Treading the Thin Line: Pharmacy Workers' Perspectives on Medication Abortion Provision in Lusaka, Zambia.

CONTEXT: Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. METHODS: We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. RESULTS: We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation. CONCLUSION: These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.

Unintended Consequences of mHealth Interactive Voice Messages Promoting Contraceptive Use After Menstrual Regulation in Bangladesh: Intimate Partner Violence Results From a Randomized Controlled Trial.

BACKGROUND: Mobile phones for health (mHealth) hold promise for delivering behavioral interventions. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to "regulate the menstrual cycle when menstruation is absent for a short duration." METHODS: We recruited MR clients from 41 public- and private-sector clinics immediately after MR. Eligibility criteria included having a personal mobile phone and consenting to receive messages about family planning by phone. We randomized participants remotely to an intervention group that received at least 11 voice messages about contraception over 4 months or to a control group (no messages). The primary outcome was LARC use at 4 months. Adverse events measured included experience of intimate partner violence (IPV). Researchers recruiting participants and 1 analyst were blinded to allocation groups. All analyses were intention to treat. The trial is registered with ClinicalTrials.gov (NCT02579785). RESULTS: Between December 2015 and March 2016, 485 women were allocated to the intervention group and 484 to the control group. We completed follow-up on 389 intervention and 383 control participants. Forty-eight (12%) participants in the intervention group and 59 (15%) in the control group reported using a LARC method at 4 months (adjusted odds ratio [aOR] using multiple imputation=0.95; 95% confidence interval [CI]=0.49 to 1.83; P=.22). Reported physical IPV was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control (aOR=1.97; 95% CI=1.12 to 3.46; P=.03) when measured using a closed question naming acts of violence. No violence was reported in response to an open question about effects of being in the study. CONCLUSIONS: The intervention did not increase LARC use but had an unintended consequence of increasing self-reported IPV. Researchers and health program designers should consider possible negative impacts when designing and evaluating mHealth and other reproductive health interventions. IPV must be measured using closed questions naming acts of violence.

Evaluating a LARC Expansion Program in 14 Sub-Saharan African Countries: A Service Delivery Model for Meeting FP2020 Goals.

Objectives In many sub-Saharan African countries, the use of long-acting reversible contraceptives (LARCs) is low while unmet need for family planning (FP) remains high. We evaluated the effectiveness of a LARC access expansion initiative in reaching young, less educated, poor, and rural women. Methods Starting in 2008, Marie Stopes International (MSI) has implemented a cross-country expansion intervention to increase access to LARCs through static clinics, mobile outreach units, and social franchising of private sector providers. We analyzed routine service statistics for 2008-2014 and 2014 client exit interview data. Indicators of effectiveness were the number of LARCs provided and the percentages of LARC clients who had not used a modern contraceptive in the last 3 months ("adopters"); switched from a short-term contraceptive to a LARC ("switchers"); were aged <25; lived in extreme poverty; had not completed primary school; lived in rural areas; and reported satisfaction with their overall experience at the facility/site. Results Our annual LARC service distribution increased 1037 % (from 149,881 to over 1.7 million) over 2008-2014. Of 3816 LARC clients interviewed, 46 % were adopters and 46 % switchers; 37 % were aged 15-24, 42 % had not completed primary education, and 56 % lived in a rural location. Satisfaction with services received was rated 4.46 out of 5. Conclusions The effectiveness of the LARC expansion in these 14 sub-Saharan African FP programs demonstrates vast untapped potential for wider use of LARC methods, and suggests that this service delivery model is a plausible way to support FP 2020 goals of reaching those with an unmet need for FP.

Family planning, antenatal and delivery care: cross-sectional survey evidence on levels of coverage and inequalities by public and private sector in 57 low- and middle-income countries.

