This study assessed how maternity waiting homes (MWHs) affect the health workforce and maternal health service delivery at their associated rural health centres. Four rounds of in-depth interviews with district health staff and health centre staff were conducted at intervention and control sites over 24 months. Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman’s final stage of pregnancy and labour onset, detect complications earlier, and either more confidently manage those complications at the health centre or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. The authors recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities and strategic selection of locations for new MWHs.
Equitable health services
KidzAlive is a child-centred intervention aimed at improving the quality of HIV care for children in South Africa. The authors conducted qualitative interviews with children, their primary caregivers, and KidzAlive trained healthcare workers using and providing child-friendly spaces, respectively. Child-friendly spaces contributed to child-centred care in primary healthcare centres. This was evidenced by the increased involvement and participation of children, increased primary caregivers participation in the care of their children and a positive transformation of the primary healthcare centre to a therapeutic environment for children. Several barriers impeding the success of child-friendly spaces were reported including space challenges; clashing health facility priorities; inadequate management support; inadequate training on how to maximise the child-friendly spaces and lastly the inappropriateness of existing child-friendly spaces for much older children. Child-friendly spaces are observed to promote HIV positive children’s right to participation and agency in accessing care. However, more rigorous quantitative evaluation is required to determine their impact on children’s HIV-related health outcomes.
Little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. Data from a household survey of 2002 women living in rural Tanzania was used to describe the extent of disrespectful care during outpatient visits, who receives disrespectful care and the association with patient satisfaction, rating of quality and recommendation of the facility to others. Women were asked about their most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. The most common reasons for seeking care were fever or malaria, vaccination and non-emergent check-up. Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic. While there is currently a lot of attention on disrespectful maternity care, the authors suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.
This study investigated health system constraints affecting treatment and care by women with cervical cancer in Harare, Zimbabwe. A sequential explanatory mixed methods design was used. Phase 1 comprised of two surveys namely: patient and health worker surveys with sample sizes of 134 and 78 participants respectively. In phase 2, 16 in-depth interviews, 20 key informant interviews and 6 focus groups were conducted to explain survey results. Health system constraints identified were: limited or lack of training for health workers, weakness of surveillance system for cervical cancer, limited access to treatment and care, inadequate health workers, reliance of patients on out-of-pocket funding for treatment services and lack of back-up for major equipment. The qualitative inquiry found barriers to be: high costs of treatment and care, lack of knowledge about cervical cancer and bad attitudes of health workers, few screening and treating centres located mostly in urban areas, lack of clear referral system resulting in bureaucratic processes and limited screening and treating capacities in health facilities due to lack of resources. The study showed that the health system and its organization present barriers to access of cervical cancer treatment and care among women.
Universal Health Coverage (UHC) is normally understood as ‘people being able to access curative, preventive and palliative health services without incurring financial hardship’. Yet this interpretation is only one part of the overall picture of health. To mitigate and prepare for such environmental and societal changes and the subsequent impact on health the authors suggest that there are at least three major ways in which health systems need to radically transform. Firstly, health systems across the world continue to be predominantly ‘sick care’ systems. Despite the success of immunization campaigns, the availability of contraceptive services and other preventive interventions, most investment is in healthcare facilities that provide primarily personal, curative health services. The World Health Organization estimates that low- and middle-income countries direct only 11-12 per cent of their total health spending towards preventive services. Secondly, animal and wildlife information systems vary enormously across countries in their objectives and structure but rarely interact with systems for tracking human health. This means that opportunities to identify dangerous viruses and diseases in the animal population before they crossover into humans are frequently missed. Thirdly, at the UN General Assembly (UNGA) the community of academics and activists concerned with non-communicable diseases were vocal, and rightly so. Such diseases now account for 41 out of the world’s 57 million deaths each year. The authors suggest that there is a need to move away from a narrow view of ‘sick care’ to one that prepares for and acknowledges present day complexities and challenges to achieve UHC.
screening programme for preschool children in the Western Cape, South Africa, supported by mobile health technology and delivered by community health workers. The authors trained four community health workers to provide dual sensory screening in preschool centres of Khayelitsha and Mitchells Plain during September 2017–December 2018. Community health workers screened children aged 4–7 years using mobile health technology software applications on smart-phones. Community health workers screened 94.4% of eligible children at 271 centres at a cost of US$5.63 per child. The number of children who failed an initial hearing and visual test was 435 and 170, respectively. Of the total screened, 111 children were diagnosed with a hearing and/or visual impairment. Mobile health technology supported community health worker delivered hearing and vision screening in preschool centres provided a low-cost, acceptable and accessible service, contributing to lower referral numbers to resource-constrained public health institutions.
The third sustainable development goal (SDG), ensuring healthy lives and well-being for all at all ages, although comprising multiple components, is often strongly linked with the concept of universal health coverage (UHC) and its underlying principles of equity, quality and financial protection. While addressing the upstream determinants of health is seen as a vital accelerator of progress in achieving the SDGs, in practice, UHC has often been focused on a disease-fighting, healthcare-centric approach. African countries are not on track to achieve global targets for non-communicable disease (NCD) prevention, driven by an insufficient focus on ecological drivers of NCD risk factors, including poor urban development and the unbridled proliferation of the commercial determinants of health. As the risk factors for NCDs are largely shaped outside the healthcare sector, an emphasis on downstream healthcare service provision to the exclusion of upstream population-level prevention limits the goals of UHC and its potential for optimal improvements in (achieving) health and well-being outcomes in Africa. The author argues for a systems for health rather than a solely healthcare-centric approach, that proactively incorporates wider health determinants (sectors)—housing, planning, waste management, education, governance and finance, among others—in strategies to improve health. This includes aligning governance and accountability mechanisms and strategic objectives of all ‘health determinant’ sectors for health creation and long-term cost savings. Researchers are seen to have a vital role to play, collaborating with policy makers to provide evidence to support implementation and to facilitate knowledge sharing between African countries.
The authors applied Tanahashi’s equity model to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. A qualitative study was implemented between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. The findings revealed that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, and limited efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. The authors suggest that if Kenya is to achieve universal health coverage, then county governments must address all aspects of equity, including quality, including through community health services.
This paper applied Tanahashi’s equity model to identify the perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. The authors carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Their findings revealed that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. The authors observe that achieving universal health coverage means that all aspects of equity need to be addressed, including quality, and that community health services can play a crucial role in this.
The author questions whether Uganda national referral hospitals are performing their function. The author asks why a section of persons should be given special treatment by government in the names of being ‘Very Important Persons’ to access the best medical services in referral facilities for first line care or in ‘uptown’ private medical facilities and abroad. The author proposes that government perform its core minimum obligation and ensure that its public health care facilities function effectively.