Getting Up to Date with What Works: A Systematic Review on the Effectiveness and Safety of Task Sharing of Modern Methods in Family Planning Services.

Objective: This systematic review was conducted to provide up-to-date evidence on the safety and effectiveness of task sharing in the delivery of modern contraceptives. Study Design. The review followed the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. We searched Medline, Embase, Cochrane CENTRAL, and Google Scholar for peer-reviewed studies that reported on effectiveness and/or safety outcomes of task sharing of any modern contraceptive method. Only Cochrane Effective Practice of Organizations of Care (EPOC) study designs were eligible, and quality assessment of the evidence was performed using the Cochrane risk of bias (RoB) tools. Meta-analyses, where possible, were carried out using Stata, and certainty of the evidence for outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation tool (GRADE). Results: Six studies met the inclusion criteria: five reported on self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) compared to administered by trained health providers; and one assessed tubal ligation performed by associate clinicians compared to advanced-level associate clinicians. Self-injection improved contraceptive continuation, with no increase in unintended pregnancy and no difference in side effects compared to provider administered. In tubal ligation, the rate of adverse events, time to complete procedure, and participant satisfaction were similar among associate clinicians and advanced clinicians. Conclusion: The evidence suggests that self-injection of DMPA-SC and tubal ligation performed by associate clinicians are safe and effective. These findings should be complemented with the evidence on the feasibility and acceptability of task sharing of these methods. The review protocol was registered with PROSPERO CRD42021283336.

Issues related to pregnancy, pregnancy prevention and abortion in the context of the COVID-19 pandemic: a WHO qualitative study protocol.

INTRODUCTION: WHO has generated standardised clinical and epidemiological research protocols to address key public health questions for SARS-CoV-2 (COVID-19) pandemic. We present a standardised protocol with the aim to fill a gap in understanding the needs, attitudes and practices related to sexual and reproductive health in the context of COVID-19 pandemic, focusing on pregnancy, pregnancy prevention and abortion. METHODS AND ANALYSIS PLAN: This protocol is a prospective qualitative research, using semi-structured interviews with at least 15 pregnant women at different gestational ages and after delivery, 6 months apart from the first interview. At least 10 partners, 10 non-pregnant women and 5 healthcare professionals will be interviewed once during the course of the research. Higher number of subjects may be needed if a saturation is not achieved with these numbers. Data collection will be performed in a standardised way by skilled trained interviewers using written notes or audio-record of the interview. The data will be explored using the thematic content analysis and the researchers will look for broad patterns, generalisations or theories from these categories. ETHICS AND DISSEMINATION: The current protocol was first technically assessed and approved by the WHO scientific committee and then approved by its ethics review committee as a guidance document. It is expected that each country/setting implementing such a generic protocol adapted to their conditions also obtain local ethical approval. Comments for the user's consideration are provided the document, as the user may need to modify methods slightly because of the local context in which this study will be carried out.

Health systems analysis and evaluation of the barriers to availability, utilisation and readiness of sexual and reproductive health services in COVID-19-affected areas: a WHO mixed-methods study protocol.

INTRODUCTION: COVID-19 has led to an unprecedented increase in demand on health systems to care for people infected, necessitating the allocation of significant resources, especially medical resources, towards the response. This, compounded by the restrictions on movement instituted may have led to disruptions in the provision of essential services, including sexual and reproductive health (SRH) services. This study aims to assess the availability of contraception, comprehensive abortion care, sexually transmitted infection prevention and treatment and sexual and gender-based violence care and support services in local health facilities during COVID-19 pandemic. This is a standardised generic protocol designed for use across different global settings. METHODS AND ANALYSIS: This study adopts both quantitative and qualitative methods to assess health facilities' SRH service availability and readiness, and clients' and providers' perceptions of the availability and readiness of these services in COVID-19-affected areas. The study has two levels: (1) perceptions of clients (and the partners) and healthcare providers, using qualitative methods, and (2) assessment of infrastructure availability and readiness to provide SRH services through reviews, facility service statistics for clients and a qualitative survey for healthcare provider perspectives. The health system assessment will use a cross-sectional panel survey design with two data collection points to capture changes in SRH services availability as a result of the COVID-19 epidemic. Data will be collected using focus group discussions, in-depth interviews and a health facility assessment survey. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the WHO Scientific and Ethics Review Committee (protocol ID CERC.0103). Each study site is required to obtain the necessary ethical and regulatory approvals that are required in each specific country.

