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Implementing a Basic Package of Health Services in post-conflict Liberia: Perceptions of key stakeholders
Abstract
Recovery of the health sector in post-conflict countries is increasingly initiated through a Basic Package of Health Services (BPHS) approach. The country government and partners, including international donors, typically contract international and local NGOs to deliver the BPHS. Evidence from routine data suggests that a BPHS approach results in rapid increases in service coverage, coordination, equity, and efficiency. However, studies also show progress may then slow down, the cause of which is not immediately obvious from routine data. Qualitative research can provide insight into possible barriers in the implementation process, particularly the role of health workers delivering the BPHS services. The aim of this study was to explore perceptions of health service providers and policy makers on the implementation of the BPHS in post-conflict Liberia, using SRH services as a tracer and Lipsky's work on "street-level bureaucrats" as a theoretical framework. In July-October 2010, 63 interviews were conducted with midwives, officers-in-charge, and supervisors in two counties of Liberia, and with policy makers in Monrovia. The findings suggest health workers had a limited understanding of the BPHS and associated it with low salaries, difficult working conditions, and limited support from policy makers. Health workers responded by sub-optimal delivery of certain services (such as facility-based deliveries), parallel private services, and leaving their posts. These responses risk distorting and undermining the BPHS implementation. There were also clear differences in the perspectives of health workers and policy makers on the BPHS implementation. The findings suggest the need for greater dialogue between policy makers and health workers to improve understanding of the BPHS and recognition of the working conditions in order to help achieve the potential benefits of the BPHS in Liberia.
... A 2010 assessment found that, although there had been progress in the provision of basic services, some communities and in particular the rural ones still had limited access to health care, and that health provision was skewed to services favoured by donors (such as HIV testing and malaria treatment) (Kruk et al., 2010b). Petit et al. (2013) pointed to a number of implementation challenges, including for health workers, who appeared to have limited understanding of the BPHS and associated it with low salaries, difficult working conditions, and limited support. ...
... They are usually seen as helpful to provide clear policies and a sense of direction, address geographical inequities, and improve alignment of all providers (Eldon et al., 2008). Other potential advantages of the national roll out of a BPHS in a post-conflict setting may be rapid increases in healthcare coverage and standardisation of services, facilities, staffing, drugs and equipment (Ameli and Newbrander, 2008;Loevinsohn and Sayed, 2008;Petit et al., 2013;WHO, 2008), although there are concern about services which are not included in BPHS (Roberts et al., 2008). ...
... There were also clear differences in the perspectives of health workers and policy makers on the BPHS implementation. These findings suggest the need for greater dialogue between policy makers and health workers to improve understanding of the BPHS and recognition of the working conditions in order to help achieve the potential benefits of the BPHS in Liberia" (Petit et al., 2013). ...
Fragile and conflict affected settings (FCAS)
present a growing challenge for achieving
UHC and other developmental goals. In
this paper, we examine core features of
FCAS, which centre on deficits in capacity,
legitimacy and security, and what this implies
for health systems, but more specifically for
health financing and in relation to the key
messages and policy guidance currently
offered by WHO. We explore common health
financing constraints and opportunities and
how policies have responded to these and draw out recommendations.
... Street-level bureaucrats are the ones who deliver a policy that has been constructed elsewhere [114]. Although his research was carried out mainly in the United States, it still seemed applicable and relevant to my research, as Lipsky's theoretical framework has been used in other low-income settings [10,115]. My research has expanded Lipsky's definition of street-level bureaucrats to include health workers who provide services directly and those who are decision makers in service provision. ...
... As a result, a number of nurses distorted the policy by not always giving free access to services for certain groups of patients [10]. Recent research by Petit (2013) has also applied Lipsky's theoretical approach in exploring health workers' perception of the implementation of Liberia's Basic Package of Health and Social Welfare Services [115]. ...
... As a result, a number of nurses distorted the policy by not always giving free access to services for certain groups of patients [10]. Recent research by Petit (2013) has also applied Lipsky's theoretical approach in exploring health workers' perception of the implementation of Liberia's Basic Package of Health and Social Welfare Services [115]. ...
Over the last decade, there have been increasing calls for respecting and integrating human rights into health, including into mental health policies, plans, and programmes. The convergence of mental health and the right to health has implications for health workers, as they are the key translators of policy- and programme-related decisions into practice. This thesis is a qualitative research study which follows a case-study approach situated in the Programme for Improving Mental Health Care in Nepal. It aims to explore the perceptions and perspectives of health workers in the Chitwan district in Nepal on the use of a human rights-based approach (HRBA) to mental health. The specific objectives are to (1) examine existing evidence on the use of an HRBA to advance health; (2) explore perspectives on the right to health among mental health workers in Nepal; (3) explore health workers’ perceptions of the application of an HRBA to mental health in planning and service provision; and (4) develop a conceptual framework regarding the use of an HRBA to mental health. The literature review identified some plausible positive evidence on the use of an HRBA to advance health, but also highlighted the very limited quantity and quality of the evidence and the difficulty in determining with certainty the direct influence of an HRBA to health. No studies were identified that explored an HRBA to mental health in low- or middle-income countries. The qualitative research highlighted that participants were aware of human rights, but faced difficulty in understanding their meaning and application, including an HRBA. An HRBA to health and related plans requires an understanding of both the health system context and involvement of health workers. A conceptual framework was developed of an HRBA to mental health to help guide the application of an HRBA in mental health planning and service provision. Recommendations are provided.
... • Semi-structured interviews (n = 2) 40,41 • Documentary analysis (n = 2) 39,43 • Survey (n = 3) 35,36,38 • Both interview and survey (n = 1) 34 • Economic analysis (n = 1) 42 ...
... • Multiple-case study methodology involving documentation, interviews, and surveys (n = 1) 37 Of the 10 included studies, seven examined factors that affected implementation and uptake of health benefit package, two focused on factors associated with quality and cost of package, 35,36 and one explored the effect on cost and technical efficiency of contracting-out the package to NGOs. 42 The studies that conducted semi-structured interviews involved a mix of participants including policymakers (n = 2), 40,41 PHC managers (n = 3), 34,40,41 and health professionals (n = 1). 41 All but one study 41 ...
... 42 The studies that conducted semi-structured interviews involved a mix of participants including policymakers (n = 2), 40,41 PHC managers (n = 3), 34,40,41 and health professionals (n = 1). 41 All but one study 41 ...
Background
One of the key requirements for achieving universal health coverage is the proper design and implementation of essential health benefits package (EHPs). We systematically reviewed the evidence on barriers and facilitators to the implementation of EHPs within primary health care settings in low‐income and middle‐income countries.
Methods
We searched multiple databases and the gray literature. Two reviewers completed independently and in duplicate data selection, data extraction, and quality assessment. We synthesized the findings according to the following health systems arrangement levels: governance, financial, and delivery arrangements.
Results
Ten studies met the eligibility criteria. At the governance level, key reported barriers were insufficient policymaker‐implementer interactions, limited involvement of consumers and stakeholders, sub‐optimal primary health care network arrangement, poor marketing and promotion of package, and insufficient coordination with community network. The key reported facilitator was the presence of a legal policy framework for package implementation. At the financial level, barriers included delays and inadequate remunerations to health care providers while facilitators included government and donor commitments to financing of package and flexibility in exploring new funding mechanisms. At the delivery level, barriers included inadequate supervision, poor facility infrastructure, limited availability of equipment and supplies, and shortages of workers. Facilitators included proper training and management of workforce, availability of female health workers, presence of clearly defined packages, and continuum of care, including referrals to promote comprehensive service delivery.
Conclusion
We identified a set of barriers and facilitators that need to be addressed to ensure proper implementation of EHPs within primary health care settings.
... A maternal care subsidy policy implementaion in Burkina Faso was altered as health providers used their own discretion to charge unapproved fees (Ridde et al., 2013). And in Liberia, a key barrier to implementation of a Basic Package of Health Services programme was nurses attitudinal obstacles to health service use (Petit et al., 2013). ...
... Referral was prescribed but parents resisted for lack of money. the implementation context, limited resources, personal values and weak administrative control (Aniteye et al., 2013;Petit et al., 2013). Overall, our findings resonate with Lipsky's (1980) assertion about the power of street-bureaucrats to transform policy implementation focus and processes in ways that align with their parochial interest (Erasmus and Gilson, 2008). ...
... Moreover, it was apparent that weak control enabled FLP make choices governed by their own discretionary decisions rather than the CHPS implementation requirements (Nyonator et al., 2005). This finding is consistent with others (Aniteye et al., 2013;Petit et al., 2013;Ridde et al., 2013), and parallel Ridde et al. (2013) that ineffective supervision enabled health providers' discretionary decisions to override bureaucratic orders in the implementation of a maternal care programme in Burkina Faso. Both the present and existing findings mirror theory. ...
