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1.
Sex Reprod Health Matters ; 28(2): 1846247, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33213298

RESUMEN

Expanding access to sexual and reproductive health (SRH) services is one of the key targets of the Sustainable Development Goals. The extent to which sexual and reproductive health and rights (SRHR) targets will be achieved largely depends on how well they are integrated within Universal Health Coverage (UHC) initiatives. This paper examines challenges and facilitators to the effective provision of three SRHR services (maternal health, gender-based violence (GBV) and safe abortion/post-abortion care) in Ghana. The analysis triangulates evidence from document review with in-depth qualitative stakeholder interviews and adopts the Donabedian framework in evaluating provision of these services. Critical among the challenges identified are inadequate funding, non-inclusion of some SRHR services including family planning and abortion/post-abortion services within the health benefits package and hidden charges for maternal services. Other issues are poor supervision, maldistribution of logistics and health personnel, fragmentation of support services for GBV victims across agencies, and socio-cultural and religious beliefs and practices affecting service delivery and utilisation. Facilitators that hold promise for effective SRH service delivery include stakeholder collaboration and support, health system structure that supports continuum of care, availability of data for monitoring progress and setting priorities, and an effective process for sharing lessons and accountability through frequent review meetings. We propose the development of a national master plan for SRHR integration within UHC initiatives in the country. Addressing the financial, logistical and health worker shortages and maldistribution will go a long way to propel Ghana's efforts to expand population coverage, service coverage and financial risk protection in accessing essential SRH services.

2.
Sex Reprod Health Matters ; 28(2): 1842153, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33236973

RESUMEN

Despite increasing calls to integrate and prioritise sexual and reproductive health (SRH) services in universal health coverage (UHC) processes, several SRH services have remained a low priority in countries' UHC plans. This study aims to understand the priority-setting process of SRH interventions in the context of UHC, drawing on the Malaysian experience. A realist evaluation framework was adopted to examine the priority-setting process for three SRH tracer interventions: pregnancy, safe delivery and post-natal care; gender-based violence (GBV) services; and abortion-related services. The study used a qualitative multi-method design, including a literature and document review, and 20 in-depth key informant interviews, to explore the context-mechanism-outcome configurations that influenced and explained the priority-setting process. Four key advocacy strategies were identified for the effective prioritisation of SRH services, namely: (1) generating public demand and social support, (2) linking SRH issues with public agendas or international commitments, (3) engaging champions that are internal and external to the public health sector, and (4) reframing SRH issues as public health issues. While these strategies successfully triggered mechanisms, such as mutual understanding and increased buy-in of policymakers to prioritise SRH services, the level and extent of prioritisation was affected by both inner and outer contextual factors, in particular the socio-cultural and political context. Priority-setting is a political decision-making process that reflects societal values and norms. Efforts to integrate SRH services in UHC processes need both to make technical arguments and to find strategies to overcome barriers related to societal values (including certain socio-cultural and religious norms). This is particularly important for sensitive SRH services, like GBV and safe abortion, and for certain populations.

4.
Sex Reprod Health Matters ; 28(2): 1779632, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-32530387

RESUMEN

If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the "hows" and "whys" of processes and pathways are essential for guiding policy and programme actions.

5.
Sex Transm Infect ; 96(5): 342-347, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32241905

RESUMEN

OBJECTIVES: In 2016, WHO estimated 376 million new cases of the four main curable STIs: gonorrhoea, chlamydia, trichomoniasis and syphilis. Further, an estimated 290 million women are infected with human papillomavirus. STIs may lead to severe reproductive health sequelae. Low-income and middle-income countries carry the highest global burden of STIs. A large proportion of urogenital and the vast majority of extragenital non-viral STI cases are asymptomatic. Screening key populations and early and accurate diagnosis are important to provide correct treatment and to control the spread of STIs. This article paints a picture of the state of technology of STI point-of-care testing (POCT) and its implications for health system integration. METHODS: The material for the STI POCT landscape was gathered from publicly available information, published and unpublished reports and prospectuses, and interviews with developers and manufacturers. RESULTS: The development of STI POCT is moving rapidly, and there are much more tests in the pipeline than in 2014, when the first STI POCT landscape analysis was published on the website of WHO. Several of the available tests need to be evaluated independently both in the laboratory and, of particular importance, in different points of care. CONCLUSION: This article reiterates the importance of accurate, rapid and affordable POCT to reach universal health coverage. While highlighting the rapid technical advances in this area, we argue that insufficient attention is being paid to health systems capacity and conditions to ensure the swift and rapid integration of current and future STI POCT. Unless the complexity of health systems, including context, institutions, adoption systems and problem perception, are recognised and mapped, simplistic approaches to policy design and programme implementation will result in poor realisation of intended outcomes and impact.


