How can we best help this patient? Exploring mental health therapists' reflections on medication-free care for patients with psychosis in Norway.

BACKGROUND: Since 2015, Norwegian Regional Health Authorities have followed new government policy and gradually implemented medication-free services for patients with psychosis. The aim of this qualitative study was to explore the tension between policy and practice, and how health care workers in Bergen reflect on their role in implementing medication-free treatment. METHODS: We performed three focus group discussions including 17 therapists working within medication free services, asking about their experiences with this new treatment program. We used Systematic Text Condensation for data analysis. The findings were discussed using Michael Lipsky's theoretical framework on the role public health workers play in policy implementation. FINDINGS: Following Norway's new policy was challenging for the therapists in our study, particularly balancing a patient's needs with treatment guidelines, the legal framework and available resources. Therapists had an overarching wish to help patients through cooperation and therapeutic alliance, but their alliance was sometimes fragile, and the therapists worried about patients' conditions worsening. CONCLUSIONS: Democratization of treatment choices, with the aim of empowering patients in mental health care, challenges the level of professional discretion given that patients and therapists might have conflicting goals. Balancing the desire to help, professional responsibility, the perceived lack of resources, and certain patient choices created conditions that can leave therapists feeling disempowered in and alienated from their work. TRIAL REGISTRATION: N/A.

Cesarean delivery rates, hospital readiness and quality of clinical management in Ethiopia: national results from two cross-sectional emergency obstetric and newborn care assessments.

BACKGROUND: Cesarean delivery (CD) rates have reached epidemic levels in many high and middle income countries while increasingly, low income countries are challenged both by high urban CD rates and high unmet need in rural areas. The managing authority of health care institutions often plays a role in these disparities. This paper shows changes between 2008 and 2016 in Ethiopian CD rates, readiness of hospitals to provide CD and quality of clinical care, while highlighting the role of hospital management authority. METHODS: This secondary data analysis draws from two national cross-sectional studies to assess emergency obstetric and newborn care. The sample includes 111 hospitals in 2008 and 316 hospitals in 2016, and 275 women whose CD chart was reviewed in 2008 and 568 in 2016. Descriptive statistics are used to describe our primary outcome measures: population- and institutional-based CD rates; hospital readiness to perform CD; quality of clinical management, including the relative size of Robson classification groups. RESULTS: The national population CD rate increased from 2008 to 2016 (< 1 to 2.7%) as did all regional rates. Rates in 2016 ranged from 24% in urban settings to less than 1% in several rural regions. The institutional rate was 54% in private for-profit hospitals in 2016, up from 46% in 2008. Hospital readiness to perform CDs increased in public and private for-profit hospitals. Only half of the women whose charts were reviewed received uterotonics after delivery of the baby, but use of prophylactic antibiotics was high. Partograph use increased from 9 to 42% in public hospitals, but was negligible or declined elsewhere. In 2016, 40% of chart reviews from public hospitals were among low-risk nulliparous women (Robson groups 1&2). CONCLUSIONS: Between 2008 and 2016, government increased the availability of CD services, improved public hospital readiness and some aspects of clinical quality. Strategies tailored to further reduce the high unmet need for CD and what appears to be an increasing number of unnecessary cesareans are discussed. Adherence to best practices and universal coverage of water and electricity will improve the quality of hospital services while the use of the Robson classification system may serve as a useful quality improvement tool.

Decolonizing Health Governance: A Uganda Case Study on the Influence of Political History on Community Participation.

This paper presents a case study of how colonial legacies in Uganda have affected the shape and breadth of community participation in health system governance. Using Habermas's theory of deliberative democracy and the right to health, we examine the key components required for decolonizing health governance in postcolonial countries. We argue that colonization distorts community participation, which is critical for building a strong state and a responsive health system. Participation processes grounded in the principles of democracy and the right to health increase public trust in health governance. The introduction and maintenance of British laws in Uganda, and their influence over local health governance, denies citizens the opportunity to participate in key decisions that affect them, which impacts public trust in the government. Postcolonial societies must tackle how imported legal frameworks exclude and limit community participation. Without meaningful participation, health policy implementation and accountability will remain elusive.