Policy analysis on why women and children in low- and middle-income settings are still disadvantaged by access to appropriate care despite Primary Health Care (PHC) programmes implementation is limited. Drawing on the street-level bureaucracy theory, we explored how and why frontline providers (FLP) actions on their own and in interaction with health system factors shape Ghana's community-based PHC implementation to the disadvantage of women and children accessing and using health services. This was a qualitative study conducted in 4 communities drawn from rural and urban districts of the Upper West region. Data were collected from 8 focus group discussions with community informants, 73 in-depth interviews with clients, 13 in-depth interviews with district health managers and FLP, and observations. Data were recorded, transcribed and coded deductively and inductively for themes with the aid of Nvivo 11 software. Findings showed that apart from FLP frequent lateness to, and absenteeism from work, that affected care seeking for children, their exercise of discretionary power in determining children who deserve care over others had ripple effects: families experienced financial hardships in seeking alternative care for children, and avoided that by managing symptoms with care provided in non-traditional spaces. FLP adverse behaviours were driven by weak implementation structures embedded in the district health systems. Basic obstetric facilities such as labour room, infusion stand, and beds for deliveries, detention and palpation were lacking prompting FLP to cope by conducting deliveries using a patchwork of improvised delivery methods which worked out to encourage unassisted home deliveries. Perceived poor conditions of service weakened FLP commitment to quality maternal and child care delivery. Findings suggest the need for strategies to induce behaviour change in FLP, strengthen district administrative structures, and improve on the supply chain and logistics system to address gaps in CHPS maternal and child care delivery.
... Yet, much of the published literature has focused on the short-term health and social needs of the communities, often emphasizing the humanitarian response to crises . There is still relatively little research about how to reconstruct systems for the sustainable provision of health services in post-conflict situations (Roberts et al. 2009;Petit et al. 2013). ...
... These settings present unique challenges especially for those concerned with health system strengthening and long-term assurance of other programs that form the social safety net for these communities. The main challenges include (1) the levels of capacity and trust enjoyed by the state, (2) multiplicity of health-related actors, (3) short-term focus of funding organizations, (4) drifting objectives and commitment of humanitarian organizations and (5) dynamic shifts in resources and capacity of the social safety nets that support the communities in these situations (Kruk et al. 2010;Petit et al. 2013). ...
... In northern Uganda, as the conflict waned in 2006, many providers of humanitarian services were phased out, a situation that created a depletion of service availability and capacity and generated discontinuities in health system functioning (Namakula et al. 2011). Nonetheless, evidence in Uganda and elsewhere shows that a multiplicity of development oriented organizations become mobilized and proceeded to initiate programs to fill the gaps created by the departure of humanitarian agencies (Fujita et al. 2011;Petit et al. 2013). ...
In post-conflict settings, service coverage indices are unlikely to be sustained if health systems are built on weak and unstable inter-organization networks-here referred to as infrastructure. The objective of this study was to assess the inter-organization infrastructure that supports the provision of selected health services in the reconstruction phase after conflict in northern Uganda. Applied social network analysis was used to establish the structure, size and function among organizations supporting the provision of (1) HIV treatment, (2) maternal delivery services and (3) workforce strengthening. Overall, 87 organizations were identified from 48 respondent organizations in the three post-conflict districts in northern Uganda. A two-stage snowball approach was used starting with service provider organizations in each district. Data included a list of organizations and their key attributes related to the provision of each service for the year 2012-13. The findings show that inter-organization networks are mostly focused on HIV treatment and least for workforce strengthening. The networks for HIV treatment and maternal services were about 3-4 times denser relative to the network for workforce strengthening. The network for HIV treatment accounted for 69-81% of the aggregated network in Gulu and Kitgum districts. In contrast, the network for workforce strengthening contributed the least (6% and 10%) in these two districts. Likewise, the networks supporting a young district (Amuru) was under invested with few organizations and sparse connections. Overall, organizations exhibited a broad range of functional roles in supporting HIV treatment compared to other services in the study. Basic information about the inter-organization setup (infrastructure)-can contribute to knowledge for building organization networks in more equitable ways. More connected organizations can be leveraged for faster communication and resource flow to boost the delivery of health services.
... However, empirical data remains limited on how the international community can best support the transition from a fragile post-conflict country, often largely dependent on international support, to a sovereign state capable of serving its citizens in an effective and sustainable manner. One approach to improving access to healthcare services after armed conflict, and thereby contributing to the state-building process, is providing a Basic Package of Health Services (BPHS) for all citizens [13][14][15]. This package prioritises effective primary healthcare interventions (e.g. ...
... First introduced nationally in Afghanistan in 2002, BPHS-centred approaches have been adopted in several countries since (e.g. South Sudan, Liberia, Somalia, Sierra Leone, the Democratic Republic of Congo, Timor Leste) [14,22]. ...
... It is limited in its ability to provide explanations for differences in performance or allow for assessment of staff and user perspectives [27]. Inclusion of qualitative research can explore wider systems issues through the perspectives of providers translating policy into practice or service-users experiencing the practical aspects of policy [14,28]. Very little qualitative research has been conducted to explore whether the BPHS strengthens the health system and builds capacity and leadership within national government [29,30]. ...
Background
Contracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are particularly constrained. Afghanistan, the longest-running example of Basic Package of Health Services (BPHS) contracting in a conflict-affected setting, enables study of how implementation of a national intervention influences access to prioritised health services. This study explores stakeholder perspectives of sexual and reproductive health (SRH) services delivered through the BPHS in Afghanistan, using Bamyan Province as a case study.
Methods
Twenty-six in-depth interviews were conducted with health-system practitioners (e.g. policy/regulatory, middle management, frontline providers) and four focus groups with service-users. Inductive thematic coding used the WHO Health System Framework categories (i.e. service delivery, workforce, medicines, information, financing, stewardship), while allowing for emergent themes.
Results
Improvements were noted by respondents in all health-system components discussed, with significant improvements identified in service coverage and workforce, particularly improved gender balance, numbers, training, and standardisation. Despite improvements, remaining weaknesses included service access and usage - especially in remote areas, staff retention, workload, and community accountability.
Conclusions
By including perspectives on SRH service provision and BPHS contracting across health-system components and levels, this study contributes to broader debates on the effects of contracting on perceptions and experiences among practitioners and service-users in conflict-affected countries.
... Liberian nurses and other healthcare workers have reported feeling unprepared to implement the BPHS, with few opportunities for support and consultation with colleagues (Petit et al., 2013), and with limited clinical or didactic training in the tasks they perform routinely (Udaya et al., 2011). Further efforts to strengthen both pre-and post-licensure nursing education in Liberia began in 2015 (Government of Liberia, 2015b), but evaluations of these efforts, and of the effects of BPHS and EPHS implementation on nurse practice, are lacking. ...
... TB) report a high degree of reliance on their clinical mentors and a great deal of satisfaction with that arrangement; generalist outpatient nurses might be helped by similar support. This would also address the concern expressed by healthcare workers that they have limited opportunities to consult with colleagues (Petit et al., 2013). operational laboratory facilities, for example, must be available to the nurse for her to act on her intellectual capital pertaining to diagnostics. ...
Aim
To explore the resources supporting current nurse practice in the post‐emergency country of Liberia, using the nursing intellectual capital framework, as nurses work to meet the targets set by Government of Liberia's Essential Package of Health Services.
Design
Case study.
Methods
Data were collected in Liberia February–June 2019. Direct observation, semi‐structured interviews and photographs were used to investigate how nurse practice is supported. Field notes, transcripts and photographs were coded using both directed and conventional content analysis. Reports were then generated by code to triangulate the data.
Results
Thirty‐seven nurses at 12 health facilities participated. The intellectual capital supporting inpatient and outpatient nurse practice differs in important ways. Inpatient nurse practice is more likely to be supported by facility‐based protocols and trainings, whereas outpatient nurse practice is more likely to be supported by external protocols and trainings, often developed by the Liberian government or non‐governmental organizations. This can lead to uneven provision of inpatient protocols and trainings, often favouring private facilities. Similarly, inpatient nurses rely primarily on other nurses at their facilities for clinical support while outpatient nurses often have external professional relationships that provided them with clinical guidance.
Conclusion
Much has been accomplished to enable outpatient nurses to provide the primary‐ and secondary‐care target services in the Essential Package of Health Services. However, as the Liberian government and its partners continue to work towards providing certain tertiary care services, developing analogous protocols, trainings and clinical mentorship networks for inpatient nurses will likely be fruitful, and will decrease the burden on individual facilities.
Impact
Nurses are often expected to meet new service provision targets in post‐emergency states. Further research into how best to support nurses as they work to meet those targets has the potential to strengthen health systems.
... We simulated ahead-of-time HCW vaccine coverage values of 50%, 30%, and 10%. These values reflect the high turnover of HCW in recently affected countries (Shoman et al., 2017;Petit et al., 2013), and the possibility that protection could wane. Vaccine coverage should be interpreted as effective levels of coverage: 30% coverage is equivalent to 100% vaccination of HCW and waning to 30% protection, or as 30% vaccination and 100% protection. ...
... HCW at three levels of coverage plus reactive mass vaccination of remaining HCW and the community (strategies f, g, and h). We selected values of coverage that were realistic given high HCW turnover in recently affected countries(Shoman et al., 2017;Petit et al., 2013), and the possibility of waning of protection. ...
Background:
Health care workers (HCW) are at risk of infection during Ebola virus disease outbreaks and therefore may be targeted for vaccination before or during outbreaks. The effect of these strategies depends on the role of HCW in transmission which is understudied.
Methods:
To evaluate the effect of HCW-targeted or community vaccination strategies, we used a transmission model to explore the relative contribution of HCW and the community to transmission. We calibrated the model to data from multiple Ebola outbreaks. We quantified the impact of ahead-of-time HCW-targeted strategies, and reactive HCW and community vaccination.