Asunto(s)
Prestación de Atención de Salud/organización & administración , Pruebas en el Punto de Atención/organización & administración , Enfermedades de Transmisión Sexual/diagnóstico , Infecciones por Chlamydia/diagnóstico , Infecciones por Chlamydia/tratamiento farmacológico , Infecciones por Chlamydia/prevención & control , Infecciones por Chlamydia/transmisión , Femenino , Gonorrea/diagnóstico , Gonorrea/tratamiento farmacológico , Gonorrea/prevención & control , Gonorrea/transmisión , Infecciones por VIH/diagnóstico , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/prevención & control , Infecciones por VIH/transmisión , Humanos , Ciencia de la Implementación , Masculino , Infecciones por Mycoplasma/diagnóstico , Infecciones por Mycoplasma/tratamiento farmacológico , Infecciones por Mycoplasma/prevención & control , Infecciones por Mycoplasma/transmisión , Mycoplasma genitalium , Infecciones por Papillomavirus/diagnóstico , Infecciones por Papillomavirus/prevención & control , Infecciones por Papillomavirus/transmisión , Enfermedades de Transmisión Sexual/tratamiento farmacológico , Enfermedades de Transmisión Sexual/prevención & control , Enfermedades de Transmisión Sexual/transmisión , Sífilis/diagnóstico , Sífilis/tratamiento farmacológico , Sífilis/prevención & control , Sífilis/transmisión , Vaginitis por Trichomonas/diagnóstico , Vaginitis por Trichomonas/tratamiento farmacológico , Vaginitis por Trichomonas/prevención & control , Vaginitis por Trichomonas/transmisión
6.
Health Policy Plan ; 34(4): 249-256, 2019 May 01.
Artículo en Inglés | MEDLINE | ID: mdl-31329845

RESUMEN

Women comprise a significant proportion of the health workforce globally but remain under-represented in the higher professional categories. Concern about the under-representation of women in health leadership positions has resulted in increased research on the topic, although this research has focused primarily on high-income countries. An improved understanding of the career trajectories and experiences of healthcare leaders in low- and middle-income countries (LMICs), and the role of gender, is therefore needed. This qualitative case study was undertaken in two counties in coastal Kenya. Drawing on the life-history approach, 12 male and 13 female healthcare leaders were interviewed between August 2015 and July 2016 on their career progression and related experiences. Although gender was not spontaneously identified as a significant influence, closer exploration of responses revealed that gendered factors played an important role. Most fundamentally, women's role as child bearers and gendered societal expectations including child nurturing and other domestic responsibilities can influence their ability to take up leadership opportunities, and their selection and appointment as leaders. Women's selection and appointment as leaders may also be influenced by positive discrimination policies (in favour of women), and by perceptions of women and men as having different leadership styles (against women, who some described as more emotive and reactive). These gendered influences intersect in relatively invisible ways with other factors more readily identified by respondents to influence their progression and experience. These factors included: professional cadre, with doctors more likely to be selected into leadership roles; and personal and professional support systems ranging from family support and role models, through to professional mentorship and continuing education. We discuss the implications of these findings for policy, practice and research, including highlighting the need for more in-depth intersectionality analyses of leadership experience in LMICs.