Understanding inequities in health and health systems in Latin America and the Caribbean: a thematic series.

Latin America, with its culturally and ethnically diverse populations, its burgeoning economies, high levels of violence, growing political instability, and its striking levels of inequality, is a region that is difficult to define and to understand. The region's health systems are deeply fragmented and segmented, which poses great challenges related to the provision of quality of care and overall equity levels in health and in Latin American society at large. Market, social, and political forces continue to push towards the poorly regulated privatization of public health care in many countries within the region, in detriment of public healthcare services where management capacities are limited.In this first collection of papers, we showcase how the region has tackled, with different levels of success, the incorporation of innovative health system reforms aimed at strengthening governance, participation, and the response to the growing epidemiological and demographic demands of its diverse population. We are delighted that this Special Collection will remain open to house future papers from Latin America and the Caribbean. The region has important experiences and lessons to share with the world. We look forward to learning more about how researchers and practitioners continue to experiment and innovate in their struggle to reach equity in health for all. This thematic series is a platform where the region's lessons and approaches can be shared with the global community of Health Policy and Systems Researchers.

Realizing the right to health in Latin America, equitably.

This special issue "Realizing the Right to Health in Latin America and the Caribbean" provides an overview of one of the most challenging objectives of health systems: equity and the realization of the right to health. In particular, it concentrates on the issues associated with such a challenge in countries suffering of deep inequity. The experience in Latin America and the Caribbean demonstrates that the efforts of health systems to achieve Universal Health Coverage are necessary but not sufficient to achieve an equitable realization of the right to health for all. The inequitable realization of all other human rights also determines the realization of the right to health.

Axes of alienation: applying an intersectional lens on the social contract during the pandemic response to protect sexual and reproductive rights and health.

While economic inequalities have been a key focus of attention through the COVID 19 pandemic, gendered relations of power at every level have undermined health rights of women, girls and gender diverse individuals. Sexual and reproductive health rights (SRHR) have always been sites of power contestations within families, societies, cultures, and politics; these struggles are exacerbated by economic, racial, religious, caste, citizenship status, and other social inequities, especially in times of crisis such as these. Policy responses to the COVID pandemic such as lockdown, quarantine, contact tracing and similar measures are premised on the existence of a social contract between the government and the people and among people, with the health sector playing a key role in preventive and curative care.We propose the use of an intersectional lens to explore the impact of the COVID-19 pandemic on the social contract, drawing on our field experiences from different continents particularly as related to SRHR. Along with documenting the ways in which the pandemic hinders access to services, we note that it is essential to interrogate state-society relations in the context of vulnerable and marginalized groups, in order to understand implications for SRHR. Intersectional analysis takes on greater importance now than in non-pandemic times as the state exercises more police or other powers and deploys myriad ways of 'othering'.We conclude that an intersectional analysis should not limit itself to the cumulative disadvantages and injustices posed by the pandemic for specific social groups, but also examine the historical inequalities, structural drivers, and damaged social contract that underlie state-society relationships. At the same time, the pandemic has questioned the status quo and in doing so it has provided opportunities for disruption; for re-imagining a social contract that reaches across sectors, and builds community resilience and solidarities while upholding human rights and gender justice. This must find place in future organizing and advocacy around SRHR.

Global Health in the Age of COVID-19: Responsive Health Systems Through a Right to Health Fund.

We propose that a Right to Health Capacity Fund (R2HCF) be created as a central institution of a reimagined global health architecture developed in the aftermath of the COVID-19 pandemic. Such a fund would help ensure the strong health systems required to prevent disease outbreaks from becoming devastating global pandemics, while ensuring genuinely universal health coverage that would encompass even the most marginalized populations. The R2HCF's mission would be to promote inclusive participation, equality, and accountability for advancing the right to health. The fund would focus its resources on civil society organizations, supporting their advocacy and strengthening mechanisms for accountability and participation. We propose an initial annual target of US$500 million for the fund, adjusted based on needs assessments. Such a financing level would be both achievable and transformative, given the limited right to health funding presently and the demonstrated potential of right to health initiatives to strengthen health systems and meet the health needs of marginalized populations-and enable these populations to be treated with dignity. We call for a civil society-led multi-stakeholder process to further conceptualize, and then launch, an R2HCF, helping create a world where, whether during a health emergency or in ordinary times, no one is left behind.