Results:
We found that for some outbreaks (we call "type 1″) HCW amplified transmission both to other HCW and the community, and in these outbreaks prophylactic vaccination of HCW decreased outbreak size. Reactive vaccination strategies had little effect because type 1 outbreaks ended quickly. However, in outbreaks with longer time courses ("type 2 outbreaks"), reactive community vaccination decreased the number of cases, with or without prophylactic HCW-targeted vaccination. For both outbreak types, we found that ahead-of-time HCW-targeted strategies had an impact at coverage of 30%.
Conclusions:
The vaccine strategies tested had a different impact depending on the transmission dynamics and previous control measures. Although we will not know the characteristics of a new outbreak, ahead-of-time HCW-targeted vaccination can decrease the total outbreak size, even at low vaccine coverage.
... Despite this backdrop, the last two decades saw concerted efforts from Liberia to improve its maternal mortality ratio through training health workers (Dolo, Clack, Gibson, Lewis, & Southall, 2016), implementing maternity waiting homes Lori, Wadsworth, Munro, & Rominski, 2013) and rolling out a national Basic Package of Health Services (Petit, Sondorp, Mayhew, Roura, & Roberts, 2013). Maternal mortality fell from 1800 per 100,000 live births in 1995 to 640 in 2015 (UN, 2015). ...
... Factors making Redemption hard to access both before and after the Ebola epidemic included perceived negative attitudes and poor interpersonal skills of staff, mistrust, and cost of care (e.g. Lori & Boyle, 2011;Petit et al., 2013;Sipsma et al., 2013). This confirms the findings of global study into why TBAs continue to be usedthey are readily available, have better relationships and shared values with clients, and have flexible attitudes towards payment (Owolabi, Glenton, Lewin, & Pakenham-Walsh, 2014). ...
During the March 2014–January 2016 Ebola crisis in Liberia, Redemption Hospital lost 12 staff and became a holding facility for suspected cases, prompting violent hostility from the surrounding New Kru Town community, in the capital city Monrovia. Inpatient services were closed for 6 months, leaving the population without maternity care. In January 2015, Redemption reopened, but utilization was low, especially for deliveries. A key barrier was community trust in health workers which worsened during the epidemic. The New Kru Town council, Redemption Hospital, the International Rescue Committee, and Training and Research Support Centre initiated participatory action research (PAR) in July 2015 to build communication between stakeholder groups, and to identify impacts of the epidemic and shared actions to improve the system. The PAR involved pregnant women, community-based trained traditional midwives (TTMs) and traditional birth attendants (TBAs), and community leaders, as well as health workers. Qualitative data and a pre-post survey of PAR participants and community members assessed changes in relationships and maternal health services. The results indicated that Ebola worsened community-hospital relations and pre-existing weaknesses in services, but also provided an opportunity to address these when rebuilding the system through shared action. Findings suggest that PAR generated evidence and improved communication and community and health worker interaction.
... A commonly used health service delivery model in post-conflict settings is contracting non-state providers to deliver health services on behalf of the government. Previous research shows promising results in rapid expansion of services, but longer term effects have not been sufficiently researched [38,39] and would therefore benefit from further investigation. In addition, this study found that future research should explore ways to improve the quality of service delivery in FCAS, possibly by learning from successful case studies in stable low-and middleincome countries. ...
... That said, health systems research has been described as having a broad utility [4] and therefore could provide lessons learned for other similar contexts. However, in order to do so, the Task Force on Health Systems Research suggests that future research should better describe contextual factors and possibly include multiple countries [39]. An exploration of transferability and appropriateness, as highlighted by study participants, is, in light of this, important to broaden the utility of research across varying contexts. ...
Background
There is increasing interest amongst donors in investing in the health sectors of fragile and conflict-affected states, although there is limited research evidence and research funding to support this. Agreeing priority areas is therefore critical. This paper describes an 18-month process to develop a consultative research agenda and questions for health systems research, providing reflections on the process as well as its output.
Methods
After a scoping review had been conducted, primary data was collected from August 2014 to September 2015. Data was collected using a mixture of methods, including an online survey (n = 61), two face-to-face group sessions (one with 11 participants; one with 17), email consultation (n = 18), a webinar (n = 65), and feedback via LinkedIn. Two steering committees of purposively selected experts guided the research process – a core steering committee (n = 10) and broad steering committee (n = 20). The process moved from developing broad topics and lists of research needs to grouping and honing them down into a smaller, prioritised agenda, with specific research questions associated to each topic.
Results
An initial list of 146 topics was honed down to 25 research needs through this process, grouped thematically under transition and sustainability, resilience and fragility, gender and equity, accessibility, capacity building, actors and accountability, community, healthcare delivery, health workforce, and health financing. They were not ranked, as all health system areas are interdependent. The research agenda forms a starting point for local contextualisation and is not definitive.
Conclusions
A wide range of stakeholders participated in the different stages of this exercise, which produced a useful starting point for health systems research agenda setting in fragile and conflict-affected states. The process of engagement may have been as valuable for building a community of researchers as the product. It is now important to drive forward the research agenda. Without both a higher profile and deeper focus for this area, there is a real risk that fragile and conflict-affected states will continue to fall behind in global health and development goals.
Electronic supplementary material
The online version of this article (doi:10.1186/s12961-016-0124-1) contains supplementary material, which is available to authorized users.
... Morbidity due to infectious diseases fell by 65% within two-and-a-half years. A few studies investigate the impact of street-level bureaucrats on the implementation of national health policies in low-income countries, for example a change in national health policy in South Africa after 1996 (Walker and Gilson 2004) and implementation of a basic package of health services in post-conflict Liberia (Petit, Sondorp et al. 2013). Both studies found that street-level bureaucrats' views and values inform their implementation of the health policy, and that failures in implementation are related to exclusion of bureaucrats from the process of policy change, and insufficient incorporation of social, financial and human resources into the policy implementation process. ...
... Both studies found that street-level bureaucrats' views and values inform their implementation of the health policy, and that failures in implementation are related to exclusion of bureaucrats from the process of policy change, and insufficient incorporation of social, financial and human resources into the policy implementation process. To overcome these problems, Walker and Gilson (2004) and Petit et al. (2013) suggests that policy makers should improve planning and management in ways that demonstrate respect and trust for street-level bureaucrats. These suggestions rest on the (contestable) assumption that bureaucratic motivation is not fixed, but can be modified by deliberate policies. ...
Many health improving interventions in low-income countries are extremely good value for money. So why has it often proven difficult to obtain political backing for highly cost-effective interventions such as vaccinations, treatments against diarrhoeal disease in children, and preventive policies such as improved access to clean water, or policies curtailing tobacco consumption? We use economic models of public choice, supported by examples, to explain how powerful interest groups, politicians or bureaucrats who pursue their own objectives, or voting and institutional arrangements in countries have shaped health priority setting. We show that it may be perfectly rational for policy makers to accommodate these constraints in their decisions, even if it implies departing from welfare maximizing solutions.
... This increase in use of facilities may be the result of a number of government policies. User fees in all public health facilities were suspended in 2006 [33], and the government implemented a Basic Package of Health Services in 2009, which included expanding provision of maternal and neonatal health services at primary and secondary level facilities [34]. There has also been a focus on rapidly expanding the health workforce, with the number of midwives increasing by 28% between 2006 and 2010 [35]. ...
Background
The provision of quality obstetric care in health facilities is central to reducing maternal mortality, but simply increasing childbirth in facilities not enough, with evidence that many facilities in sub-Saharan Africa do not fulfil even basic requirements for safe childbirth care. There is ongoing debate on whether to recommend a policy of birth in hospitals, where staffing and capacity may be better, over lower level facilities, which are closer to women’s homes and more accessible. Little is known about the quality of childbirth care in Liberia, where facility births have increased in recent decades, but maternal mortality remains among the highest in the world. We will analyse quality in terms of readiness for emergency care and referral, staffing, and volume of births.
Methods
We assessed the readiness of the Liberian health system to provide safe care during childbirth use using three data sources: Demographic and Health Surveys (DHS), Service Availability and Readiness Assessments (SARA), and the Health Management Information System (HMIS). We estimated trends in the percentage of births by location and population caesarean-section coverage from 3 DHS surveys (2007, 2013 and 2019–20). We examined readiness for safe childbirth care among all Liberian health facilities by analysing reported emergency obstetric and neonatal care signal functions (EmONC) and staffing from SARA 2018, and linking with volume of births reported in HMIS 2019.
Results
The percentage of births in facilities increased from 37 to 80% between 2004 and 2017, while the caesarean section rate increased from 3.3 to 5.0%. 18% of facilities could carry out basic EmONC signal functions, and 8% could provide blood transfusion and caesarean section. Overall, 63% of facility births were in places without full basic emergency readiness. 60% of facilities could not make emergency referrals, and 54% had fewer than one birth every two days.
Conclusions
The increase in proportions of facility births over time occurred because women gave birth in lower-level facilities. However, most facilities are very low volume, and cannot provide safe EmONC, even at the basic level. This presents the health system with a serious challenge for assuring safe, good-quality childbirth services.
