Can positive inquiry strengthen obstetric referral systems in Cambodia?

Maternal death remains high in low resource settings. Current literature on obstetric referral that sets out to tackle maternal death tends to focus on problematization. We took an alternative approach and rather asked what works in contemporary obstetric referral in a low income setting to find out if positive inquiry could generate original insights on referral that could be transformative. We documented and analysed instances of successful referral in a rural province of Cambodia that took place within the last year. Thirty women, their families, healthcare staff and community volunteers were purposively sampled for in-depth interviews, conducted using an appreciative inquiry lens. We found that referral at its best is an active partnership between families, community and clinicians that co-constructs care for labouring women during referral and delivery. Given the short time frame of the project we cannot conclude if this new understanding was transformative. However, we can show that acknowledging positive resources within contemporary referral systems enables health system stakeholders to widen their understanding of the kinds of resources that are available to them to direct and implement constructive change for maternal health. Copyright © 2016 John Wiley & Sons, Ltd.

A new methodology for assessing health policy and systems research and analysis capacity in African universities.

BACKGROUND: The importance of health policy and systems research and analysis (HPSR+A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR+A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening. METHODS: The Consortium for Health Policy and Systems Analysis in Africa 2011-2015 designed and implemented a new framework for capacity assessment for HPSR+A within universities. The methodology is reported in detail. RESULTS: Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR+A that focus solely on universities - we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR+A, the unit of assessment can be a challenge, because HPSR+A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity. CONCLUSIONS: From our experience, we propose that future systematic assessments of HPSR+A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR+A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening.

Trading legitimacy: everyday corruption and its consequences for medical regulation in southern Vietnam.

Government regulation of health professionals is believed to ensure the efficacy and expertise of practitioners for and on behalf of patients. Certification and licensing are two common means to do so, legalizing a physician to practice medicine. However, ethnography from Ho Chi Minh City (HCMC) suggests that in corrupt socioeconomic environments, certification and licensing can alternatively produce a trade in legitimacy. Drawing on participant observations during 15 months of fieldwork with 25 medical acupuncturists in private practice in HCMC, southern Vietnam, and their patients, I argue that everyday practices of corruption and the importance of personal networks meant that legality, efficacy, and expertise separated. Certificates and licenses did not unproblematically validate expertise and efficacy. Consequently, compliance and enforcement of regulations as solutions to inadequate medical care may not achieve the effects intended.

Sustainable Transition From Donor Grant Financing: What Could It Look Like?

Donor transition is an important aspect of sustaining the impact of donor investments after financial support has ceased. This article compares, contrasts, and critiques the transition policies of the top health donors in the Asia Pacific, which includes Global Fund to fight AIDS, tuberculosis, and malaria, Gavi-the Vaccine Alliance, World Bank (International Development Association), and the United States US Agency for International Development to gain a deeper understanding of what a sustainable financial transition could look like. A literature review of the academic and gray literature was undertaken to ascertain these donors' transition policies and to determine the success of these policies in ensuring sustainable and effective transition. It is proposed that sustainable transition requires a clearly articulated vision of long-term impact, explicit and transparent transition policies, clear time frames for transition, donor coordination, and evaluation of long-term impacts of donor withdrawal.

Socio-cultural change in conflict and post conflict settings: five decades of giving birth in Cambodia.

BACKGROUND: This paper explores the changing experience of giving birth in Cambodia over a 53-year period. During this time, Cambodian people experienced armed conflict, extreme privation, foreign invasion, and civil unrest. METHODS: An historical perspective was used to explore the changing place and nature of birth assistance given to Cambodian women between 1950 and 2013. Twenty-four life histories of poor and non-poor Cambodians aged 40-74 were gathered and analysed using a grounded thematic approach. RESULTS: In the early lives of the respondents, almost all births occurred at home and were assisted by Traditional Birth Attendants. In modern times, towards the end of their lives, the respondents' grand-children and great grand-children are almost universally born in institutions in which skilled birth attendants are available. Respondents recognise that this is partly due to the availability of modern health care facilities but also describe the process by which attitudes to institutional and homebirth changed over time. Interviews can also chart the increasing awareness of the risks of homebirth, somewhat influenced by the success of health education messages transmitted by public health authorities. CONCLUSIONS: The life histories provide insight into the factors driving the underlying cultural change: a modernising supply side; improving transport and communications infrastructure. In addition, a step-change occurred in the aftermath of the conflict with significant influence of extensive contact with the Vietnamese recognised. TRIAL REGISTRATION: None.