Asunto(s)
Personal Administrativo , Movilidad Laboral , Liderazgo , Sexismo , Actitud del Personal de Salud , Países en Desarrollo , Femenino , Identidad de Género , Humanos , Kenia , Masculino , Sistemas de Apoyo Psicosocial , Investigación Cualitativa
7.
Hum Resour Health ; 17(1): 29, 2019 04 27.
Artículo en Inglés | MEDLINE | ID: mdl-31029139

RESUMEN

There has been a welcome emphasis on gender issues in global health in recent years in the discourse around human resources for health. Although it is estimated that up to 75% of health workers are female (World Health Organization, Global strategy on human resources for health: Workforce 2030, 2016), this gender ratio is not reflected in the top levels of leadership in international or national health systems and global health organizations (Global Health 50/50, The Global Health 50/50 report: how gender responsive are the world's leading global health organizations, 2018; Clark, Lancet, 391:918-20, 2018). This imbalance has led to a deeper exploration of the role of women in leadership and the barriers they face through initiatives such as the WHO Global Strategy on Human Resources for Health: Workforce 2030, the UN High Level Commission on Health Employment and Economic Growth, the Global Health 50/50 Reports, Women in Global Health, and #LancetWomen. These movements focus on advocating for increasing women's participation in leadership. While efforts to reduce gender imbalance in global health leadership are critical and gaining momentum, it is imperative that we look beyond parity and recognize that women are a heterogeneous group and that the privileges and disadvantages that hinder and enable women's career progression cannot be reduced to a shared universal experience, explained only by gender. Hence, we must take into account the ways in which gender intersects with other social identities and stratifiers to create unique experiences of marginalization and disadvantage.


Asunto(s)
Salud Global , Liderazgo , Sexismo , Femenino , Humanos , Masculino , Sexismo/prevención & control
8.
Int J Equity Health ; 17(1): 148, 2018 09 18.
Artículo en Inglés | MEDLINE | ID: mdl-30227872

RESUMEN

BACKGROUND: The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women's full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being 'left behind' in terms of career development and progression into senior health leadership positions. METHODS: Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments. RESULTS: Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the 'first' to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture. CONCLUSION: This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play.


Asunto(s)
Personal Administrativo , Movilidad Laboral , Identidad de Género , Liderazgo , Sexismo , Adulto , Grupo de Ascendencia Continental Africana , Actitud del Personal de Salud , Grupos de Población Continentales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cultura Organizacional , Poder Psicológico , Prejuicio , Investigación Cualitativa , Sudáfrica , Encuestas y Cuestionarios
9.
Artículo en Inglés | MEDLINE | ID: mdl-29582844

RESUMEN

A country's health workforce plays a vital role not only in serving the health needs of the population but also in supporting economic prosperity. Moreover, a well-funded and well-supported health workforce is vital to achieving universal health coverage and Sustainable Development Goal 3 to ensure healthy lives and promote well-being for all at all ages. This perspective article highlights the potential of underutilized health policy and systems research (HPSR) approaches for developing more effective human resources for health policy. The example of health worker motivation is used to showcase four types of HPSR (exploratory, influence, explanatory and emancipatory) that move beyond describing the extent of a problem. Most of the current literature aiming to understand determinants and dynamics of motivation is descriptive in nature. While this is an important basis for all research pursuits, it often gives little information about mechanisms to improve motivation and strategies for intervention. Motivation is an essential determinant of health worker performance, particularly for those working in difficult conditions, such as those facing many health workers in low- and middle-income countries. Motivation mediates health workforce performance in multiple ways: internally governing health worker behaviour; informing decisions on becoming a health worker; workplace location and ability to perform; and influencing willingness to engage politically. The four fresh research approaches described can help policy-makers better understand why health workers behave the way they do, how interventions can improve performance, the mechanisms that lead to change, and strategies for empowering health workers to be agents of change themselves.


Asunto(s)
Personal de Salud/psicología , Investigación sobre Servicios de Salud/métodos , Motivación , Salud Global , Política de Salud , Recursos en Salud , Humanos
10.
Int J Equity Health ; 17(1): 1, 2018 01 04.
Artículo en Inglés | MEDLINE | ID: mdl-29301537

RESUMEN

BACKGROUND: Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC. METHODS: Using a cross-sectional survey across four of South Africa's nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status. RESULTS: A quarter of respondents remained uninsured, even higher among 20-29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits. CONCLUSIONS: By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country's financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.