... Liberia is a low-income country with a population of about 5 million people with half reportedly living in urban areas (32,33). Access to and quality and comprehensiveness of health services, particularly in rural settings, has been reported as disparate across the country with implications for prevention and control of threats to health security including infectious disease outbreaks (34,35,36,37). Liberia has been affected by a range of public health and humanitarian emergencies including, most notably, two civil wars spanning three decades (1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003) and the EVD outbreaks between 2014 and 2016. ...
https://www.who.int/publications/i/item/9789240033290
This report was produced as part of an initiative funded by the United States Agency for International Development (USAID), “Strengthening health security and health systems linkages to improve quality health services in emergencies”. A key feature of this work is to understand the extent of integration of health systems strengthening (HSS) and health security efforts in low- and middle-income countries.
This report explores HSS and health security integration in Liberia and Bangladesh. The scope of the report is to provide a narrative synthesis of key findings from health systems assessments, policies, plans and practices. supplemented by relevant academic literature.
The objectives of this analysis were to:
1. describe the public health context and structure in Liberia and Bangladesh;
2. ascertain the state of HSS and health security integration in national and subnational policies, plans and practices for public health protection;
3. document relevant experiences from past and ongoing emergencies to inform long-term health systems resilience; and
4. understand the nexus of health systems and health security integration in emergency
preparedness and response planning.
The primary audience for this report is policymakers from the global to national levels involved in HSS and public health.
services.
... In its most basic form, priority-setting is the process of making decisions about how best to allocate scarce resources to improve population health [1]. This challenge is especially difficult in low and middle income countries (LIMCs) and fragile and conflict affected settings (FCAS) where health needs are immense, financial resources are scarce, health infrastructure is rudimentary or damaged, and government stewardship is limited [2]. In these settings there is an absence of systematic processes to guide decision-making, a lack of reliable information to inform decisions, and a presence of multiple actors with differing agendas [3]. ...
Objective
In fragile and conflict affected settings (FCAS) such as South Sudan, where health needs are immense, resources are scarce, health infrastructure is rudimentary or damaged, and government stewardship is weak, adequate health intervention priority-setting is especially important. There is a scarcity of research examining priority-setting in FCAS and the related political economy. Yet, capturing these dynamics is important to develop context-specific guidance for priority-setting. The objective of this study is to analyze the priority-setting practices in the Health Pooled Fund (HPF) of South Sudan using a political economy perspective.
Methods
A mixed methods study was conducted combining document review, 30 stakeholder interviews, and a quantitative assessment of service delivery. An adapted version of the Walt and Gilson policy analysis triangle guided the study’s design and analysis.
Results
Priority-setting in the context of HPF takes place throughout program design, implementing partner (IP) contract negotiation, and implementation of the service package. The National Basic Package does not provide adequate guidance because it is too expansive and unrealistic given financial and health system constraints. Furthermore, power asymmetries between actors are pronounced. At the local level, IPs must manage the competing interests of the HPF program and local health authorities as well as challenging contextual factors, including conflict and shortages of skilled health workers, which eventually affect service provision. The resulting priority-setting process remains implicit, scarcely documented, and primarily driven by donors’ interests.
Conclusion
This study highlights power asymmetries between donors and national health authorities within a FCAS context, which drive a priority-setting process that is dominated by donor agendas and leave little room for government ownership. These findings emphasize the importance of paying attention to the influence of stakeholders and their interests on the priority-setting process in FCAS. Ultimately, the process of contracting out services is particularly political and requires guidance.
... In its most basic form, priority-setting is the process of making decisions about how best to allocate scarce resources to improve population health [1]. This challenge is especially difficult in low and middle income countries (LIMCs) and fragile and conflict affected settings (FCAS) where health needs are immense, financial resources are scarce, health infrastructure is rudimentary or damaged, and government stewardship is limited [2]. In these settings there is an absence of systematic processes to guide decision-making, a lack of reliable information to inform decisions, and a presence of multiple actors with differing agendas [3]. ...
Background
In fragile and conflict affected settings (FCAS) such as South Sudan, where health needs are immense, resources are scarce, health infrastructure is rudimentary or damaged, and government stewardship is weak, adequate health intervention priority-setting is especially important. There is a scarcity of research examining priority-setting in FCAS and the related political economy. Yet, capturing these dynamics is important to develop context-specific guidance for priority-setting. The objective of this study is to analyze the priority-setting practices in the Health Pooled Fund (HPF), a multi-donor fund that supports service delivery in South Sudan, using a political economy perspective.
Methods
A multi-method study was conducted combining document review, 30 stakeholder interviews, and an examination of service delivery. An adapted version of the Walt and Gilson policy analysis triangle guided the study’s design and analysis.
Results
Priority-setting in HPF occurs in a context of immense fragility where health needs are vast, service delivery remains weak, and external funding is essential. HPF's service package gives priority to the health of mothers and children, gender-sensitive programming, immunization services, and a community health initiative. HPF is structured by a web of actors at national and local levels with pronounced power asymmetries and differing vested interests and ideas about HPF’s role. Priority-setting takes place throughout program design, implementing partner (IP) contract negotiation, and implementation of the service package. In practice the BPHNS does not provide adequate guidance for priority-setting because it is too expansive and unrealistic given financial and health system constraints. At the local level, IPs must manage the competing interests of the HPF program and local health authorities as well as challenging contextual factors, including conflict and shortages of qualified health workers, which affect service provision. The resulting priority-setting process remains implicit, scarcely documented, and primarily driven by donors’ interests.
Conclusion
This study highlights power asymmetries between donors and national health authorities within a FCAS context, which drive a priority-setting process that is dominated by donor agendas and leave little room for government ownership. These findings emphasize the importance of paying attention to the influence of stakeholders and their interests on the priority-setting process in FCAS.
... This is particularly the case of humanitarian settings and fragile states, where contexts are dynamic, unpredictable and require methodological adaptations (Smith et al., 2020), while a large gap remains in evidence availability (Kohrt et al., 2019). The literature on health service priority setting has frequently focused on key steps in the process, such as methodology, donor financing, political will and lobbying, disease group characteristics and resources, or on implementation though technical aspects have also more recently been documented (see, for example Eregata et al., 2020;Petit et al., 2013, Petricca et al., 2018. These technical activities that make up the actual priority-setting process in-country deserve to be unpacked further, as they form the arena in which data, evidence and national and international experts come together to make decisions toward the development of strong, revised, health systems. ...
Health systems in fragile states need to respond to shifting demographics, burden of disease and socio-economic circumstances in the revision of their health service packages. This entails making difficult decisions about what is and is not included therein, especially in resource-constrained settings offering or striving for universal health coverage. In this paper we turn the lens on the 2017–2021 development of Afghanistan's Integrated Package of Essential Health Services (IPEHS) to analyse the dynamics of the priority setting process and the role and value of evidence. Using participant observation of meetings and interviews with 25 expert participants, we conducted a qualitative study of the consultation process aimed at examining the characteristics of its technical, socio-cultural and organisational aspects, in particular data use and expert input, and how they influenced how evidence was discussed, taken up, and used (or not used) in the process. Our analysis proposes that the particular dynamics shaped by the context, information landscape and expert input shaped and operationalised knowledge sharing and its application in such a way to constitute a sort of “vernacular evidence”. Our findings underline the importance of paying attention to the constellation of the priority setting processes in order to contribute to an ethical allocation of resources, particularly in contexts of resource scarcity and humanitarian need.
... An EHSP is a common, yet poorly understood, health policy instrument. Essential health services packages have been developed in a number of LMICs, 43 including post-conflict fragile states such as Liberia 44 and Afghanistan. 45 While they can take alternate forms, their intention is to prioritize certain health services over others and must be sensitive to local needs. ...
Priority setting is a key function of health systems in low- and middle-income countries that seek to achieve universal health coverage. Essential health services packages (EHSPs) and health benefit plans are two types of instruments used in setting health care priorities. Both instruments exist in Ethiopia, but little is known about how they are aligned. To gain insights into the evolution, purpose, policy objectives, and governance of the EHSP, community-based health insurance (CBHI), and social health insurance (SHI) in Ethiopia, we conducted a case study. This included a desk review of relevant documents as well as qualitative analysis of key informant interviews conducted with 15 leading health finance experts in Addis Ababa. Interviewees understood the EHSP to be a key priority-setting instrument in the country by coordinating the activities of health system stakeholders, and guaranteeing the right of citizens to a basic level of care. Community-based health insurance and SHI were described as mechanisms for the government to expand health coverage and provide financial protection. Interviewees acknowledged that Ethiopia had drawn on the experience of other countries when designing health benefit plans, but contrasted Ethiopia's experience with that of other countries. We found that in Ethiopia, the EHSP, CBHI, and SHI are not explicitly aligned. We propose that EHSPs play an important role in early stages of health systems development. However, as governments develop health benefit plans with expansive packages of services, the importance of EHSPs becomes less clear.
... Basic or essential packages of health services have been introduced in many post-conflict settings such as Afghanistan, Liberia, South Sudan, Somalia, the DRC, and Cambodia, although they often remain aspirational and unrealistic [50]. Other advantages can include a rapid increase in service coverage and a standardization of services, facilities, staffing, drugs and equipment [96,100,101]. ...
The motivation for the paper is to review existing health financing policy recommendations and consider whether, and if so how, these need revising given the challenging context of FCAS. The paper aims to inform policy i.e. the decisions and actions of those engaged in financing and delivering health services in FCAS, and its scope is limited to this agenda. The paper is based on a thorough review of the evidence published separately as a WHO working paper. We are particularly interested in the perspective of public policy given its central importance for the long-term development of health systems, and as such is closely linked to the humanitarian development nexus agenda, which tries to ensure better connectivity between humanitarian and development efforts as highlighted during the World Humanitarian Summit.
