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.
Equitable health services
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.
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’.
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.