Household perceptions towards a redistributive policy across health insurance funds in Tanzania.

BACKGROUND: The Tanzanian health insurance system comprises multiple health insurance funds targeting different population groups but which operate in parallel, with no mechanisms for redistribution across the funds. Establishing such redistributive mechanisms requires public support, which is grounded on the level of solidarity within the country. The aim of this paper is to analyse the perceptions of CHF, NHIF and non-member households towards cross-subsidisation of the poor as an indication of the level of solidarity and acceptance of redistributive mechanisms. METHODS: This study analyses data collected from a survey of 695 households relating to perceptions of household heads towards cross-subsidisation of the poor to enable them to access health services. Kruskal-Wallis test is used to compare perceptions by membership status. Generalized ordinal logistic regression models are used to identify factors associated with support for cross-subsidisation of the poor. RESULTS: Compared to CHF and NHIF households, non-member households expressed the highest support for subsidised CHF membership for the poor. The odds of expressing support for subsidised CHF membership are higher for NHIF households and non-member households, households that are wealthier, whose household heads have lower education levels, and have sick members. The majority of households support a partial rather than fully subsidised CHF membership for the poor and there were no significant differences by membership status. The odds of expressing willingness to contribute towards subsidised CHF membership are higher for households that are wealthier, with young household heads and have confidence in scheme management. CONCLUSION: The majority may support a redistributive policy, but there are indications that this support and willingness to contribute to its achievement are influenced by the perceived benefits, amount of subsidy considered, and trust in scheme management. These present important issues for consideration when designing redistributive policies.

Health care seeking behaviour and utilisation in a multiple health insurance system: does insurance affiliation matter?

BACKGROUND: Many countries striving to achieve universal health insurance coverage have done so by means of multiple health insurance funds covering different population groups. However, existence of multiple health insurance funds may also cause variation in access to health care, due to the differential revenue raising capacities and benefit packages offered by the various funds resulting in inequity and inefficiency within the health system. This paper examines how the existence of multiple health insurance funds affects health care seeking behaviour and utilisation among members of the Community Health Fund, the National Health Insurance Fund and non-members in two districts in Tanzania. METHODS: Using household survey data collected in 2011 with a sample of 3290 individuals, the study uses a multinomial logit model to examine the influence of predisposing, enabling and need characteristics on the probability of seeking care and choice of provider. RESULTS: Generally, health insurance is found to increase the probability of seeking care and reduce delays. However, the probability, timing of seeking care and choice of provider varies across the CHF and NHIF members. CONCLUSIONS: Reducing fragmentation is necessary to provide opportunities for redistribution and to promote equity in utilisation of health services. Improvement in the delivery of services is crucial for achievement of improved access and financial protection and for increased enrolment into the CHF, which is essential for broadening redistribution and cross-subsidisation to promote equity.

Risk distribution across multiple health insurance funds in rural Tanzania.

INTRODUCTION: Multiple insurance funds serving different population groups may compromise equity due to differential revenue raising capacity and an unequal distribution of high risk members among the funds. This occurs when the funds exist without mechanisms in place to promote income and risk cross-subsidisation across the funds. This paper analyses whether the risk distribution varies across the Community Health Fund (CHF) and National Health Insurance Fund (NHIF) in two districts in Tanzania. Specifically we aim to 1) identify risk factors associated with increased utilisation of health services and 2) compare the distribution of identified risk factors among the CHF, NHIF and non-member households. METHODS: Data was collected from a survey of 695 households. A multivariate logisitic regression model was used to identify risk factors for increased health care utilisation. Chi-square tests were performed to test whether the distribution of identified risk factors varied across the CHF, NHIF and non-member households. RESULTS: There was a higher concentration of identified risk factors among CHF households compared to those of the NHIF. Non-member households have a similar wealth status to CHF households, but a lower concentration of identified risk factors. CONCLUSION: Mechanisms for broader risk spreading and cross-subsidisation across the funds are necessary for the promotion of equity. These include risk equalisation to adjust for differential risk distribution and revenue raising capacity of the funds. Expansion of CHF coverage is equally important, by addressing non-financial barriers to CHF enrolment to encourage wealthy non-members to join, as well as subsidised membership for the poorest.