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Publications

Filtering by Category: Open access

Service delivery transformation for UHC in Asia and the Pacific

Future Health Systems

Bloom G (2018) Service Delivery Transformation for UHC in Asia and the Pacific, Health Systems & Reform, Volume 5, Issue 1, DOI: 10.1080/23288604.2018.1541498

This article was drafted as part of a review of strategies for making progress toward universal health coverage in the countries of Asia and the Pacific. It focuses on strengthening the delivery of services, in the context of population aging. It argues that it is important to take into account big differences in development contexts and also the rapid, interconnected changes that many countries are experiencing. The article focuses especially on countries with relatively undeveloped institutions and pluralistic and highly segmented health sectors. It argues that attempts by these countries to import institutional arrangements from outside are likely to be complicated. It argues that government needs to focus on both short-term measures to meet immediate needs and the longer-term aim of establishing effective institutional arrangements. This means that they need to take into account the political factors that influence the direction of health system change. The article emphasizes the need to strengthen the capacity of the health system to address the growing challenge of chronic noncommunicable diseases to avoid heavy political pressure to expand hospital services. It then explores the opportunities and challenges associated with the rapid expansion of digital health services. It concludes with a discussion of government stewardship and management of health system transformation to address the major challenges associated with population aging.

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Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation

Future Health Systems

MacGregor H, McKenzie A, Jacobs T and Ullauri A (2018) Scaling up ART adherence clubs in the public sector health system in the Western Cape, South Africa: a study of the institutionalisation of a pilot innovation, Globalization and Health, 14:40, DOI: 10.1186/s12992-018-0351-z

In 2011, a decision was made to scale up a pilot innovation involving ‘adherence clubs’ as a form of differentiated care for HIV positive people in the public sector antiretroviral therapy programme in the Western Cape Province of South Africa. In 2016 we were involved in the qualitative aspect of an evaluation of the adherence club model, the overall objective of which was to assess the health outcomes for patients accessing clubs through epidemiological analysis, and to conduct a health systems analysis to evaluate how the model of care performed at scale. In this paper we adopt a complex adaptive systems lens to analyse planned organisational change through intervention in a state health system. We explore the challenges associated with taking to scale a pilot that began as a relatively simple innovation by a non-governmental organisation.

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Reflecting strategic and conforming gendered experiences of community health workers (CHWs) using photovoice in rural Wakiso district, Uganda

Future Health Systems

Musoke D, Ssemugabo C, Ndejjo R, Ekirapa-Kiracho E and George AS (2018) Reflecting strategic and conforming gendered experiences of community health workers (CHWs) using photovoice in rural Wakiso district, Uganda, Human Resources for Health, 16:41, DOI: 10.1186/s12960-018-0306-8

Community health workers (CHWs) are an important human resource in Uganda as they are the first contact of the population with the health system. Understanding gendered roles of CHWs is important in establishing how they influence their performance and relationships in communities. This paper explores the differential roles of male and female CHWs in rural Wakiso district, Uganda, using photovoice, an innovative community-based participatory research approach.

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Evaluation and learning in complex, rapidly changing health systems: China’s management of health sector reform

Future Health Systems

Xiao, Y, Husain, L and Bloom, G (2018) Evaluation and learning in complex, rapidly changing health systems, Globalization and Health, 14:112, DOI: 10.1186/s12992-018-0429-7

Healthcare systems are increasingly recognised as complex, in which a range of non-linear and emergent behaviours occur. China’s healthcare system is no exception. The hugeness of China, and the variation in conditions in different jurisdictions present very substantial challenges to reformers, and militate against adopting one-size-fits-all policy solutions. As a consequence, approaches to change management in China have frequently emphasised the importance of sub-national experimentation, innovation, and learning. Multiple mechanisms exist within the government structure to allow and encourage flexible implementation of policies, and tailoring of reforms to context. These limit the risk of large-scale policy failures and play a role in exploring new reform directions and potentially systemically-useful practices. They have helped in managing the huge transition that China has undergone from the 1970s onwards. China has historically made use of a number of mechanisms to encourage learning from innovative and emergent policy practices. Policy evaluation is increasingly becoming a tool used to probe emergent practices and inform iterative policy making/refining. This paper examines the case of a central policy research institute whose mandate includes evaluating reforms and providing feedback to the health ministry. Evaluation approaches being used are evolving as Chinese research agencies become increasingly professionalised, and in response to the increasing complexity of reforms. The paper argues that learning from widespread innovation and experimentation is challenging, but necessary for stewardship of large, and rapidly-changing systems.