OBJECTIVE: The objective of this study was to assess the role of the private sector in low- and middle-income countries (LMICs). We used Demographic and Health Surveys for 57 countries (2000-2013) to evaluate the private sector's share in providing three reproductive and maternal/newborn health services (family planning, antenatal and delivery care), in total and by socio-economic position. METHODS: We used data from 865 547 women aged 15-49, representing a total of 3 billion people. We defined 'met and unmet need for services' and 'use of appropriate service types' clearly and developed explicit classifications of source and sector of provision. RESULTS: Across the four regions (sub-Saharan Africa, Middle East/Europe, Asia and Latin America), unmet need ranged from 28% to 61% for family planning, 8% to 22% for ANC and 21% to 51% for delivery care. The private-sector share among users of family planning services was 37-39% across regions (overall mean: 37%; median across countries: 41%). The private-sector market share among users of ANC was 13-61% across regions (overall mean: 44%; median across countries: 15%). The private-sector share among appropriate deliveries was 9-56% across regions (overall mean: 40%; median across countries: 14%). For all three healthcare services, women in the richest wealth quintile used private services more than the poorest. Wealth gaps in met need for services were smallest for family planning and largest for delivery care. CONCLUSIONS: The private sector serves substantial numbers of women in LMICs, particularly the richest. To achieve universal health coverage, including adequate quality care, it is imperative to understand this sector, starting with improved data collection on healthcare provision.

Who, What, Where: an analysis of private sector family planning provision in 57 low- and middle-income countries.

OBJECTIVE: Family planning service delivery has been neglected; rigorous analyses of the patterns of contraceptive provision are needed to inform strategies to address this neglect. METHODS: We used 57 nationally representative Demographic and Health Surveys in low- and middle-income countries (2000-2013) in four geographic regions to estimate need for contraceptive services, and examined the sector of provision, by women's socio-economic position. We also assessed method mix and whether women were informed of side effects. RESULTS: Modern contraceptive use among women in need was lowest in sub-Saharan Africa (39%), with other regions ranging from 64% to 72%. The private sector share of the family planning market was 37-39% of users across the regions and 37% overall (median across countries: 41%). Private sector users accessed medical providers (range across regions: 30-60%, overall mean: 54% and median across countries 23%), specialised drug sellers (range across regions: 31-52%, overall mean: 36% and median across countries: 43%) and retailers (range across regions: 3-14%, overall mean: 6% and median across countries: 6%). Private retailers played a more important role in sub-Saharan Africa (14%) than in other regions (3-5%). NGOs and FBOs served a small percentage. Privileged women (richest wealth quintile, urban residents or secondary-/tertiary-level education) used private sector services more than the less privileged. Contraceptive method types with higher requirements (medical skills) for provision were less likely to be acquired from the private sector, while short-acting methods/injectables were more likely. The percentages of women informed of side effects varied by method and provider subtype, but within subtypes were higher among public than private medical providers for four of five methods assessed. CONCLUSION: Given the importance of private sector providers, we need to understand why women choose their services, what quality services the private sector provides, and how it can be improved. However, when prioritising one of the two sectors (public vs. private), it is critical to consider the potential impact on contraceptive prevalence and equity of met need.

Role of the private sector in childbirth care: cross-sectional survey evidence from 57 low- and middle-income countries using Demographic and Health Surveys.

OBJECTIVE: Maternal mortality rates have decreased globally but remain off track for Millennium Development Goals. Good-quality delivery care is one recognised strategy to address this gap. This study examines the role of the private (non-public) sector in providing delivery care and compares the equity and quality of the sectors. METHODS: The most recent Demographic and Health Survey (2000-2013) for 57 countries was used to analyse delivery care for most recent birth among >330 000 women. Wealth quintiles were used for equity analysis; skilled birth attendant (SBA) and Caesarean section rates served as proxies for quality of care in cross-sectoral comparisons. RESULTS: The proportion of women who used appropriate delivery care (non-facility with a SBA or facility-based births) varied across regions (49-84%), but wealth-related inequalities were seen in both sectors in all regions. One-fifth of all deliveries occurred in the private sector. Overall, 36% of deliveries with appropriate care occurred in the private sector, ranging from 9% to 46% across regions. The presence of a SBA was comparable between sectors (≥93%) in all regions. In every region, Caesarean section rate was higher in the private compared to public sector. The private sector provided between 13% (Latin America) and 66% (Asia) of Caesarean section deliveries. CONCLUSION: This study is the most comprehensive assessment to date of coverage, equity and quality indicators of delivery care by sector. The private sector provided a substantial proportion of delivery care in low- and middle-income countries. Further research is necessary to better understand this heterogeneous group of providers and their potential to equitably increase the coverage of good-quality intrapartum care.

Dialysis services for tourists to the Veneto Region: a qualitative study.