The commercialization of traditional medicine in modern Cambodia.

Globally, traditional medicine has long been used to address relatively common illness, mental ill health and during childbirth and post-natal care. However, traditional medicine is primarily provided by the private sector and it is unclear how far expenditures on traditional medicine contribute to household impoverishment. A life history method was used to understand the health seeking experience of 24 households over the last 60 years in Cambodia, a country with high out-of-pocket expenditures for health. The life histories suggest that traditional medicine in Cambodia has been undergoing a process of commercialization, with significant impacts on poor households. In the earlier lives of respondents, payments for traditional medicine were reported to have been flexible, voluntary or appropriate to patients' financial means. In contrast, contemporary practitioners appear to seek immediate cash payments that have frequently led to considerable debt and asset sales by traditional medicine users. Given traditional medicine's popularity as a source of treatment in Cambodia and its potential to contribute to household impoverishment, we suggest that it needs to be included in a national conversation about achieving Universal Health Coverage in the country.

Can service integration work for universal health coverage? Evidence from around the globe.

Universal health coverage (UHC) is at the heart of the new 2030 Agenda for Sustainable Development. Health service integration is seen by World Health Organization as an essential requirement to achieve UHC. However, to date the debate on service integration has focused on perceived benefits rather than empirical impact. We conducted a global review in a systematic manner searching for empirical outcomes of service integration experiments in UHC countries and those on the path to UHC. Sixty-seven articles and reports were found. We grouped results into a unique integration typology with six categories - medical staff from different disciplines; patients and medical staff; care package for one medical condition; care package for two or more medical conditions; specialist stand-alone services with GP services; community locations. We showed that it is possible to integrate services in different human development contexts delivering positive outcomes for patients and clinicians without incurring additional costs. However, the improved outcomes shown were incremental rather than radical and suggest that integration is likely to enhance already well established systems rather than fundamentally changing the outcomes of care.

Assessment of capacity for Health Policy and Systems Research and Analysis in seven African universities: results from the CHEPSAA project.

The importance of health policy and systems research and analysis (HPSR+A) is widely recognized. Universities are central to strengthening and sustaining the HPSR+A capacity as they teach the next generation of decision-makers and health professionals. However, little is known about the capacity of universities, specifically, to develop the field. In this article, we report results of capacity self- assessments by seven universities within five African countries, conducted through the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA). The capacity assessments focused on both capacity 'assets' and 'needs', and covered the wider context, as well as organizational and individual capacity levels. Six thematic areas of capacity were examined: leadership and governance, organizations' resources, scope of HPSR+A teaching and research, communication, networking and getting research into policy and practice (GRIPP), demand for HPRS+A and resource environment. The self-assessments by each university used combinations of document reviews, semi-structured interviews and staff surveys, followed by comparative analysis. A framework approach, guided by the six thematic areas, was used to analyse data. We found that HPSR+A is an international priority, and an existing activity in Africa, though still neglected field with challenges including its reliance on unpredictable international funding. All universities have capacity assets, such as ongoing HPSR+A teaching and research. There are, however, varying levels of assets (such as differences in staff numbers, group sizes and amount of HPSR+A teaching and research), which, combined with different capacity needs at all three levels (such as individual training, improvement in systems for quality assurance and fostering demand for HPSR+A work), can shape a future agenda for HPSR+A capacity strengthening. Capacity assets and needs at different levels appear related. Possible integrated strategies for strengthening universities' capacity include: refining HPSR+A vision, mainstreaming the subject into under- and post-graduate teaching, developing emerging leaders and aligning HPSR+A capacity strengthening within the wider organizational development.