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A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality

Future Health Systems

Huda TM, Rahman MM, Raihana S, Islam S, Tahsina T, Alam A, Agho K, Rasheed S, Hayes A, Karim MA and Rahman QS (2018) A community-based cluster randomised controlled trial in rural Bangladesh to evaluate the impact of the use of iron-folic acid supplements early in pregnancy on the risk of neonatal mortality: the Shonjibon trial, BMC Public Health, 18(1):816, DOI: 10.1186/s12889-018-5713-1

Iron-deficiency is the most common nutritional deficiency globally. Due to the high iron requirements for pregnancy, it is highly prevalent and severe in pregnant women. There is strong evidence that maternal iron deficiency anaemia increases the risk of adverse perinatal outcomes. However, most of the evidence is from observational epidemiological studies except for a very few randomised controlled trials. IFA supplements have also been found to reduce the preterm delivery rate and neonatal mortality attributable to prematurity and birth asphyxia. These results combined indicate that IFA supplements in populations of iron-deficient pregnant women could lead to a decrease in the number of neonatal deaths mediated by reduced rates of preterm delivery. In this paper, we describe the protocol of a community-based cluster randomised controlled trial that aims to evaluate the impact of maternal antenatal IFA supplements on perinatal outcomes.

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Health policy and systems research: the future of the field

Future Health Systems

Peters D (2018) Health policy and systems research: the future of the field, Health Research Policy and Systems, 16:84, DOI: 10.1186/s12961-018-0359-0

Health policy and systems research (HPSR) has changed considerably over the last 20 years, but its main purpose remains to inform and influence health policies and systems. Whereas goals that underpin health systems have endured – such as a focus on health equity – contexts and priorities change, research methods progress, and health organisations continue to learn and adapt, in part by using HPSR. For HPSR to remain relevant, its practitioners need to re-think how health systems are conceptualised, to keep up with rapid changes in how we diagnose and manage disease and use information, and consider factors affecting people’s health that go well beyond healthcare systems. The Sustainable Development Goals (SDGs) represent a shifting paradigm in human development by seeking convergence across sectors. They also offer an opportunity for HPSR to play a larger role, given its pioneering work on applying systems thinking to health, its focus on health equity, and the strength of its multi-disciplinary approaches that make it a good fit for the SDG era.

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Gendered health systems: evidence from low- and middle-income countries

Future Health Systems

Morgan R, Ayiasi RM, Barman D, Buzuzi S, Ssemugabo C, Ezumah N, George AS, Hawkins K, Hao X, King R, Liu T, Molyneux S, Muraya KW, Musoke D, Nyamhanga T, Ros B, Tani K, Theobald S, Vong S and Waldman L (2018) Gendered health systems: evidence from low- and middle-income countries, Health Research Policy and Systems, 16:58, DOI: 10.1186/s12961-018-0338-5

Gender is often neglected in health systems, yet health systems are not gender neutral. Within health systems research, gender analysis seeks to understand how gender power relations create inequities in access to resources, the distribution of labour and roles, social norms and values, and decision-making. This paper synthesises findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gendered and/or intersectional gender approach can be applied by researchers in a range of low- and middle-income settings (Cambodia, Zimbabwe, Uganda, India, China, Nigeria and Tanzania) to issues across the health system and demonstrates that these types of analysis can uncover new and novel ways of viewing seemingly intractable problems.

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Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries

Future Health Systems

Waldman L, Theobald S and Morgan R (2018) Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries, IDS Bulletin, 49(2), DOI: 10.19088/1968-2018.137

This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability; we need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. We suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.

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Introduction: Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage

Future Health Systems

Nelson E, Bloom G and Shankland A. (2018) Introduction: Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage, IDS Bulletin, 49(2), DOI: 10.19088/1968-2018.131

In July 2017, IDS hosted a workshop on ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity’, with the aim of generating dialogue and mutual learning among activists, researchers, policymakers, and funders working towards more equitable health systems and a commitment to Universal Health Coverage (UHC). This issue of the IDS Bulletin is based around three principal themes that emerged from the workshop as needing particular attention. First, the nature of accountability politics ‘in time’ and the cyclical aspects of efforts towards accountability for health equity. Second, the contested politics of ‘naming’ and measuring accountability, and the intersecting dimensions of marginalisation and exclusion that are missing from current debates. Third, the shifting nature of power in global health and new configurations of health actors, social contracts, and the role of technology.For the first time in IDS Bulletin history, themes are explored not only in text but also through a selection of online multimedia content, including a workshop video, a photo story and a documentary. This expansion into other forms of communication is explicitly aimed at galvanising larger numbers of people in a movement towards UHC and the linked agenda of accountability for health equity.The articles and multimedia in this IDS Bulletin reflect the fact that while the desired outcome might be the same – better health for all – accountability strategies are as diverse as the contexts in which they have developed.