Health equity and COVID-19: global perspectives.

The COVID-19 is disproportionally affecting the poor, minorities and a broad range of vulnerable populations, due to its inequitable spread in areas of dense population and limited mitigation capacity due to high prevalence of chronic conditions or poor access to high quality public health and medical care. Moreover, the collateral effects of the pandemic due to the global economic downturn, and social isolation and movement restriction measures, are unequally affecting those in the lowest power strata of societies. To address the challenges to health equity and describe some of the approaches taken by governments and local organizations, we have compiled 13 country case studies from various regions around the world: China, Brazil, Thailand, Sub Saharan Africa, Nicaragua, Armenia, India, Guatemala, United States of America (USA), Israel, Australia, Colombia, and Belgium. This compilation is by no-means representative or all inclusive, and we encourage researchers to continue advancing global knowledge on COVID-19 health equity related issues, through rigorous research and generation of a strong evidence base of new empirical studies in this field.

Triangulating data sources for further learning from and about the MDSR in Ethiopia: a cross-sectional review of facility based maternal death data from EmONC assessment and MDSR system.

BACKGROUND: Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. METHODS: This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. RESULTS: A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10-27%) and severe preeclampsia/eclampsia (10-24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7-33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. CONCLUSION: The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.

Healthcare workers' clinical knowledge on maternal and newborn care in Ethiopia: findings from 2016 national EmONC assessment.

BACKGROUND: Improving maternal and newborn health indicators are key if Ethiopia is to achieve the Sustainable Development Goals. To do so, women need access to skilled attendance at birth and emergency obstetric and newborn care. To maximize their impact, understanding gaps in workers' knowledge is required to remedy the weakness. This assessment determines knowledge levels of clinical management of maternal and newborn healthcare and factors that influence knowledge. METHODS: This study used data from the National Emergency Obstetric and Neonatal Care assessment conducted in 2016. Provider knowledge for MNH was assessed by interviewing providers. Respondents were scored on each question by calculating the number of correct responses provided out of the total possible answers, and standardizing this to a scale of 100. Mixed linear regression was used to determine individual and contextual factors associated with the score. RESULTS: A total of 3800 interviews with complete data were included in this study. Most respondents were diploma midwives (73%), BSc midwives (11%) and diploma nurses (10%). On average, midwives scored 60 out of 100 on the question regarding the primary aspects of focused antenatal care and elements of a birth plan. Half of the midwives and health officers, and one-third of nurses knew to provide a loading dose of magnesium sulphate. Midwives scored 90% on the steps of active management of third stage of labor. In the mixed linear regression, working in a private for profit facility, health center/clinic, rural area, or in a facility with a protocol on referral/counter referral predicted lower knowledge scores. More positive scores were associated with work environments that had a computer, internet, and protocols on safe abortion care, management of selected obstetric topics, integrated management of pregnancy, childbirth, postnatal, and newborn, care for low birth weight including kangaroo mother care, and treatment of infection in young infants. CONCLUSION: With regard to most knowledge related questions, health officers and midwives scored similarly. Providers scored substantially better on routine intrapartum and newborn care than on aspects related to care for complications. A substantial proportion of providers indicated that they would never give a loading dose of magnesium sulphate.

Readiness to treat and factors associated with survival of newborns with breathing difficulties in Ethiopia.