BACKGROUND: The European Union has an established mechanism which enables patients with end-stage kidney disease (ESKD) to receive dialysis abroad, allowing them to benefit from the legal right to freedom of movement. The number of patients seeking dialysis abroad has increased in recent years and the Veneto Region of Italy, a major tourist destination, has made significant investment in providing tourist haemodialysis services. AIMS: To understand the issues involved in providing dialysis services for tourists moving within the European Union, such as the experience of patients using the service, the challenges faced by professionals and patients and continuity of care. DESIGN: Semi-structured interviews. PARTICIPANTS: Interviews were conducted with patients, health professionals and key stakeholders in two dialysis centres set up for tourists in the Veneto Region's Local Health Authority 10. RESULTS: The study uncovered high levels of patient satisfaction and a positive impact on patients' quality of life. However, the service faces a number of challenges relating to accessibility, language barriers and continuity of care for the patient when leaving Veneto. The study also demonstrates the importance of coordinating care prior to the tourists' stay. CONCLUSIONS: Tourist dialysis centres are necessary to make the right to freedom of movement for patients with ESKD a reality. The findings suggest that communicating and coordinating high-quality care across borders in the EU may be facilitated by increased standardisation of norms and documents for continuity of care, such as care plans and discharge summaries.

A systematic mapping of funders of maternal health intervention research 2000-2012.

BACKGROUND: The priorities of research funding bodies govern the research agenda, which has important implications for the provision of evidence to inform policy. This study examines the research funding landscape for maternal health interventions in low- and middle-income countries (LMICs). METHODS: This review draws on a database of 2340 academic papers collected through a large-scale systematic mapping of research on maternal health interventions in LMICs published from 2000-2012. The names of funders acknowledged on each paper were extracted and categorised into groups. It was noted whether support took a specific form, such as staff fellowships or drugs. Variations between funder types across regions and topics of research were assessed. RESULTS: Funding sources were only reported in 1572 (67%) of articles reviewed. A high number of different funders (685) were acknowledged, but only a few dominated funding of published research. Bilateral funders, national research agencies and private foundations were most prominent, while private companies were most commonly acknowledged for support 'in kind'. The intervention topics and geographic regions of research funded by the various funder types had much in common, with HIV being the most common topic and sub-Saharan Africa being the most common region for all types of funder. Publication outputs rose substantially for several funder types over the period, with the largest increase among bilateral funders. CONCLUSIONS: A considerable number of organisations provide funding for maternal health research, but a handful account for most funding acknowledgements. Broadly speaking, these organisations address similar topics and regions. This suggests little coordination between funding agencies, risking duplication and neglect of some areas of maternal health research, and limiting the ability of organisations to develop the specialised skills required for systematically addressing a research topic. Greater transparency in reporting of funding is required, as the role of funders in the research process is often unclear.

Foregoing medicines in the former Soviet Union: changes between 2001 and 2010.

Pharmaceutical costs dominate out-of-pocket payments in former Soviet countries, posing a severe threat to financial equity and access to health services. Nationally representative household survey data collected in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine were analysed to compare the level of population having to forego medicines in 2001 and 2010. Subgroup analysis was conducted to assess differences between populations of different economic status, and rural and urban populations. A substantial proportion of the population did forego medicines in 2010, from 29.2% in Belarus to 72.9% in Georgia. There was a decline in people foregoing medicines between 2001 and 2010; the greatest decline was seen in Moldova [rate ratio (RR)=0.67 (0.63; 0.71)] and Kyrgyzstan [RR=0.63 (0.60; 0.67)], while very little improvement took place in countries with a higher Gross National Income (GNI) per capita and greater GNI growth over the decade such as Armenia [RR=0.92 (0.87; 0.96)] and Georgia [RR=0.95 (0.92; 0.98)]. Wealthier, urban populations have benefited more than poorer, rural households in some countries. Countries experiencing the greatest improvement over the study period were those that have implemented policies such as price controls, expanded benefits packages, and encouragement of rational prescribing. Greater commitment to pharmaceutical reform is needed to ensure that people are not forced to forego medicines.

An examination of Roma health insurance status in Central and Eastern Europe.

