The “Sustainability Doctrine” in Donor-Driven Maternal Health Programs in Tanzania

Strengthening health systems to provide equitable, sustainable health care has been identified as essential for improving maternal and reproductive health. Many donors and non-governmental organizations (NGOs) have contributed to undermining health system strengthening, however, through adhering to what Swidler and Watkins call the “sustainability doctrine,” policies that prioritize time-limited, targeted interventions best suited for short-term funding streams, rather than the long-term needs of local populations. This chapter presents ethnographic data from semi-structured and key informant interviews with 16 policymakers and NGO directors in Dar es Salaam, Tanzania from 2011 to 2012. I illustrate how sustainability doctrine policies were put into practice, and how they have persisted, despite their shortcomings, using examples of donor-prioritized maternal healthcare initiatives in Tanzania rolled-out several years apart: prevention of mother-to-child transmission of HIV (PMTCT) and basic emergency obstetric and newborn care (BEmONC) programs in the late 2000s, and more recent efforts to implement respectful maternity care (RMC) programs. I focus on several issues informants identified as crippling efforts to build strong health systems, particularly the internal brain drain of healthcare workers from the public sector to higher-paying NGO jobs, and the prioritization of types of programs donors believed could be sustained after the funding period ended, specifically trainings and workshops. I describe how despite these issues, international organizations still design and implement less effective programs that often fail to account for local circumstances in their efforts to solve some of the more intractable health issues facing Tanzania today, in particular, the country’s stagnating maternal mortality rate. In this chapter, I argue that practices promoted and implemented under the guise of “sustainability” in policy papers and reports generated by donors paradoxically contribute to health system precarity in Tanzania.

Qualitative study exploring the feasibility, usability and acceptability of neonatal continuous monitoring technologies at a public tertiary hospital in Nairobi, Kenya

ObjectiveTo assess the feasibility, usability and acceptability of two non-invasive, multiparameter, continuous physiological monitoring (MCPM) technologies for use in neonates within a resource-constrained healthcare setting in sub-Saharan Africa.DesignA qualitative study using in-depth interviews and direct observations to describe healthcare professional and caregiver perspectives and experiences with investigational MCPM technologies from EarlySense and Sibel compared with selected reference technologies.SettingPumwani Maternity Hospital is a public, high-volume, tertiary hospital in Nairobi, Kenya.ParticipantsIn-depth interviews were conducted with five healthcare administrators, 12 healthcare providers and 10 caregivers. Direct observations were made of healthcare providers using the technologies on 12 neonates overall.ResultsDesign factors like non-invasiveness, portability, ease-of-use and ability to measure multiple vital signs concurrently emerged as key themes supporting the usability and acceptability of the investigational technologies. However, respondents also reported feasibility challenges to implementation, including overcrowding in the neonatal unit, lack of reliable access to electricity and computers, and concerns about cost and maintenance needs. To improve acceptability, respondents highlighted the need for adequate staffing to appropriately engage caregivers and dispel misconceptions about the technologies.ConclusionStudy participants were positive about the usefulness of the investigational technologies to strengthen clinical care quality and identification of at-risk neonates for better access to timely interventions. These technologies have the potential to improve equity of access to appropriate healthcare services and neonatal outcomes in sub-Saharan African healthcare facilities. However, health system strengthening is also critical to support sustainable uptake of technologies into routine care.Trial registration numberNCT03920761.