BACKGROUND: Ethiopia is one of five countries that account for half of the world's 2.6 million newborn deaths. A quarter of neonatal deaths in Ethiopia are caused by birth asphyxia. Understanding different dimensions of the quality of care for newborns with breathing difficulties can lead to improving service provision environments and practice. We describe facility readiness to treat newborns with breathing difficulties, the extent to which newborn resuscitation is provided, and by modeling the survival of newborns with difficulties breathing, we identify key factors that suggest how mortality from asphyxia can be reduced. METHODS: We carried out a secondary analysis of the 2016 Ethiopia Emergency Obstetric and Newborn Care Assessment that included 3804 facilities providing childbirth services and 2433 chart reviews of babies born with difficulties breathing. We used descriptive statistics to assess health facilities' readiness to treat these newborns and a binary logistic regression to identify factors associated with survival. RESULTS: Over one-quarter of facilities did not have small-sized masks (size 0 or 1) to complete the resuscitation kits. Among the 2190 cases with known survival status, 49% died before discharge, and among 1035 cases with better data quality, 29% died. The odds of surviving birth asphyxia after resuscitation increased eightfold compared to newborns not resuscitated. Other predictors for survival were the availability of a newborn corner, born at term or post-term, normal birth weight (≥2500 g) and delivered by cesarean or assisted vaginal delivery. CONCLUSION: The survival status of newborns with birth asphyxia was low, particularly in the primary care facilities that lacked the required resuscitation pack. Newborns born in a facility with better data quality were more likely to survive than those born in facilities with poor data quality. Equipping health centers/clinics with resuscitation packs and reducing the incidence of preterm and low birth weight babies should improve survival rates.

Does Information and Communication Technology Add Value to Citizen-Led Accountability Initiatives in Health? Experiences from India and Guatemala.

Information and Communication Technology (ICT) may facilitate the collection and dissemination of citizen-generated data to enhance governmental accountability for the fulfillment of the right to health. The aim of this multiple case study research was to distill considerations related to the implementation of ICT and health accountability projects, describe the added operational value of ICT tools (as compared to similar projects that do not use ICT), and make preliminary statements regarding government responsiveness to accountability demands through ICT projects. In all three projects, the need for relationship building, continuous community engagement and technical support, and training for volunteers or service users was identified. Government responsiveness to the data varied, suggesting that political will is lacking in certain contexts. Despite these challenges, ICT initiatives provided an easy, accessible, and low-risk platform for reporting violations and demanding accountability from service providers and decision-makers. ICT-enabled citizen generated data can add significant operational value and some political value to project activities and goals, and may affect systems change when it is part of a broad-based, multi-level civil societal and governmental effort to improve health care quality.

Showcasing the contribution of social sciences to health policy and systems research.

BACKGROUND: This Special Issue represents a critical response to the frequent silencing of qualitative social science research approaches in mainstream public health journals, particularly in those that inform the field of health policy and systems research (HPSR), and the study of equity in health. METHODS: This collection of articles is presented by SHAPES, the thematic working group of Health Systems Global focused on social science approaches to research and engagement in health policy and systems. The issue aims to showcase how qualitative and theory-driven approaches can contribute to better promoting equity in health within the field of HPSR. RESULTS: This issue builds on growing recognition of the complex social nature of health systems. The articles in this collection underscore the importance of employing methods that can uncover and help explain health system complexities by exploring the dynamic relationships and decision-making processes of the human actors within. Articles seek to highlight the contribution that qualitative, interpretivist, critical, emancipatory, and other relational methods have made to understanding health systems, health policies and health interventions from the perspective of those involved. By foregrounding actor perspectives, these methods allow us to explore the impact of vital but difficult-to-measure concepts such as power, culture and norms. CONCLUSION: This special issue aims to highlight the critical contribution of social science approaches. Through the application of qualitative methods and, in some cases, development of theory, the articles presented here build broader and deeper understanding of the way health systems function, and simultaneously inform a more people-centred approach to collective efforts to build and strengthen those systems.

Community health workers and accountability: reflections from an international "think-in".

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a 'think in', held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger "accountability ecosystem." This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs' social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability.

Oral medicine acceptance in infants and toddlers: measurement properties of the caregiver-administered Children's acceptance tool (CareCAT).