BACKGROUND: Roma in Central and Eastern Europe (CEE) face problems in accessing health care, and a lack of access to statutory health insurance schemes is a key factor. This study seeks to quantify differences in health insurance coverage between Roma and non-Roma and assess whether variations can be explained by socio-economic factors. METHODS: Secondary household survey data collected in 12 CEE countries in 2011 were analysed. A univariate analysis assessed the effect of Roma status on insurance coverage by country. Multivariate analyses were used to progressively adjust for socio-demographic factors, employment status and income. Country-specific literature was drawn on to examine the context of the findings. RESULTS: Lack of insurance coverage for Roma populations varied considerably between countries, from 2.8% without insurance in Slovakia to 67.7% in Albania. Roma were significantly less likely to have health insurance than non-Roma in all countries except Slovakia and Serbia. The greatest differences in Roma and non-Roma insurance coverage were in Montenegro, Bosnia and Herzegovina, Croatia, Bulgaria and Romania. When adjusting for employment status and income, the gap between Roma and non-Roma remained significant in Montenegro, Croatia, Bosnia and Herzegovina, Bulgaria, Romania and Moldova. CONCLUSION: Roma are significantly less likely to have insurance coverage in most CEE countries, and this gap remains when adjusting for socio-economic differences between Roma and non-Roma in many countries. Much needs to be done to address the known barriers that Roma face in accessing insurance coverage, such as tackling problems related to documentation and the receipt of social benefits.

Do cancer-specific websites meet patient's information needs?

OBJECTIVE: To evaluate commonly used cancer websites' information provision, we developed and applied an Information Comprehensiveness Tool to breast and prostate cancer websites. METHODS: We first collated questions from a systematic literature review on patient information needs. We then classified the questions in terms of spectrum of care, theme, and nature of question. "Breast cancer" and "prostate cancer" were typed into Google, and websites listed on the first page of results were selected. Two researchers, blind to each others' scores, assessed the same websites using the coding system. Each question was scored on a 3-point scale as not (0%), partially (50%) and fully (100%) answered by two researchers. Average scores were calculated across all questions. Inter-rater reliability was assessed. RESULTS: We identified 79 general, 5 breast, and 5 prostate cancer questions. Inter-rater reliability was good, with an intraclass coefficient of 0.756 (95% CIs 0.729-0.781). 17 questions were not answered thoroughly by any website. Questions about "future planning", "monitoring", and "decision-making" were discussed least. Biomedical questions scored highest. CONCLUSIONS: More comprehensive information needs to be provided on breast and prostate cancer websites. PRACTICE IMPLICATIONS: This ICT can improve cancer information online and enable patients to engage more actively regarding their information needs.

Quality check: does it matter for quality how you organize and pay for health care? A review of the international evidence.

Health systems in high-income countries have experienced significant organizational and financial reforms over the last 25 years. The implications of these changes for the effectiveness of health care systems need to be examined, particularly in relation to their effects on the quality of health services (a pertinent issue in the United Kingdom in light of the Francis Report). Systematic review methodology was used to locate and evaluate published systematic reviews of quantitative intervention studies (experimental and observational) on the effects of health system organizational and financial reforms (system financing, funding allocations, direct purchasing arrangements, organization of service provision, and service integration) on quality of care in high-income countries. Nineteen systematic reviews were identified. The evidence on the payment of providers and purchaser-provider splits was inconclusive. In contrast, there is some evidence that greater integration of services can benefit patients. There were no relevant studies located relating to funding allocation reforms or direct purchasing arrangements. The systematic review-level evidence base suggests that the privatization and marketization of health care systems does not improve quality, with most financial and organizational reforms having either inconclusive or negative effects.

Cross-border health care in Europe

Patient mobility is high on the political agenda in the EU, with increasing numbers of people crossing European borders. Issues relating to health professional mobility have received less attention, yet this is an important policy issue for the EU considering the scale of and reliance on professional mobility between countries, and existing variations in educational and professional standards. How are health systems in Europe responding to patient and professional mobility, and what are the implications for access and quality of health services? Is greater coordination needed, or do calls for increasing integration reflect a political agenda for increasingly competitive markets in health care? Recent legislative changes which clarify patient entitlements to cross-border care will have important impacts on national and EU-wide health policies. This policy summary provides a review of the current state of issues relating to cross-border health care in Europe. It combines a literature search with evidence gathered by the Evaluating Care Across Borders (European Union Cross Border Care Collaboration) Project to provide an update on the 2005 ‘Policy Brief on Cross-Border Health Care in the European Union’.