracted and synthesized themes related to health system preparedness. Five ‘context’ related categories and four health system ‘capability’ themes were searched. The contextual enabling and constraining factors for frontline service integration were: the organizational framework of frontline services, health care worker preparedness, community and client preparedness, upstream logistics and policy and governance issues. The intersecting health system capabilities identified were the need for: sufficiently functional frontline health services, sufficiently trained and motivated health care workers, availability of technical tools and equipment suitable to facilitate integrated frontline services and appropriately devolved authority and decision-making processes to enable frontline managers and staff to adapt integration to local circumstances. This review demonstrates that synthesis is possible. It presents a common set of contextual factors and health system capabilities necessary for successful service integration which may be considered indicators of preparedness and could form the basis for an ‘integration preparedness tool’.
Equitable health services
Recent health system shocks such as the Ebola disease outbreak have focused global health attention on the notion of resilient health systems. In this commentary, the authors reflect on the current framing of the concept of resilience in health systems discourse and propose a reframing. Specifically, the authors propose that: (1) in addition to sudden shocks, health systems face the ongoing strain of multiple factors. Health systems need the capacity to continue to deliver services of good quality and respond effectively to wider health challenges. The authors call this capacity everyday resilience; (2) health system resilience entails more than bouncing back from shock. In complex adaptive systems, resilience emerges from a combination of absorptive, adaptive and transformative strategies; (3) nurturing the resilience of health systems requires understanding health systems as comprising not only hardware elements (such as finances and infrastructure), but also software elements (such as leadership capacity, power relations, values and appropriate organizational culture). The authors also reflect on current criticisms of the concept of resilient health systems, such as that it assumes that systems are apolitical, ignoring actor agency, promoting inaction, and requiring that there is a need to accept and embrace vulnerability, rather than strive for stronger and more responsive systems. They observe that these criticisms are warranted to the extent that they refer to notions of resilience that are mismatched with the reality of health systems.
In an effort to examine ways to sustain the intervention beyond external financial resources, project implementers conducted a follow-up qualitative study to explore the root causes of women’s lack of maternal health care access and utilization. This paper reports the key gender dynamics identified, detailing how gender power relations affect maternal health care access and utilization in relation to: access to resources; division of labour, including women’s workload during and after pregnancy and lack of male involvement at health facilities; social norms, including perceptions of women’s attitudes and behaviour during pregnancy, men’s attitudes towards fatherhood, attitudes towards domestic violence, and health worker attitudes and behaviour; and decision-making. It concludes by discussing the need to integrate gender into maternal health care interventions if they are to address the root causes of these barriers to maternal health care.
This paper captures common implementation experiences and lessons learned to understand core elements of successful health systems interventions. Qualitative data was used rom key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through African Health Initiative in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. Four major overarching lessons were highlighted. First, a variety and inclusiveness of concerned key players are necessary to address complex health system issues at all levels, with a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Also identified was inclusion of strong implementation science tools and strategies that allowed informed and measured learning processes and efficient dissemination of best practices. Five to seven years was seen to be the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects. The authors conclude that the African Health Initiative experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.
Tremendous challenges remain for the most vulnerable populations, including women, children, and adolescents, to enjoy the healthy lives and well-being. Much of their poor health is caused by poverty, gender, lack of education, and social marginalization as well as inaccessible healthcare services. Strong, equitable, and well-governed health systems can contribute to sustainably improving their lives. But building strong health systems is challenging. This book draws on 15 years of IDRC-funded health systems research undertaken by researchers working closely with communities and decision-makers. They have generated contextually relevant evidence at local, national, regional, and global levels to tackle these entrenched health systems challenges. Six lessons have been distilled to inform and inspire a new generation of health leaders and researchers while some critical reflections on the remaining challenges are shared with others in the global health community, including funding organizations.
Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers’ ability to counsel women about pregnancy risks and contraceptive options. This study assessed trends in the use of contraceptive methods after implementing an electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15–49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi. The authors conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. Between February 2012 and December 2016, in HIV clinics, the proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016. Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence and never thought about it. Incorporating the FP EMR module into HIV clinical care was found to prompt healthcare workers to encourage the use of contraceptives.