... However, communication about what was covered was unclear. 8 The availability of services increased under the scheme, 9 but the experience of residents of West Point was mixed. Although all government health facilities were meant to be free, a survey in 2014 by the Community-Based Initiative, an organisation set up to engage the community in tackling Ebola, found that many community members were paying large sums out of pocket. ...
Epidemics of infectious disease often highlight underlying weaknesses in health systems. Two recent outbreaks of Ebola virus disease, for example, have exposed high levels of distrust that contributed to the spread of disease but also have implications for universal health coverage. By the end of August 2019 just over a quarter of deaths from Ebola in the Democratic Republic of the Congo (DRC) had occurred outside treatment centres. Since treatment protocols include isolation, this suggests people have been refraining from seeking care when symptoms arise or not remaining in treatment for suggested durations.
One reason for this is lack of trust in institutions, and specifically health systems. Surveys conducted in North Kivu, the centre of the current outbreak, found that people viewed Ebola as a government scheme to marginalise certain groups or as part of a business to profit aid workers, researchers, and government officials. These findings parallel those of a similar study conducted in Liberia during the west African Ebola crisis in 2014-15. In Liberia, distrust was evident before the crisis, with an earlier survey finding approximately half of respondents did not believe that they could obtain needed services for themselves or their children if they became sick.
Low rates of early care seeking are thought to have increased mortality from Ebola. But early presentation is also fundamental to mitigating unnecessary morbidity and mortality associated with diseases from diabetes to HIV/AIDs. We know surprisingly little about the state of health system distrust or what drives it. We use the Ebola outbreak in West Point, Liberia (the largest slum in the country’s capital city) to illustrate how distrust in the health system undermined care coverage when it was most needed and lay out three strategies to better understand and tackle distrust within the broader context of universal health coverage (UHC).
... Basic or essential packages of health services have been introduced in many post-conflict settings such as Afghanistan, Liberia, South Sudan, Somalia, the DRC, and Cambodia, although they often remain aspirational and unrealistic [50]. Other advantages can include a rapid increase in service coverage and a standardization of services, facilities, staffing, drugs and equipment [96,100,101]. ...
Based on a review of the evidence and expert consultation, we reviewed challenges and promising practices in relation to financing health care in fragile, conflict-affected and emergency contexts. Key messages and recommendations for global policy-makers and health systems are provided.
... Researchers have suggested that integrated packages of services may help in initial scale-up and improvements, but require additional inputs and adjustments to sustain these improvements. 59 60 62 66 Community-level education, empowerment and outreach are also recommended to improve utilisation and access to basic interventions and improve refer- rals from the community to the facility levels. 4 67-70 Expanding cadres of traditional birth attendants and community health workers has been found to be partic- ularly key in restoring maternal and neonatal services in conflict-affected settings. ...
Objectives
Only 12 countries in the WHO’s African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia’s success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality.
Design
A case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country’s civil war.
Setting
The interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region).
Participants
Key informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services.
Results
Three prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals.
Conclusions
Although Liberia experiences continued challenges related to limited resources, Liberia’s effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.
... Nandi (Nandi et al., 2012) 2012 5 Not about community-based health insurance (Onwujekwe, Onoka, et al., 2010) 2010 4 Proposed scheme (Onwujekwe, Okereke, et al., 2010) 2010 7 Willingness to pay Petit (Petit, Sondorp, Mayhew, Roura, & Roberts, 2013) 2013 5 Not about community-based health insurance (essential package at primary health care) ...
... Alternative providers of Ebola prevention include the Liberian government, local county governments, and prominent NGOs. Liberian public health has been poor since the late 1970s (Varpilah et al., 2011) and especially since its civil wars (Petit et al. 2013;Ghobarah et al., 2004;and Kruk et al., 2010). While there were 3,526 healthcare workers in 1988, the conflict had reduced this sector by 60 percent, i.e., to 1,396 employees by 1998 (Ali et al., 2015). ...
During the recent Ebola epidemic, large agricultural and industrial firms in Liberia helped to lower the prevalence rate of Ebola, despite the lack of functioning governmental public health services. Firestone, Sime Darby, and ArcelorMittal are three instances of firm-led Ebola prevention whereby the private goals of owners, managers, and workers aligned with the social goal of Ebola prevention. The phenomenon of firm-led Ebola prevention, however, is contrary to standard public health approaches to Ebola and underexplored in the economics of epidemiology. This paper develops three conditions under which firms respond to epidemiological disasters, provide prevention, and lower prevalence rates. First, firms have well-defined and enforceable property rights. Second, labor is relatively scarce. Third, there are few public health alternatives. The aforementioned firms each held well-defined property rights and few public health alternatives, while Firestone faced a relatively abundant supply of labor. These conditions and experiences from Liberia suggest private actors can be a significant source of preventing in epidemiological disasters and the welfare consequences of epidemics may be overstated.
... This included three sequential phases of action and response: prevention, response and treatment, and sequelae. Both the findings and the figures represented in this section detail community responses, and suggest implications that concatenate with the existing literature on social structure, gender roles, healthcare capacity, and conflict histories in the region [34,[36][37][38][39][40]. Prevention Community leaders agreed that prevention was the best strategy to curtail the Ebola outbreak. ...
... After going through a terrible civil war, maternal health outcomes in Liberia were beginning to recover from their earlier low rates (Petit et al., 2013). For instance, maternal mortality estimates showed that rates declined by 48% between 1990 and 2013, from 1200 to 640 deaths per 100,000 live births (WHO, 2014). ...
In Liberia, 75% of those who died from 2014 Ebola epidemic were women and the effects of this gruelling epidemic were more severely felt by pregnant women. This immediately raised fears about the long-term impacts of the epidemic on maternal and child health. As part of a larger study, this paper uses Andersen's behavioural model of health care utilization and Goffman's stigma theory to explain the timing and utilization of maternal health services before the outbreak of the Ebola epidemic as a background to the potential long-term effects on maternal health. We conducted survival and multiple regression analysis using the 2007 (N = 3,524) and 2013 (N = 5,127) Liberia's Demographic and Health Survey (LDHS) data. Our sample consisted of women of reproductive age (15–49 years) that had given birth in the last five years preceding the survey year. The findings show that from 2007 to 2013, there was an overall improvement in the timing of first antenatal care (ANC) visits (TR = 0.92, p < 0.001), number of ANC visits and delivery with skilled birth attendants. The results also show county and regional disparities in the utilization of ANC services with South Eastern A region emerging as a relatively vulnerable place. Also, access to ANC services defined by distance to a health facility strongly predicted utilization. We argue that the Ebola epidemic likely eroded many of the previous gains in maternal health care, and may have left a lingering negative effect on the access and utilization of maternal health services in the long-term. The study makes relevant policy recommendations.
... An increasingly common first step in restoring health systems in countries emerging from civil conflict is to rapidly scale up a set of cost-effective primary care services to address the country's priority health problems (Cassels, 2005;Petit, Sondorp, Mayhew, Roura, & Roberts, 2013). In brief, the Basic Package of Health Services (BPHS) in these countries has consisted of a limited set of cost-effective priority health services addressing the country's major health problems, with non-governmental organisations commonly contracted to deliver the agreed package of services, while the government and international donors take responsibility for stewardship and monitoring of implementation. ...
Reducing preventable maternal mortality and achieving Sustainable Development Goal targets for 2030 will require increased investment in improving access to quality health services in fragile and conflict-affected states. This study explores the conditions that affect availability and utilisation of intrapartum care services in four districts of Afghanistan where mortality studies were conducted in 2002 and 2011. Information on changes in each district was collected through interviews with community members; service providers; and district, provincial and national officials. This information was then triangulated with programme and policy documentation to identify factors that affect the coverage of safe delivery and emergency obstetric care services. Comparison of barriers to maternal health service coverage across the four districts highlights the complexities of national health policy planning and resource allocation in Afghanistan, and provides examples of the types of challenges that must be addressed to extend the reach of life-saving maternal health interventions to women in fragile and conflict-affected states. Findings suggest that improvements in service coverage must be measured at a sub-national level, and context-specific service delivery models may be needed to effectively scale up intrapartum care services in extremely remote or insecure settings.
... This included three sequential phases of action and response: prevention, response and treatment, and sequelae. Both the findings and the figures represented in this section detail community responses, and suggest implications that concatenate with the existing literature on social structure, gender roles, healthcare capacity, and conflict histories in the region [34,[36][37][38][39][40]. Prevention Community leaders agreed that prevention was the best strategy to curtail the Ebola outbreak. ...
Background:
The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia.
Methodology/principal findings:
This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia--one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support.
Conclusions/significance:
Local communities' strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.
... Gallagher et al. (2012) applied the Chronic Illness Trajectory Framework in their study on continuity of care, and Orzech's (2013) application of a bio-cultural model in adolescent sleep patterns is threaded throughout the publication. Petit et al. (2013) refer to their underpinning theory throughout the paper and make an explicit statement about how it informed the analysis. Additionally, this is reflected in the discussion and conclusion sections of the paper. ...
Background
Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict.
Objective
The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale.