Asunto(s)
Empleados de Gobierno/estadística & datos numéricos , Disparidades en Atención de Salud/economía , Sector Privado/estadística & datos numéricos , Sector Público/estadística & datos numéricos , Cobertura Universal del Seguro de Salud/estadística & datos numéricos , Adulto , Anciano , Estudios Transversales , Femenino , Servicios de Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/economía , Estado de Salud , Humanos , Cobertura del Seguro/estadística & datos numéricos , Seguro de Salud/estadística & datos numéricos , Entrevistas como Asunto , Modelos Logísticos , Masculino , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Calidad de la Atención de Salud , Seguridad Social , Factores Socioeconómicos , Sudáfrica , Encuestas y Cuestionarios , Cobertura Universal del Seguro de Salud/economía , Adulto Joven
11.
Health Policy Plan ; 32(suppl_5): v4-v12, 2017 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-28973503

RESUMEN

In a webinar in 2015 on health financing and gender, the question was raised why we need to focus on gender, given that a well-functioning system moving towards Universal Health Coverage (UHC) will automatically be equitable and gender balanced. This article provides a reflection on this question from a panel of health financing and gender experts.We trace the evidence of how health-financing reforms have impacted gender and health access through a general literature review and a more detailed case-study of India. We find that unless explicit attention is paid to gender and its intersectionality with other social stratifications, through explicit protection and careful linking of benefits to needs of target populations (e.g. poor women, unemployed men, female-headed households), movement towards UHC can fail to achieve gender balance or improve equity, and may even exacerbate gender inequity. Political trade-offs are made on the road to UHC and the needs of less powerful groups, which can include women and children, are not necessarily given priority.We identify the need for closer collaboration between health economists and gender experts, and highlight a number of research gaps in this field which should be addressed. While some aspects of cost sharing and some analysis of expenditure on maternal and child health have been analysed from a gender perspective, there is a much richer set of research questions to be explored to guide policy making. Given the political nature of UHC decisions, political economy as well as technical research should be prioritized.We conclude that countries should adopt an equitable approach towards achieving UHC and, therefore, prioritize high-need groups and those requiring additional financial protection, in particular women and children. This constitutes the 'progressive universalism' advocated for by the 2013 Lancet Commission on Investing in Health.


Asunto(s)
Financiación de la Atención de la Salud , Cobertura Universal del Seguro de Salud/organización & administración , Salud del Niño , Femenino , Política de Salud , Accesibilidad a los Servicios de Salud/economía , Necesidades y Demandas de Servicios de Salud , Humanos , India , Masculino , Pobreza , Factores Sexuales , Sexismo , Cobertura Universal del Seguro de Salud/economía
12.
Int J Equity Health ; 16(1): 164, 2017 09 15.
Artículo en Inglés | MEDLINE | ID: mdl-28911338

RESUMEN

BACKGROUND: This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policies - the Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems' people-centeredness and "software". METHODS: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. RESULTS: Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. CONCLUSIONS: Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected.


Asunto(s)
Equidad en Salud , Política de Salud , Administración Hospitalaria , Cultura Organizacional , Confianza , Estudios de Casos y Controles , Honorarios y Precios , Administradores de Hospital/psicología , Humanos , Relaciones Interprofesionales , Derechos del Paciente , Personal de Hospital/psicología , Sudáfrica
14.
Health Policy Plan ; 31(4): 454-61, 2016 May.
Artículo en Inglés | MEDLINE | ID: mdl-26384375