This study assessed uptake and correlates of cervical screening among HIV-infected women in care in Uganda. A nationally representative cross-sectional survey of HIV-infected women in care was conducted from August to November 2016. Structured interviews were conducted with 5198 women aged 15–49 years, from 245 HIV clinics. Knowledge and uptake of cervical screening and human papillomavirus (HPV) vaccination were determined. Overall, 94% had ever heard of cervical screening and 66% knew a screening site. However, 47% did not know the schedule for screening and 50% did not know the symptoms of cervical cancer. One-third rated their risk of cervical cancer as low. Uptake of screening was 30%. Women who had never been screened cited lack of information and no time as the main reasons. Increased likelihood of screening was associated with receipt of HIV care at a level II health center and private facilities, knowledge of cervical screening, where to go for screening, and low perception of risk. HPV vaccination was 2%. Cervical screening and HPV vaccination uptake were very low among HIV-infected women in care in Uganda. Improved knowledge of cervical screening schedules and sites, and addressing fears and risk perception are thus seen to potentially increase uptake of cervical screening in this vulnerable population.
The timing of the first antenatal care visit is paramount for ensuring optimal health outcomes for women and children, and it is recommended that all pregnant women initiate antenatal care in the first trimester of pregnancy (early antenatal care visit). Systematic global analysis of early antenatal care visits has not been done previously. This study reports on regional and global estimates of the coverage of early antenatal care visits from 1990 to 2013. Data were obtained from nationally representative surveys and national health information systems. Estimates of coverage of early antenatal care visits were generated with linear regression analysis and based on 516 logit-transformed observations from 132 countries. The model accounted for differences by data sources in reporting the cutoff for the early antenatal care visit. The estimated worldwide coverage of early antenatal care visits increased from 40.9% in 1990 to 58.6% in 2013, corresponding to a 43.3% increase. Overall coverage in the developing regions was 48.1% in 2013 compared with 84.8% in the developed regions. In 2013, the estimated coverage of early antenatal care visits was 24% in low-income countries compared with 81.9% in high-income countries. Progress in the coverage of early antenatal care visits has been achieved but coverage is still far from universal. Substantial inequity exists in coverage both within regions and between income groups. The absence of data in many countries is of concern and the authors argue that efforts should be made to collect and report coverage of early antenatal care visits to enable better monitoring and evaluation.
The Ebola virus disease outbreak in west Africa and the rapid spread of other emerging viruses, such as the severe acute respiratory syndrome or the Middle East respiratory syndrome coronaviruses, showed how limited or non-existent infection prevention and control (IPC) programmes, combined with an inadequate water supply, poor sanitation, and a weak hygiene infrastructure in health facilities, can threaten global health security. In such outbreaks, instead of serving as points where disease was controlled, health-care facilities became dangerous places for outbreak amplification among staff and patients and transmission back to communities. The authors argue that it is now urgent to consider IPC capacity building and actual implementation as global health priorities. Among its efforts in this field, WHO coordinates the Global IPC (GIPC) Network. There are strong economic and ethical reasons to enhance IPC within the national and global health security agendas and efforts should capitalise upon evidence-based recommendations, proven and feasible implementation strategies, and awareness raised by AMR and epidemic-prone disease threats.
This study evaluates the service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Using existing data from service provision assessments of the health systems of the 10 study countries, the authors calculated a service readiness index for each of 8443 health facilities. This index represents the percentage availability of 50 items that the World Health Organization considers essential for providing health care. For the analysis, the authors used 37–49 of the items on the list. The mean values for the service readiness index were 77% for the 636 hospitals and 52% for the 7807 health centres/clinics. Deficiencies in medications and diagnostic capacity were particularly common. The readiness index varied more between hospitals and health centres/clinics in the same country than between countries. There was weak correlation between national factors related to health financing and the readiness index. Most health facilities in the study countries were insufficiently equipped to provide basic clinical care. The authors argue that if countries are to bolster health-system capacity towards achieving universal coverage, more attention needs to be given to within-country inequities.