Methods
We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme.
Results
Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%).
Conclusions
This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.
How can governments in low-trust settings overcome their credibility deficit when promoting public welfare? To answer this question, we evaluate the effectiveness of the Liberian government’s door-to-door canvassing campaign during the 2014–2015 Ebola epidemic, which aimed to persuade residents to voluntarily comply with policies for containing the disease. Combining data from an original representative survey of Monrovia during the crisis with variation in the campaign’s reach and using multiple identification strategies, we find that the informational campaign was remarkably effective at increasing adherence to safety precautions, support for contentious control policies, and general trust in government. To uncover the pathways through which the campaign proved so effective, we conducted over 80 in-depth qualitative interviews in 40 randomly sampled communities. This investigation suggests that local intermediaries were effective because their embeddedness in communities subjected them to monitoring and sanctioning, thereby assuring their fellow residents that they were accountable and thus credible.
Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS)from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.
Liberia, Africa’s oldest republic founded by freed Black slaves and the American Colonisation Society, was stunted by a civil war that killed 250,000 people and displaced another 850,000 between 1989 and 2003. In 2005, Liberia made headlines for being the first African country to democratically elect a female president. However, the Ebola virus descended upon Liberia on 30 March, 2014. Almost 2 years after, Liberia was the outbreak’s hardest hit country with 10,666 cases and 4806 deaths. The Global Fund for Women suggests 75% of those who died from Ebola were women, with past studies revealing that a mortality rate among pregnant women could be as high as 93.3%. Of the 184 health workers who died, nurses and nursing aids (mostly females) accounted for the highest proportion (35%) of the 810 Ebola health worker cases reported by mid-August 2014. During the Ebola outbreak, both the World Health Organisation and the government of Liberia declared a “public health emergency,” providing an opportunity to canvass various fields of law responsive to the threat of the disease and strengthen public health security. The World Health Organisation declared Liberia Ebola-free for the fourth time on 14 January, 2016. Despite having a crippled health system, an outdated Public Health Act, extremely low numbers of health workers, and under-funded government institutions of health and social welfare, Liberia stands out as a success story in curbing the Ebola outbreak. This chapter examines the extent to which international, regional, and national law and policy impacted upon and contributed to reproductive and maternal health outcomes of girls and women during the Ebola crisis in Liberia.
The UN Security Council meeting on 18 September 2014 represented a major turning-point in the international response to the Ebola outbreak then underway in West Africa. However, in the light of widespread criticism over the tardiness of the international response, it can be argued that the UN, and particularly the Security Council, failed to make best use of a potential resource it already had on the ground in Liberia: the United Nations Mission in Liberia (UNMIL). This article examines whether UNMIL could have done more to contribute to the emergency response and attempts to draw some lessons from this experience for potential peacekeeper involvement in future public health emergencies. UNMIL could have done more than it did within the terms of its mandate, although it may well have been hampered by factors such as its own capacities, the views of Troop Contributing Countries and the approach taken by the Liberian government. This case can inform broader discussions over the provision of medical and other forms of humanitarian assistance by peacekeeping missions, such as the danger of politicising humanitarian aid and peacekeepers doing more harm than good. Finally, we warn that a reliance on peacekeepers to deliver health services during ‘normal’ times could foster a dangerous culture of dependency, hampering emergency responses if the need arises.
Objective To explore the feasibility of health systems strengthening from the perspective of international healthcare implementers and donors in South Sudan.
Design A qualitative interview study, with thematic analysis using the WHO health system building blocks framework.
Setting South Sudan.
Participants 17 health system practitioners, working for international agencies in South Sudan, were purposively sampled for their knowledge and experiences of health systems strengthening, services delivery, health policy and politics in South Sudan.
Results Participants universally reported the health workforce as insufficient and of low capacity and service delivery as poor, while access to medicines was restricted by governmental lack of commitment in undertaking procurement and supply. However, progress was clear in improved county health department governance, health management information system functionality, increased health worker salary harmonisation and strengthened financial management.
Conclusions Resurgent conflict and political tensions have negatively impacted all health system components and maintaining or continuing health system strengthening has become extremely challenging. A coordinated approach to balancing humanitarian need particularly in conflict-affected areas, with longer term development is required so as not to lose improvements gained.
The 2014 West African Ebola epidemic differed considerably from previous Ebola epidemics in scope and spread. This paper draws from historical and ethnographic methodologies to contextualize the 2014 Ebola outbreak. I argue that the 2014 Ebola outbreak was unprecedented in multiple ways and that Senegal and Nigeria were able to respond much more swiftly and successfully than the three countries at the epicenter—Liberia, Sierra Leone, and Guinea—because of their more advanced healthcare systems. I seek to unpack the basis for these disparities in biomedical, political, and social responses to the epidemic and to suggest recommendations for the future.
It is the aim of this chapter to summarize the theoretical lessons to be drawn from the wealth of literature produced by more than thirty years of implementation research. The chapter is structured as follows: Section 2 discusses three different analytical approaches in traditional implementation theory in more detail: top-down models, bottom-up critiques, and hybrid theories that try to combine elements of the two other strands of literature. We explicate the theoretical underpinnings and discuss the pros and cons of the respective approaches. Section 3 then provides an overview of more recent theoretical approaches to implementation, all of which depart from central underpinnings of traditional implementation studies. In particular, we address insights gained from the study of implementation processes in the context of the European Union and we discuss the interpretative approach to implementation, which follows an alternative ontological path. Section 4 focuses on the main insights gained from more than thirty years of implementation research for a proper understanding of implementation processes. Moreover, it discusses the contributions of implementation analysis to the wider field of policy analysis and political science. Finally, Section 5 identifies a number of persistent weaknesses of implementation analysis and concludes by suggesting possible directions of future research to overcome these weaknesses in the years to come.
A review of the policy implementation literature finds the field split into two major schools, top-down and bottom-up. Pre- vious attempts to reconcile these models are described, followed by an alternative model. This model reconciles these approaches by concentrating on the theoretical significance of ambiguity and conflict for policy implementation. A number of factors crucial to the implementation process are identified as varyingty dependent on a policy's ambiguity and conflict level. Four policy implemen- tation paradigms are identified and the relevance of the existing literature to these conditions is discussed. The four paradigms are low conflict-low ambiguity (administrative implementation), high conflict-low ambiguity (political implementation), high con- flict-high ambiguity (symbolic implementation), and low conflict- high ambiguity (experimental implementation).
In this qualitative study we used an interpretive, critical ethnographic approach to provide an understanding of childbirth and maternal illness and death in Liberia through the lens of women, families, and communities. We identified three major themes from the data: (a) secrecy surrounding pregnancy and childbirth; (b) power and authority; and (c) distrust of the health care system. The interpretive theory, Behind the House, generated from data analysis provides an understanding of the larger social and cultural context of childbirth in Liberia. Our findings provide a more complete understanding of the contextual factors that impact on the intractable problem of maternal mortality.
In recent years, dozens of countries have introduced accreditation and other quality improvement initiatives. A great deal of information is available regarding best practices in high- and middle-income countries; however, little is available to guide developing nations seeking to introduce an accreditation programme. This paper describes the outputs and lessons learned in the first year of establishing an accreditation programme in Liberia, a developing nation in West Africa that in 2003 emerged from a brutal 14-year civil war. The Liberian experience of developing and implementing a government-sponsored, widespread accreditation programme may provide insight to other low-income and post-conflict countries seeking a way to drive rapid, system-wide reform in the health system, even with limited infrastructure and extremely challenging conditions.
To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war.
We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness.
Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba county's 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively.
Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.
Policy analysis can contribute to meeting health objectives by untangling the complex forces of power and process that underpin change. Health policy analysis has not been adequately developed and applied in low and middle income countries. Building a critical mass of networked researchers and policy-makers provides the key to developing the field and improving its contribution to health outcomes.
To research the effects of changes in health service utilization and quality on the costs of the Basic Package of Health Services (BPHS) in 13 provinces of Afghanistan.
The study grouped data from 355 health facilities and more than 4000 health posts into 21 data points that represented 21 different nongovernmental organization contracts for service delivery between April 2006 and March 2007. Data were pooled from five data sets on expenditure, service utilization, quality (i.e. client satisfaction and the availability of essential medicines and female health-care providers), pharmaceuticals, and security and remoteness scores. Pearson's partial correlation and multiple linear regression models were used to examine correlations between expenditure and other study variables.
Fixed costs were found to comprise most of the cost of BPHS contracts. There was no correlation between cost and utilization rate or security. The distance to the health facility was negatively correlated with costs (R(2) = 0.855, F-significance < 0.001). The presence of female health workers, indicative of good quality in this cultural context, was negatively correlated with security (r = -0.70; P < 0.001). There was a significant correlation between the use of curative services and client satisfaction but not between the use of preventive services and client satisfaction (R(2) = 0.389 and 0.272 for two types of health facilities studied).
Access to health services can be extended through contracting mechanisms in a post-conflict state even in the presence of security problems. Service characteristics, geographical distance and the security situation failed to consistently explain, alone or in combination, the observed variations in per capita costs or visits. Therefore, using these parameters as the basis for planning does not necessarily lead to better resource allocation.