RESUMEN

Directly observed treatment short course (DOTS) has been the recommended strategy for Tuberculosis (TB) control since 1995. Developed as an alternative to inpatient treatment, it involves observation of patients' medication intake to promote adherence. However, the burden of daily clinic visits may affect access to care. Using a mixed methods approach, we consider whether (1) non-adherence differs systematically between patients required to make daily clinic visits and patients cared for under less frequent clinic visits and (2) the association between frequency of required clinic visits and adherence depends on affordability and acceptability of care. Data were collected in facility exit interviews with 1200 TB patients in two rural and two urban sub-districts in South Africa. Additionally, 17 in-depth interviews were completed with TB patients. After controlling for socioeconomic and demographic factors, patient type (new or retreatment) and treatment duration, regression analyses showed that daily attending patients were over twice as likely to report a missed clinic visit (P < 0.001) or a missed dose of treatment (P = 0.002) compared with patients required to attend clinics for treatment collection less frequently. Missed visits increased with treatment duration (P = 0.01). The significant interaction between clinic visit frequency and treatment duration indicated that sustaining daily visits over time may become increasingly difficult over the course of treatment. The qualitative analysis identified treatment cost and duration, patients' physical condition and varying social contexts (family, community and work) as important influences on adherence. These findings suggest that strategies involving daily clinic visits may require reconsideration if resources for TB care are to be used efficiently. The adoption of approaches that place patient interests at the centre of TB treatment delivery would appear to be of high priority, particularly in countries where TB prevalence is high and resources for TB care are highly constrained.


Asunto(s)
Antituberculosos/uso terapéutico , Terapia por Observación Directa , Cumplimiento de la Medicación , Tuberculosis Pulmonar/tratamiento farmacológico , Adulto , Instituciones de Atención Ambulatoria , Antituberculosos/administración & dosificación , Terapia por Observación Directa/métodos , Femenino , Humanos , Entrevistas como Asunto , Masculino , Cumplimiento de la Medicación/psicología , Sudáfrica , Tuberculosis Pulmonar/psicología
15.
BMC Health Serv Res ; 15: 432, 2015 Sep 29.
Artículo en Inglés | MEDLINE | ID: mdl-26420405

RESUMEN

BACKGROUND: South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. METHODS: As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system's realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. RESULTS: The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients' narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. CONCLUSIONS: Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.


Asunto(s)
Adaptación Psicológica , Accesibilidad a los Servicios de Salud/normas , Resiliencia Psicológica , Adulto , Actitud del Personal de Salud , Cuidadores/psicología , Femenino , Infecciones por VIH/psicología , Infecciones por VIH/terapia , Conocimientos, Actitudes y Práctica en Salud , Personal de Salud/psicología , Humanos , Masculino , Atención Primaria de Salud/normas , Práctica Profesional , Relaciones Profesional-Paciente , Servicio Social , Sudáfrica , Encuestas y Cuestionarios , Tuberculosis/psicología , Tuberculosis/terapia , Adulto Joven
16.
BMC Health Serv Res ; 15: 227, 2015 Jun 09.
Artículo en Inglés | MEDLINE | ID: mdl-26050715

RESUMEN

BACKGROUND: In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, we consider 1) inequalities in access to the DG for patients on ART and 2) implications of DG access for on-going access to healthcare. METHODS: Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. RESULTS: Grant recipients were comparatively worse off than non-recipients in terms of employment (9.1 % vs. 29.9 %) and wealth (58.3 % in the poorest half vs. 45.8 %). After controlling for socioeconomic and demographic factors, site, treatment duration, adherence and concomitant TB treatment, the regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed (p < 0.001). Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG (significant at the 5 % level). The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. CONCLUSIONS: These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.


Asunto(s)
Personas con Discapacidad , Organización de la Financiación , Infecciones por VIH , Síndrome de Inmunodeficiencia Adquirida , Adulto , Grupo de Ascendencia Continental Africana , Enfermedades Transmisibles , Prestación de Atención de Salud/economía , Femenino , Infecciones por VIH/economía , Humanos , Entrevistas como Asunto , Masculino , Pobreza/economía , Investigación Cualitativa , Población Rural , Seguridad Social , Factores Socioeconómicos , Sudáfrica , Encuestas y Cuestionarios , Tuberculosis , Desempleo
17.
Glob Public Health ; 10(2): 228-42, 2015.
Artículo en Inglés | MEDLINE | ID: mdl-25536851

