Lesotho has one of the highest maternal mortality rates in the world, Partners In Health (PIH) has included maternity waiting homes since 2009 as part of a comprehensive effort to increase facility-based deliveries and reduce maternal mortality. The maternity waiting homes are located at seven PIH-supported health centres in some of the most remote, underserved areas of rural Lesotho. The homes provide food and shelter for women who live far away from the health centre or have risk factors for potential obstetric complications, and are well-regarded by both health centre staff and pregnant women. Since the implementation of the Maternal Mortality Reduction Project, PIH has seen waiting home admissions and the number of monthly deliveries at health centres increase dramatically. The authors suggest that failure of previous studies to demonstrate a positive impact of maternity waiting homes may reflect the failure to successfully implement other supporting components of a larger, comprehensive strategy to increase access to maternal health services.
Equitable health services
This study contributes to the health policy debate on medical systems integration by describing and analysing the interactions between health-care users, indigenous healers, and the biomedical public health system, in the so far rarely documented case of post-conflict Burundi. The authors adopted a mixed-methods approach combining (1) data from an existing survey on access to health-care, with 6,690 individuals, and (2) original interviews and focus groups conducted in 2014 with 121 respondents, including indigenous healers, biomedical staff, and health-care users. The findings reveal pluralistic patterns of health-care seeking behaviour, which are not primarily based on economic convenience or level of education. Indigenous healers’ diagnosis is shown to revolve around the concept of ‘enemy’ and the need for protection against it. The authors suggest ways in which this category may intersect with the widespread experience of trauma following the civil conflict. They find that, while biomedical staff display ambivalent attitudes towards healers, cross-referrals occasionally take place between healers and health centres. The authors emphasise healers’ psychological support role in helping communities deal with trauma.
The Executive Secretary of the East African Health Research Commission (EAHRC), Professor Gibson Kibiki, has decried the high number of East Africans going to India to seek medical services which can be accessed in hospitals in the region. Prof. Kibiki attributed the huge exodus of patients to India to the lack of information on health services that were available at referral hospitals in the region. He revealed that East Africans may soon be able to access treatment across national borders in addition to enjoying portable health insurance across the region, adding that the Commission would soon undertake research to gauge the feasibility of a regional health insurance scheme before piloting the scheme. He described as counterproductive the tendency by health researchers and medics in the Partner States to work in silos since the region was one and that diseases did not know national borders.
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.
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.
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.
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.
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.
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.
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.