Although baseline data for post-conflict situations are frequently unavailable, there is a clear deterioration in the health conditions of populations during and following conflict. Excess mortality and morbidity, displaced populations, and vulnerability to communicable diseases during and following conflict all call for immediate relief and restoration of basic services. As much as possible, short-term relief and assistance programmes should be implemented in a manner compatible with longer term health system rehabilitation. This paper presents a framework for analyzing the inputs and policies that make up post-conflict rehabilitation programmes in the health sector. Post-conflict ...
News from Afghanistan has tended to focus on suicide bombings, the insurgency, and opium production. Relatively less attention has been paid to socioeconomic developments and how day-to-day life has been affected by the ongoing insecurity and the large development effort. The lack of interest in developments in Afghanistan's health sector is unfortunate because there are some potentially useful lessons to be learned for other countries confronting violence, insecurity, or deep poverty.
Qualitative research methods have a long history in the social sciences and deserve to be an essential component in health and health services research. Qualitative and quantitative approaches to research tend to be portrayed as antithetical; the aim of this series of papers is to show the value of a range of qualitative techniques and how they can complement quantitative research.
Motivation in the work context can be defined as an individual's degree of willingness to exert and maintain an effort towards organizational goals. Health sector performance is critically dependent on worker motivation, with service quality, efficiency, and equity, all directly mediated by workers' willingness to apply themselves to their tasks. Resource availability and worker competence are essential but not sufficient to ensure desired worker performance. While financial incentives may be important determinants of worker motivation, they alone cannot and have not resolved all worker motivation problems. Worker motivation is a complex process and crosses many disciplinary boundaries, including economics, psychology, organizational development, human resource management, and sociology. This paper discusses the many layers of influences upon health worker motivation: the internal individual-level determinants, determinants that operate at organizational (work context) level, and determinants stemming from interactions with the broader societal culture. Worker motivation will be affected by health sector reforms which potentially affect organizational culture, reporting structures, human resource management, channels of accountability, types of interactions with clients and communities, etc. The conceptual model described in this paper clarifies ways in which worker motivation is influenced and how health sector reform can positively affect worker motivation. Among others, health sector policy makers can better facilitate goal congruence (between workers and the organizations they work for) and improved worker motivation by considering the following in their design and implementation of health sector reforms: addressing multiple channels for worker motivation, recognizing the importance of communication and leadership for reforms, identifying organizational and cultural values that might facilitate or impede implementation of reforms, and understanding that reforms may have differential impacts on various cadres of health workers.
Although prepayment schemes are being hailed internationally as part of a solution to health care financing problems in low-income countries, literature has raised problems with such schemes. This paper reports the findings of a study that examined the factors influencing low enrollment in Tanzania's health prepayment schemes (Community Health Fund). The paper argues that district managers had a direct influence over the factors explaining low enrollment and identified in other studies (inability to pay membership contributions, low quality of care, lack of trust in scheme managers and failure to see the rationale to insure). District managers' actions appeared, in turn, to be at least partly a response to the manner of this policy's implementation. In order better to achieve the objectives of prepayment schemes, it is important to focus attention on policy implementers, who are capable of re-shaping policy during its implementation, with consequences for policy outcomes.
The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13 843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context.
OBJECTIVE: To assess the availability of essential health services in northern Liberia in 2008, five years after the end of the civil war. METHODS: We carried out a population-based household survey in rural Nimba county and a health facility survey in clinics and hospitals nearest to study villages. We evaluated access to facilities that provide index essential services: artemisinin combination therapy for malaria, integrated management of childhood illness, human immunodeficiency virus (HIV) counselling and testing, basic emergency obstetric care and treatment of mental illness. FINDINGS: Data were obtained from 1405 individuals (98% response rate) selected with a three-stage population-representative sampling method, and from 43 of Nimba county's 49 health facilities selected because of proximity to the study villages. Respondents travelled an average of 136 minutes to reach a health facility. All respondents could access malaria treatment at the nearest facility and 55.9% could access HIV testing. Only 26.8%, 14.5%, and 12.1% could access emergency obstetric care, integrated management of child illness and mental health services, respectively. CONCLUSION: Although there has been progress in providing basic services, rural Liberians still have limited access to life-saving health care. The reasons for the disparities in the services available to the population are technical and political. More frequently available services (HIV testing, malaria treatment) were less complex to implement and represented diseases favoured by bilateral and multilateral health sector donors. Systematic investments in the health system are required to ensure that health services respond to current and future health priorities.
Armed conflict is an unfortunately common reality in modern times: more than 50 countries have experienced conflict since 1980. The countries afflicted are disproportionately poor — 15 of the 20 poorest countries in the world had conflict in the last two decades of the twentieth century (World Bank 1998b); and nine of the 10 countries with the highest infant mortality and under-five mortality rates have experienced some form of conflict since 1990 (UNDP 2005). In 2002, countries with a low Human Development Index (HDI) in conflict spent, on average, 3.7 per cent of their GDP on military expenditure, compared with only 2.4 per cent on health (UNDP 2005). By the year 2020, mortality and morbidity from war are expected to represent the eighth largest category of disease burden, worldwide (Krug et al. 2000).
First published in 1980, Street-Level Bureaucracy received critical acclaim for its insightful study of how public service workers, in effect, function as policy decision makers, as they wield their considerable discretion in the day-to-day implementation of public programs. Three decades later, the need to bolster the availability and effectiveness of healthcare, social services, education, and law enforcement is as urgent as ever. In this thirtieth anniversary expanded edition, Michael Lipsky revisits the territory he mapped out in the first edition to reflect on significant policy developments over the last several decades. Despite the difficulties of managing these front-line workers, he shows how street-level bureaucracies can be and regularly are brought into line with public purposes. Street-level bureaucrats-from teachers and police officers to social workers and legal-aid lawyers-interact directly with the public and so represent the frontlines of government policy. In Street-Level Bureaucracy, Lipsky argues that these relatively low-level public service employees labor under huge caseloads, ambiguous agency goals, and inadequate resources. When combined with substantial discretionary authority and the requirement to interpret policy on a case-by-case basis, the difference between government policy in theory and policy in practice can be substantial and troubling. The core dilemma of street-level bureaucrats is that they are supposed to help people or make decisions about them on the basis of individual cases, yet the structure of their jobs makes this impossible. Instead, they are forced to adopt practices such as rationing resources, screening applicants for qualities their organizations favor, "rubberstamping" applications, and routinizing client interactions by imposing the uniformities of mass processing on situations requiring human responsiveness. Occasionally, such strategies work out in favor of the client. But the cumulative effect of street-level decisions made on the basis of routines and simplifications about clients can reroute the intended direction of policy, undermining citizens' expectations of evenhanded treatment. This seminal, award-winning study tells a cautionary tale of how decisions made by overburdened workers translate into ad-hoc policy adaptations that impact peoples' lives and life opportunities. Lipsky maintains, however, that these problems are not insurmountable. Over the years, public managers have developed ways to bring street-level performance more in line with agency goals. This expanded edition of Street-Level Bureaucracy underscores that, despite its challenging nature, street-level work can be made to conform to higher expectations of public service.
Part of the Understanding Public Health series, this bestselling book is the leading text in the field. It focuses on how health policy is made nationally and globally, clearly explaining the key concepts from political science with a wide array of engaging examples.
This edition is fully updated to reflect new research and ways of thinking about the health policy process. Written by leading experts, this clear and accessible book addresses the "how" of health policy making in a range of international settings.
The book provides an accessible approach to understanding:
Health policy analysis
Power and policy making
Public and private sector
Agenda setting
Government roles in policy
Interest groups and policy
Policy implementation
Globalization and policy process
Policy research and evaluation
Doing policy analysis
Making Health Policy 2nd edition is an ideal resource for students of public health and health policy, public health practitioners and policy makers.
This article argues that a multiorganizational unit of analysis, an implementation structure, should be used when describing and evaluating the implementation and administration of programmes.
Programmes are implemented by clusters of parts of public and private organizations. An implementation structure is the administrative entity which programme implementors use for accomplishing objectives within programmes. An organizationally rooted analy sis is therefore inadequate to rationalize the activities surrounding programme imple mentation.
This article defines implementation structures and argues the advantage of using a multiorganizational analytic perspective over the perspective of single organizations.
This paper first reviews the implementation literature of the past fifteen years, with particular emphasis on the relative strengths and weaknesses of the ‘top-down’ and ‘bottom-up’ approaches. It also argues that the 4–6 year time-frame used in most implementation research misses many critical features of public policy-making. The paper then outlines a conceptual framework for examining policy change over a 10–20 year period which combines the best features of the ‘top-down’ and ‘bottom-up’ approaches with insights from other literatures.
To assess the availability and utilization of emergency obstetric and neonatal care (EmONC) facilities in Afghanistan, as defined by UN indicators.
In a cross-sectional study of 78 first-line referral facilities located in secure areas of Afghanistan, EmONC service delivery was evaluated by using Averting Maternal Deaths and Disabilities (AMDD) Program assessment tools.
Forty-two percent of peripheral facilities did not perform all 9 signal functions required of comprehensive EmONC facilities. The study facilities delivered 17% of all neonates expected in their target populations and treated 20% of women expected to experience direct complications. The population-based rate of cesarean delivery was 1%. Most maternal deaths (96%) were due to direct causes. The direct and indirect obstetric case fatality rates were 0.8% and 0.2%, respectively.