Impact of health system strengthening on delivery strategies to improve child immunisation coverage and inequalities in rural Madagascar

BackgroundTo reach global immunisation goals, national programmes need to balance routine immunisation at health facilities with vaccination campaigns and other outreach activities (eg, vaccination weeks), which boost coverage at particular times and help reduce geographical inequalities. However, where routine immunisation is weak, an over-reliance on vaccination campaigns may lead to heterogeneous coverage. Here, we assessed the impact of a health system strengthening (HSS) intervention on the relative contribution of routine immunisation and outreach activities to reach immunisation goals in rural Madagascar.MethodsWe obtained data from health centres in Ifanadiana district on the monthly number of recommended vaccines (BCG, measles, diphtheria, tetanus and pertussis (DTP) and polio) delivered to children, during 2014–2018. We also analysed data from a district-representative cohort carried out every 2 years in over 1500 households in 2014–2018. We compared changes inside and outside the HSS catchment in the delivery of recommended vaccines, population-level vaccination coverage, geographical and economic inequalities in coverage, and timeliness of vaccination. The impact of HSS was quantified via mixed-effects logistic regressions.ResultsThe HSS intervention was associated with a significant increase in immunisation rates (OR between 1.22 for measles and 1.49 for DTP), which diminished over time. Outreach activities were associated with a doubling in immunisation rates, but their effect was smaller in the HSS catchment. Analysis of cohort data revealed that HSS was associated with higher vaccination coverage (OR between 1.18 per year of HSS for measles and 1.43 for BCG), a reduction in economic inequality, and a higher proportion of timely vaccinations. Yet, the lower contribution of outreach activities in the HSS catchment was associated with persistent inequalities in geographical coverage, which prevented achieving international coverage targets.ConclusionInvestment in stronger primary care systems can improve vaccination coverage, reduce inequalities and improve the timeliness of vaccination via increases in routine immunisations.

Experiences of COVID-19 patients admitted in a government infectious disease hospital in Nepal and its implications for health system strengthening: A qualitative study

Introduction The COVID-19 pandemic has affected the health systems in many ways. It has put unprecedented strain on health systems worldwide and exposed gaps in public health infrastructure. A health system comprises all institutions and resources working towards improving and maintaining health. Among the different aspects of health system strengthening, a patient’s experiences and expectations play a crucial role in determining how well the health facilities function. This study aims to explore health system strengthening’s implications based on experiences and feedback provided by COVID-19 patients admitted to a government tropical and infectious disease hospital in Nepal. Methods In this qualitative study, we collected the voluntary handwritten feedback by the admitted COVID-19 patients to document the feedback and experiences from a book, maintained by the hospital. We performed thematic content analysis using the World Health Organization’s six building blocks of health system as a theoretical framework which included service delivery, health workforce, information, leadership and governance, financing, and access to medicines. Results Most patients in this study had positive experiences on service delivery and health workforce. Some also highlighted the gaps in infrastructure, cleanliness, and hygiene. Many suggested positive experiences on other dimensions of the health system such as financing, governance and leadership, and access to medicines reflected upon by the patients’ thankfulness to the hospital and the government for the treatment they received. The responses also reflected the inter-connectedness between the different building blocks of health system. Conclusion This study approached a unique way to strengthen the health system by exploring patients’ feedback, which suggested an overall positive impression on most building blocks of health system. However, it also highlighted certain gaps in infrastructure, cleanliness, and hygiene. It reinforces the hospital management and government’s role to continue its efforts to strengthen the health system.

Assessing the Quality of Care at Primary Health Care Level in Two Pilot Regions of Albania

The quality of care (QoC) of primary health care (PHC) services in Albania faces challenges on multiple levels including governance, access, infrastructure and health care workers. In addition, there is a lack of trust in the latter. The Health for All Project (HAP) funded by the Swiss Agency for Development and Cooperation therefore aimed at enhancing the population's health by improving PHC services and implementing health promotion activities following a multi-strategic health system strengthening approach. The objective of this article is to compare QoC before and after the 4 years of project implementation. A cross-sectional study was implemented at 38 PHC facilities in urban and rural locations in the Diber and Fier regions of Albania in 2015 and in 2018. A survey measured the infrastructure of the different facilities, provider–patient interactions through clinical observation and patient satisfaction. During clinical observations, special attention was given to diabetes and hypertensive patients. Infrastructure scores improved from base- to endline with significant changes seen on national level and for rural facilities (p < 0.01). Facility infrastructure and overall cleanliness, hygiene and basic/essential medical equipment and supplies improved at endline, while for public accountability/transparency and guidelines and materials no significant change was observed. The overall clinical observation score increased at endline overall, in both areas and in rural and urban setting. However, infection prevention and control procedures and diabetes treatment still experienced relatively low levels of performance at endline. Patient satisfaction on PHC services is generally high and higher yet at endline. The changes observed in the 38 PHC facilities in two regions in Albania between 2015 and 2018 were overall positive with improvements seen at all three levels assessed, e.g., infrastructure, service provision and patient satisfaction. However, to gain overall improvements in the QoC and move toward a more efficient and sustainable health system requires continuous investments in infrastructure alongside interventions at the provider and user level.

