Equitable health services

Gendered health systems: evidence from low- and middle-income countries
Morgan R; Ayiasi R; Barman D; et al: Health Research Policy and Systems 16(58) 2-12, 2018

This paper synthesizes findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gender approach can be applied by researchers in a range of low- and middle-income settings to these domains and demonstrates that this can uncover new ways of viewing seemingly intractable problems. The studies used a combination of mixed, quantitative, qualitative and participatory methods, including photovoice and life histories, to prompt deeper and more personal reflections on gender norms. Five core themes that cut across the different studies were the intersection of gender with other social stratifiers, the importance of male involvement, the influence of gendered social norms on health system structures and processes, the reliance on unpaid carers within the health system and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis by researchers, policy-makers and health practitioners.

Socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over in China, Ghana, and India
Kailembo A; Preet R; Williams J; et al.: International Journal for Equity in Health 17(99) 1-14, 2018

This study measures and describes socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over, in China, Ghana and India. The prevalence of unmet need was 60, 80, and 62% in China, Ghana and India respectively. The adjusted relative index of inequality for education was statistically significant for China, Ghana, and India, whereas the adjusted relative index of inequality for wealth was significant only in Ghana. Male sex was significantly associated with self-reported unmet need for oral health services in India. Given rapid population ageing, the author argues that further evidence of socioeconomic inequalities in unmet need for oral health services by older adults in low to medium income countries are needed to inform policies to mitigate inequalities in the availability of oral health services.

Oral cholera vaccine in cholera prevention and control, Malawi
M’bangombe M; Pezzoli L; Reeder B; et al: Bulletin of the World Health Organisation 96(66), 2018

With limited global supplies of oral cholera vaccine, countries need to identify priority areas for vaccination while longer-term solutions, such as water and sanitation infrastructure, are being developed. In 2017, Malawi integrated oral cholera vaccine into its national cholera control plan. The process started with a desk review and analysis of previous surveillance and risk factor data. At a consultative meeting, researchers, national health and water officials and representatives from nongovernmental and international organizations reviewed the data and local epidemiological knowledge to determine priority districts for oral cholera vaccination. The final stage was preparation of an application to the global oral cholera vaccine stockpile for non-emergency use. Malawi collects annual data on cholera and most districts have reported cases at least once since the 1970s. The government’s application for 3.2 million doses of vaccine to be provided over 20 months in 12 districts was accepted in April 2017. By April 2018, over 1 million doses had been administered in five districts. Continuing surveillance in districts showed that cholera outbreaks were notably absent in vaccinated high-risk areas, despite a national outbreak in 2017–2018. Augmenting advanced mapping techniques with local information helped to extend priority areas beyond those identified as high-risk based on cholera incidence reported at the district level. Involvement of the water, sanitation and hygiene sectors is key to ensuring that short-term gains from cholera vaccine are backed by longer-term progress in reducing cholera transmission.

"Scared of going to the clinic’: Contextualising healthcare access for men who have sex with men, female sex workers and people who use drugs in two South African cities
Duby Z; Nkosi B; Scheibe A; et al: Southern African Journal of HIV Medicine 19(1), doi:https://doi.org/10.4102/sajhivmed.v19i1.701, 2018

This study examined the context of access to healthcare experienced by men who have sex with men, female sex workers and people who use drugs in two South African cities: Bloemfontein in the Free State province and Mafikeng in the North West province. In-depth interviews were conducted to explore healthcare workers’ perceptions, beliefs and attitudes. Focus group discussions were also conducted with members of these groups exploring their experiences of accessing healthcare. Healthcare workers demonstrated a lack of relevant knowledge, skills and training to manage the particular health needs and vulnerabilities facing these social groups. Men who have sex with men, female sex workers and people who use drugs described experiences of stigmatisation, and of being made to feel guilt, shame and a loss of dignity as a result of the discrimination by healthcare providers and other community. members. The findings suggest that the uptake and effectiveness of health services amongst these three groups is limited by internalised stigma, reluctance to seek care, unwillingness to disclose risk behaviours to healthcare workers, combined with a lack of knowledge and understanding on the part of the broader community members, including healthcare workers.

Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia
Banks K; Karim A; Ratcliffe H; et al: Health Policy and Planning 33(3) 317–327, 2017

The study explored the frequency and associated factors of disrespect and abuse in four rural health centres in Ethiopia. The experiences of women who delivered in these facilities were captured by direct observation of client-provider interaction and exit interview at time of discharge. Incidence of disrespect and abuse were observed in each facility, with failure to ask woman for preferred birth position most commonly observed. During exit interviews, 21% of respondents reported at least one occurrence of disrespect and abuse. Bivariate models using client characteristics and index birth experience showed that women’s reporting of disrespect and abuse was significantly associated with childbirth complications, weekend delivery and no previous delivery at the facility. Facility-level fixed-effect models found that experience of complications and weekend delivery remained significantly and most strongly associated with self-reported disrespect and abuse. The results suggest that addressing disrespect and abuse in health centres in Ethiopia will require a sustained effort to improve infrastructure, support the health workforce in rural settings, enforce professional standards and target interventions to improve women’s experiences as part of quality of care initiatives.

Scoping literature review on the basic health benefit package and its determinant criteria
Hayati R; Bastani P; Kabir M; et al: Globalization and Health 14(26), https://doi.org/10.1186/s12992-018-0345-x, 2018

This study aimed to extract criteria used in health systems for defining the benefit package in different countries around the world using scoping review method. A systematic search was carried out in online libraries and databases between January and April 2016. After studying the articles’ titles, abstracts, and full texts, 9 articles and 14 reports were selected for final analysis. In the final analysis, 19 criteria were extracted. Due to diversity of criteria in terms of number and nature, they were divided into three categories. The categories included intervention-related criteria, disease-related criteria, and community-related criteria. The largest number of criteria belonged to the first category. Indeed, the most widely applied criteria included cost-effectiveness, effectiveness, budget impact, equity, and burden of disease. According to the results, different criteria were identified in terms of number and nature in developing benefit package in world health systems. The authors conclude that it seems that certain criteria, such as cost-effectiveness, effectiveness, budget impact, burden of disease, equity, and necessity, that were most widely utilized in countries under study could be for designing benefit package with regard to social, cultural, and economic considerations.

Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries
Rwabukwisi F; Bawah A; Gimbel S; Phillips J et al: BMC Health Services Research 17(Suppl3) doi: https://doi.org/10.1186/s12913-017-2662-9, 2017

In this study, the authors captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. Four major overarching lessons were highlighted. Variety and inclusiveness of concerned key players are necessary to address complex health system issues at all levels. A learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Five to seven years was 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 Population Health Implementation and Training partnership projects.

How to assess and prepare health systems in low- and middle-income countries for integration of services—a systematic review
Topp S; Abimbola S; Joshi R: Health Policy and Planning 33(2) March 2018, doi: https://doi.org/10.1093/heapol/czx169, 2017

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’.

From bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening
Barasa E; Cloete K; Gilson L: Health Policy and Planning 32(Suppl 3) ii91 – iii94, 2017

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.

Gender dynamics affecting maternal health and health care access and use in Uganda
Morgan R; Tetui M; Kananura R; et al: Health Policy and Planning 32, Supp 5, v13-v21, 2017

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.