RESUMEN

Sexual and reproductive health and rights (SRHR) are centrally important to health. However, there have been significant shortcomings in implementing SRHR to date. In the context of health systems reform and universal health coverage/care (UHC), this paper explores the following questions. What do these changes in health systems thinking mean for SRHR and gender equity in health in the context of renewed calls for increased investments in the health of women and girls? Can SRHR be integrated usefully into the call for UHC, and if so how? Can health systems reforms address the continuing sexual and reproductive ill health and violations of sexual and reproductive rights (SRR)? Conversely, can the attention to individual human rights that is intrinsic to the SRHR agenda and its continuing concerns about equality, quality and accountability provide impetus for strengthening the health system? The paper argues that achieving equity on the UHC path will require a combination of system improvements and services that benefit all, together with special attention to those whose needs are great and who are likely to fall behind in the politics of choice and voice (i.e., progressive universalism paying particular attention to gender inequalities).


Asunto(s)
Reforma de la Atención de Salud , Salud Reproductiva , Derechos Sexuales y Reproductivos , Disparidades en Atención de Salud , Humanos , Calidad de la Atención de Salud , Cobertura Universal del Seguro de Salud
18.
PLoS One ; 9(4): e93887, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24728103

RESUMEN

Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households.


Asunto(s)
Gastos en Salud/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Femenino , Financiación Personal/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Nigeria , Aceptación de la Atención de Salud/estadística & datos numéricos , Factores Sexuales
19.
Glob Health Action ; 6: 19253, 2013 Jan 24.
Artículo en Inglés | MEDLINE | ID: mdl-23364093

RESUMEN

BACKGROUND: In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. OBJECTIVES: This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. METHODS: Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. RESULTS: Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. CONCLUSION: Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.


Asunto(s)
Programas de Gobierno/organización & administración , Seguro de Salud/organización & administración , Cobertura Universal del Seguro de Salud/organización & administración , Adulto , Factores de Edad , Recolección de Datos , Escolaridad , Femenino , Programas de Gobierno/estadística & datos numéricos , Humanos , Renta , Seguro de Salud/estadística & datos numéricos , Entrevistas como Asunto , Modelos Logísticos , Masculino , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Factores Sexuales , Sudáfrica , Cobertura Universal del Seguro de Salud/estadística & datos numéricos , Programas Voluntarios
20.
Int J MCH AIDS ; 2(1): 153-62, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-27621968

RESUMEN

OBJECTIVES: International guidelines on infant feeding for HIV- positive mothers promote Exclusive Replacement Feeding (ERF) (infant formula or animal milk) or exclusive breastfeeding (with no supplements of any kind). A mixed feeding pattern, where breastfeeding is combined with other milks, liquid foods or solids, has been shown to increase the risk of transmission of HIV and is strongly discouraged. However, little is known about the ability of women to adhere to recommended feeding strategies to prevent mother-to-child transmission (MTCT) of HIV from breast milk. The objective of this study was to assess the individual and community-level factors that affect perspectives, attitudes and practices of HIV-positive mothers on MTCT and infant feeding in sub-Saharan Africa as documented in peer-reviewed and grey literature. METHODS: This work is based on an extensive review of peer-reviewed articles and grey literature from the period 2000-2012. The literature search was carried out using electronic databases like Medline Ovid, Google Scholar, PubMed and EBSCOhost. Both quantitative and qualitative studies written in English language on HIV and infant feeding with particular emphasis on Sub-Saharan Africa were included. RESULTS: The review found low adherence to the chosen infant feeding method by HIV-positive mothers. The following factors emerged as influencing infant feeding decisions: cultural and social norms; economic conditions; inadequate counselling; and mother's level of education. CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS: Unless local beliefs and customs surrounding infant feeding is understood by policy makers and program implementers, Prevention of Mother-to-Child Transmission (PMTCT) programs will only be partially successful in influencing feeding practices of HIV-positive women. Hence programs should provide affordable, acceptable, feasible, safe and sustainable feeding recommendations that do not erode strong cultural practices. Advice to HIV-positive mothers should be based on local conditions that are acceptable to the community.

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