BACKGROUND: Developing age-appropriate medications remains a challenge in particular for the population of infants and toddlers, as they are not able to reliably self-report if they would accept and consequently take an oral medicine. Therefore, it is common to use caregivers as proxies when assessing medicine acceptance. The outcome measures used in this research field differ and most importantly lack validation, implying a persisting gap in knowledge and controversy in the field. The newly developed Caregiver-administered Children's Acceptance Tool (CareCAT) is based on a 5-point nominal scale, with descriptors of medication acceptance behavior. This cross-sectional study assessed the measurement properties of the tool with regards to the user's understanding and its intra- and inter-rater reliability. METHODS: Participating caregivers were enrolled at a primary healthcare facility where their children (median age 6 months) had been prescribed oral antibiotics. Caregivers, trained observers and the tool developer observed and scored on the CareCAT tool what behavior children exhibited when receiving the medicine (n = 104). The video-records of this process served as replicate observations (n = 69). After using the tool caregivers were asked to explain their observations and the tool descriptors in their own words. The tool's reliability was assessed by percentage agreement and Cohen's unweighted kappa coefficients of agreement for nominal scales. RESULTS: The study found that caregivers using CareCAT had a satisfactory understanding of the tool's descriptors. Using its dichotomized scores the tool reliably was strong for acceptance behavior (agreement inter-rater 84-88%, kappa 0.66-0.76; intra-rater 87-89%, kappa 0.68-0.72) and completeness of medicine ingestion (agreement inter-rater 82-86%, kappa 0.59-0.67; intra-rater 85-93%, kappa 0.50-0.70). CONCLUSIONS: The CareCAT is a low-cost, easy-to-use and reliable instrument, which is relevant to assess acceptance behavior and completeness of medicine ingestion, both of which are of significant importance for developing age-appropriate medications in infants and toddlers.

Development and validation of a Screening Questionnaire of Family Mistreatment against Older Adults for use in primary care settings in Mexico.

The abuse of older adults is a serious public health issue that can be difficult to identify at the first level of care. Medical and nursing personnel are sometimes unable to identify older adults who suffer family mistreatment. This can occur when victims feel shame or as a result of cultural factors. In the light of this, healthcare personnel require a screening tool that can be used to identify signs of mistreatment. The aim of this study was to develop and validate a screening tool for detecting the familial mistreatment of older adults in primary care settings. A mixed method cross-sectional study was carried out in three phases between 2009 and 2012 in Mexico. The formative phase involved using a qualitative methodology to identify terms that older adults use to identify practices defined as forms of mistreatment. On this basis, the second phase involved the design of a screening tool through the formation of items in collaboration with a panel of experts. These items were tested on older adults to ensure their intelligibility. Finally, validity and reliability levels were evaluated through the application of the screening tool to a sample of older adults at a primary care facility and at a legal centre. These findings were discussed with gerontologists, and the data were analysed through an exploratory factor analysis with orthogonal rotation and Cronbach's alpha using STATA v13. From the results, we generated a screening tool that is culturally and socially tailored to older adults in Mexico. The tool has a Cronbach's alpha of 0.89, a sensitivity value of 86% (p < .05) and a specificity value of 90% (p < .05) for positive answers to the tool's 15 items. Applying this tool at the first level of care could limit damage to older adults' health and could lower the frequency of emergency room use in hospitals.

Looking forward to the next 15 years: innovation and new pathways for research in health equity.

Since our launch in 2002, the International Journal for Equity in Health (IJEqH) has furthered our collective understanding of equity in health and health services by providing a platform on which academics and practitioners can share their work. Today, we celebrate our fifteenth anniversary with an article collection that presents a call for new and novel research in equity in health and we invite our authors to use new approaches and methods, and to focus on emerging areas of research related to health equity in order to set the stage for the next fifteen years of health equity research.Our anniversary issue provides a platform for expanding the conceptualization, diversity of populations and study designs, and for increasing the use of novel methodologies in the field. The IJEqH has helped to support the wider group of researchers, policymakers and practitioners with a commitment to social justice and equity but there is still more to do. With the help of the highly committed editorial team and editorial board, the innovative work of researchers worldwide, and the countless of hours dedicated by hundreds of reviewers, we are confident in the IJEqH's ability to continue supporting the dissemination of health equity research for years to come.