Critical Holism as Public Health Theory: Towards A Unifying Framework for Research, Policy and Planning

The wide range of subject matter Public Health (PH) incorporates makes it a synthesizing science that draws upon very many disciplines of the natural, applied and social sciences. The sub-fields of research and application PH, epidemiology, health systems research, policy studies, health education and further sub-fields within each of these, draw from the theories of relevant base disciplines and thereby tend to think in silos rather than make the interlinkages between them. This paper argues for Critical Holism (CH) as an overarching theoretical framework that can provide PH and its sub-fields a unifying structure within which they can locate themselves in relation to each other. Thereby CH would remind PH researchers about attending to interlinkages between elements of a health problem and across problems, their multi-level and multi-dimensional complexity. Policy, planning and implementation require such unifying thought processes in order to ensure coherence between the various elements of PH action for a common objective such as policy formulation for improving the health of populations, health system strengthening, designing of programmes, pandemic response strategies and so on. PH research that generates knowledge to inform these politico-administrative processes, has also to provide them with the comprehensive lens with which to perceive the complexity of health problems, assess the resources at hand and design interventions. The paper presents an outline of what PH research adopting the Critical Holism theoretical frame would look like, as an invitation to further developments of the theoretical frame and its application.

Healthcare worker risk of COVID-19: A 20-month analysis of protective measures from vaccination and beyond

Background: As the COVID-19 pandemic continues and new variants such as Omicron emerge, we aimed to re-evaluate vaccine effectiveness as well as impacts of rigorously implemented infection control, public health and occupational health measures in protecting healthcare workers (HCWs). Methods: Following a cohort of 21,242 HCWs in Vancouver, British Columbia, Canada, for 20 months since the pandemic started, we used Cox regression and test-negative design to examine differences in SARS-COV-2 infection rates compared to community counterparts, and within the HCW workforce, assessing the role of occupation, testing accessibility, vaccination rates, and vaccine effectiveness over time. Results: Nurses, allied health professionals and medical staff in this jurisdiction had a significantly lower rate of infection compared to their age-group community counterparts, at 47.4, 41.8, and 55.3% reduction respectively; controlling for vaccine-attributable reductions, the protective impact was still substantial, at 33.4, 28.0, and 36.5% respectively. Licensed practical nurses and care aides had the highest risk of infection among HCWs, more than double that of medical staff. However, even considering differences in vaccination rates, no increase in SARS-CoV-2 infection was found compared to community rates, with combined protective measures beyond vaccination associated with a 17.7% reduced SARS-COV-2 rate in the VCH workforce overall. There was also no evidence of waning immunity within at least 200 days after second dose. Conclusion: Rigorously implemented occupational health, public health and infection control measures results in a well-protected healthcare workforce with infection rates at or below rates in community counterparts. Greater accessibility of vaccination worldwide is essential; however, as implementing measures to protect this workforce globally also requires considerable health system strengthening in many jurisdictions, we caution against overly focusing on vaccination to the exclusion of other crucial elements for wider protection of HCWs, especially in facing ongoing mutations which may escape current vaccines.