Notable progress has been made in Afghanistan over the past 8 years in improving the quality, coverage, and utilization of EmONC services, but gaps remain. Re-examination of the criteria for selecting and positioning EmONC facilities is recommended, as is the provision of high-quality, essential maternal and neonatal health services at all levels of the healthcare system, linked by appropriate communication and functional referral systems.
We conducted a randomized trial to address the health needs of in-school adolescents in Liberia, where we analyzed data from a behavioral survey administered to 820 students from eight urban schools. Our findings suggest that adolescents are at significant risk for HIV and other sexually transmitted diseases (STDs): 36% of respondents were sexually experienced, 34% of those had first sex at ages 14 or younger, 66% of first sexual encounters were unprotected, and 16% were described as "forced." Also, females were more likely to have older boyfriends (Pearson's chi square = 19.2, p = .0001) and sex resulting in pregnancies (Pearson's chi square = 11.5, p = .01), while males were more likely to have a greater number of sexual partners (Pearson's chi square = 5.6, p = .05) in the previous 3 months. We recommend further research to explore challenges associated with implementing behavioral-driven studies in post-conflict environments.
Objective. To quantify the influence of health system attributes, particularly quality of care, on preferences for health clinics in Liberia, a country with a high burden of disease that is rebuilding its health system after 14 years of civil war.
Data Sources/Study Setting. Informed by focus group discussions, a discrete choice experiment (DCE) was designed to assess preferences for structure and process of care at health clinics. The DCE was fielded in rural, northern Liberia as part of a 2008 population-based survey on health care utilization.
Data Collection. The survey response rate was 98 percent with DCE data available for 1,431 respondents. Mixed logit models were used to estimate the influence of six attributes on choice of hypothetical clinics for a future illness.
Principal Findings. Participants' choice of clinic was most influenced by provision of a thorough physical exam and consistent availability of medicines. Respectful treatment and government (versus NGO) management marginally increased utility, whereas waiting time was not significant.
Conclusions. Liberians value technical quality of care over convenience, courtesy, and public management in selecting clinics for curative care. This suggests that investments in improved competence of providers and availability of medicines may increase population utilization of essential services as well as promote better clinical outcomes.
Liberia is rebuilding its health system after a lengthy civil war in which traditional health care was the only reliable source of care.
This study explored individual, village, and health system factors related to the utilization of health clinics versus informal providers (eg, healers, medicine sellers) in Liberia. RESEARCH DESIGN, PARTICIPANTS, AND MEASURES: This was a cross-sectional population-representative survey of 1435 adults living in rural Nimba County, Liberia. Participants were asked about past year visits to traditional and formal health care providers and demographics, health, and trauma indicators. The association between formal and informal visits and potential determinants was estimated in separate models using generalized estimating equations to adjust for village-level clustering.
The median number of visits in the past year to formal and informal providers was 3 and 10, respectively. Clinic visits increased with younger age and female sex, past trauma exposure, the number of traditional healers, and the presence of a facility dispenser. Frequency of informal visits increased with poor self-reported mental and physical health, the presence of facility fees and decreased with literacy and wealth and satisfaction with the formal health system.
Rural Liberians use both formal and informal health care extensively and as complements rather than substitutes. The reliance on traditional medicine to address health needs is of concern in a country with a high disease burden. Health system investments that build public confidence in the health system may help shift demand from informal to formal health care.
The huge majority of the annual 6.3 million perinatal deaths and half a million maternal deaths take place in developing countries and are avoidable. However, most of the interventions aiming at reducing perinatal and maternal deaths need a health care system offering appropriate antenatal care and quality delivery care, including basic and comprehensive emergency obstetric care facilities. To promote the uptake of quality care, there are two possible approaches: influencing the demand and/or the supply of care. Five lessons emerged from experiences. First, it is difficult to obtain robust evidence of the effects of a particular intervention in a context, where they are always associated with other interventions. Second, the interventions tend to have relatively modest short-term impacts, when they address only part of the health system. Third, the long-term effects of an intervention on the whole health system are uncertain. Fourth, because newborn health is intimately linked with maternal health, it is of paramount importance to organise the continuum of care between mother and newborn. Finally, the transfer of experiences is delicate, and an intervention package that has proved to have a positive effect in one setting may have very different effects in other settings.
Violent conflicts claim lives, disrupt livelihoods, and halt delivery of essential services, such as health care and education. Health systems are often devastated in conflicts as health professionals flee, infrastructure is destroyed, and the supply of drugs and supplies is halted. We propose that early reconstruction of a functioning, equitable health system in countries recovering from conflict is an investment with a range of benefits for post-conflict countries. Building on the growing literature about health systems as social and political institutions, we elaborate a logic model that outlines how health systems may contribute not only to improved health status but also potentially to broader statebuilding and enhanced prospects for peace. Specifically, we propose that careful design of the core elements of the health system by national governments and their development partners can promote reliable provision of essential health services while demonstrating a commitment to equity, strengthening government accountability to citizens, and building the capacity of government to manage core social programs. We review the conceptual basis and extant empirical evidence for these mechanisms, identify knowledge gaps, and suggest a research agenda.
An appraisal of government health facilities documented generally poor conditions, a shortage of drugs and supplies, and inadequate skills among staff. Focus group discussions in the community revealed a lack of knowledge about obstetric complications and difficulty in reaching health facilities.
Improvements were made in services at primary health units (PHUs) through May 1993. Community motivators were trained in June and provided with bicycles and raingear in September 1993. Among their duties were community education, formation of village action groups for emergency transport and facilitation of referral for women with obstetric complications.
Between August 1992 and December 1995, women with major complications seen at the PHUs increased from nine to 16 per month, with fluctuations due to disruptions in services and civil strife. The proportion of women with complications who were referred by the community motivators diminished over time, dropping from 24% to 1% over the first two years (1993-1994) and then recovering somewhat to 10% in the final period of observation.
The cost of this intervention was approximately US$5082, with about half coming from the project and the rest from the government (44%) and the community (8%).
The project improved utilization of the PHUs by women with complications, indicating that once services are of acceptable quality, many women will use them. The contribution of the motivators was positive, though smaller than expected.
This study investigates how a group of nurses based in busy urban primary care health clinics experienced the implementation of the free care (the removal of fees) and other South African national health policies introduced after 1996. The study aimed to capture the perceptions and perspectives of front-line providers (street-level bureaucrats) concerning the process of policy implementation. Using qualitative and quantitative research methods, the study paid particular attention to the personal and professional consequences of the free care policy; the factors which influence nurses' responses to policy changes such as free care; and what they perceive to be barriers to effective policy implementation. The research reveals firstly that nurses' views and values inform their implementation of health policy; secondly that nurses feel excluded from the process of policy change; and finally that social, financial and human resources are insufficiently incorporated into the policy implementation process. The study recommends that the practice of policy change be viewed through the lens of the 'street-level bureaucrat' and highlights three sets of related managerial actions.
In 1991, the Somali National Movement fighters recaptured the Somaliland capital city of Hargeisa after a 3-year civil war. The government troops of the dictator General Mohamed Siad Barre fled south, plunging most of Somalia into a state of anarchy that persists to this day. In the north of the region, the redeclaration of independence of Somaliland took place on May 18, 1991. Despite some sporadic civil unrest between 1994 and 1996, and a few tragic killings of members of the international community, the country has enjoyed peace and stability and has an impressive development record. However, Somaliland continues to await international recognition. The civil war resulted in the destruction of most of Somaliland's health-care facilities, compounded by mass migration or death of trained health personnel. Access to good, affordable health care for the average Somali remains greatly compromised. A former medical director of the general hospital of Hargeisa, Abdirahman Ahmed Mohamed, suggested the idea of a link between King's College Hospital in London, UK, and Somaliland. With support from two British colleagues, a fact-finding trip sponsored by the Tropical Health and Education Trust (THET) took place in July, 2000, followed by a needs assessment by a THET programme coordinator. Here, we describe the challenges of health-care reconstruction in Somaliland and the evolving role of the partnership between King's College Hospital, THET, and Somaliland within the context of the growing movement to link UK NHS trusts and teaching institutions with counterparts in developing countries.
The Ministry of Public Health (MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-care settings, this represents the first time that the BSC has been employed in a developing country. The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13,843 households. Nationally, health services were found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces; no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan context.
The Ministry of Public Health (MOPH) of Afghanistan has adopted the Balanced Scorecard (BSC) as a tool to measure and manage performance in delivery of a Basic Package of Health Services. Based on results from the 2004 baseline round, the MOPH identified eight of the 29 indicators on the BSC as priority areas for improvement. Like the 2004 round, the 2005 and 2006 BSCs involved a random selection of more than 600 health facilities, 1700 health workers and 5800 patient-provider interactions. The 2005 and 2006 BSCs demonstrated substantial improvements in all eight of the priority areas compared to 2004 baseline levels, with increases in median provincial scores for presence of active village health councils, availability of essential drugs, functional laboratories, provider knowledge, health worker training, use of clinical guidelines, monitoring of tuberculosis treatment, and provision of delivery care. For three of the priority indicators-drug availability, health worker training and provider knowledge-scores remained unchanged or decreased between 2005 and 2006. This highlights the need to ensure that early gains achieved in establishment of health services in Afghanistan are maintained over time. The use of a coherent and balanced monitoring framework to identify priority areas for improvement and measure performance over time reflects an objectives-based approach to management of health services that is proving to be effective in a difficult environment.
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