Barriers to increase surgical productivity in Sierra Leone: a qualitative study

ObjectiveTo explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet surgical need from 92.2% to 92.7% and the decrease in surgical productivity to 1.7 surgical procedures per provider per week between 2012 and 2017.Design and methodsThis explanatory qualitative study consisted of in-depth interviews about factors influencing surgical productivity in Sierra Leone. Interviews were analysed with a thematic network analysis and used to develop a conceptual framework.Participants and setting21 surgical providers and hospital managers working in 12 public and private non-profit hospitals in all regions in Sierra Leone.ResultsSurgical providers in Sierra Leone experience a broad range of factors within and outside the health system that influence their productivity. The main barriers involve both patient and facility financial constraints, lack of equipment and supplies, weak regulation of providers and facilities and a small surgical workforce, which experiences a lack of recognition. Initiation of a Free Health Care Initiative for obstetric and paediatric care, collaborations with partners or non-governmental organisations, and increased training opportunities for highly motivated surgical providers are identified as opportunities to increase productivity.DiscussionBroader nationwide health system strengthening is required to facilitate an increase in surgical productivity and meet surgical needs in Sierra Leone. Development of a national strategy for surgery, obstetrics and anaesthesia, including methods to reduce financial barriers for patients, improve supply-mechanisms and expand training opportunities for new and established surgical providers can increase surgical capacity. Establishment of legal frameworks and appropriate remuneration are crucial for sustainability and retention of surgical health workers.

Geographic barriers to establishing a successful hospital referral system in rural Madagascar

BackgroundThe provision of emergency and hospital care has become an integral part of the global vision for universal health coverage. To strengthen secondary care systems, we need to accurately understand the time necessary for populations to reach a hospital. The goal of this study was to develop methods that accurately estimate referral and prehospital time for rural districts in low and middle-income countries. We used these estimates to assess how local geography can limit the impact of a strengthened referral programme in a rural district of Madagascar.MethodsWe developed a database containing: travel speed by foot and motorised vehicles in Ifanadiana district; a full mapping of all roads, footpaths and households; and remotely sensed data on terrain, land cover and climatic characteristics. We used this information to calibrate estimates of referral and prehospital time based on the shortest route algorithms and statistical models of local travel speed. We predict the impact on referral numbers of strategies aimed at reducing referral time for underserved populations via generalised linear mixed models.ResultsAbout 10% of the population lived less than 2 hours from the hospital, and more than half lived over 4 hours away, with variable access depending on climatic conditions. Only the four health centres located near the paved road had referral times to the hospital within 1 hour. Referral time remained the main barrier limiting the number of referrals despite health system strengthening efforts. The addition of two new referral centres is estimated to triple the population living within 2 hours from a centre with better emergency care capacity and nearly double the number of expected referrals.ConclusionThis study demonstrates how adapting geographic accessibility modelling methods to local scales can occur through improving the precision of travel time estimates and pairing them with data on health facility use.

Promoting Access to Health Technologies in the Post-pandemic Era: Gavi, Global Fund, Unitaid, and Access to COVID-19 Tools Accelerator (ACT-A) Programs

Purpose: Global collaboration to accelerate development and equitable access to COVID-19 tests, treatments, and vaccines was launched with the name of the Access to COVID-19 Tools Accelerator (ACT-A), and this initiative owes its expertise to the lessons learned of the global health organizations. To date, the comprehensive mechanisms and potential effects of the initiative remain largely unknown. Methods: This study reviewed the programs of Gavi, the Global Fund, Unitaid, and ACT-A, which mitigating barriers to greater use of health technology with an analytic framework. Results and conclusion: The study findings are as follows. First, programs to alleviate the absence of necessary technology include the International Finance Facility for Immunization and Covax Facility. Second, Pooled Procurement Mechanism and Accelerated Order Mechanism are examples of mitigating the inability to access technology. Third, programs to overcome reluctance to adopt accessible technology include health system strengthening efforts such as the capacity-building health workforces. Further actions of Korea are needed to collaborate with the initiatives to enhance health outcomes.