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‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information

Future Health Systems

Waldman L, Ahmed T, Scott N, Akter S, Standing H and Rasheed S (2018) ‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information, Globalization and Health, 14:31, DOI: 10.1186/s12992-018-0349-6

Information and Communications Technologies (ICTs) which enable people to access, use and promote health information through digital technology, promise important health systems innovations which can challenge gatekeepers’ control of information, through processes of disintermediation. College students, in pursuit of sexual and reproductive health (SRH) information, are particularly affected by gatekeeping as strong social and cultural norms restrict their access to information and services. This paper examines mobile phone usage for obtaining health information in Mirzapur, Bangladesh. It contrasts college students’ usage with that of the general population, asks whether students are using digital technologies for health information in innovative ways, and examines how gender affects this.

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Health system innovations: adapting to rapid change

Future Health Systems

Bloom G, Wilkinson A and Bhuiya A  (2018) Health system innovations: adapting to rapid change, Globalization and Health, 14:29, DOI: 10.1186/s12992-018-0347-8

A fundamental challenge for health systems is the need to adapt to changes in the patterns of health service need, scientific and technological developments, and the economic and institutional contexts within which providers of health services are embedded. This is especially true of many low and middle-income countries, where the pace of multiple and interconnected changes is breath-taking. This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries. 

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ICT-Facilitated Accountability and Engagement in Health Systems: a Review of Making All Voices Count mHealth for Accountability Projects

Future Health Systems

Information and communication technologies (ICTs) and mHealth innovations hold great potential to improve health systems and health outcomes while at the same time enhancing citizen engagement and accountability. Yet there has been little assessment of the impact of mHealth innovations on the ground. 

This paper reviews the experiences of seven mHealth initiatives funded by the Making All Voices Count programme: OurHealth, eThekwini WACs and Thuthuzela Voices (all in South Africa), Mobile Mapping for Women’s Health (Tanzania), Text2Speak (Nigeria), SMS Gateway (Indonesia) and Citizen Journalism for Quality Governance of Universal Health Insurance Scheme (also Indonesia). It discusses the accountability model adopted by each project, and the challenges they faced. 

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Accountability in Health Systems and the Potential of mHealth

Future Health Systems

This Working Paper explores the literature on accountability in health systems and on mHealth and to build theoretical and empirical bridges between them. In so doing, the authors lay out a clearer understanding of the role that mHealth can play in accountability for public health services in LMICs, as well as its limitations. At the centre of this role is technology-facilitated information which, for instance, can help governments enforce and improve existing health policy, and which can assist citizens and civil society to communicate with each other to learn more about their rights, and to engage in data collection, monitoring and advocacy. Ultimately however, information, facilitated as it may be by mHealth, does not automatically lead to improved accountability. Different forms of health care come with different accountability challenges to which mHealth is only variably up to task. Furthermore, health systems, embedded as they are in diverse political, social and economic contexts, are extremely complex, and accountability requires far more than information. Thus, mHealth can serve as a tool for accountability, but is likely only able to make a difference in institutional systems that support accountability in other ways (both formal and informal) and in which political actors and health service providers are willing and able to change their behaviour. 

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The slowing pace of life expectancy gains since 1950

Future Health Systems

Cardona C and Bishai D (2018) The slowing pace of life expectancy gains since 1950, BMC Public Health, 18(1), 151, DOI: 10.1186/s12889-018-5058-9

New technological breakthroughs in biomedicine should have made it easier for countries to improve life expectancy at birth (LEB). This paper measures the pace of improvement in the decadal gains of LEB, for the last 60-years adjusting for each country’s starting point of LEB.

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Doctoral level research and training capacity in the social determinants of health at universities and higher education institutions in India, China, Oman and Vietnam: a survey of needs

Future Health Systems

Ali F, Shet A, Yan W, Al-Maniri A, Atkins and Lucas H (2017) Doctoral level research and training capacity in the social determinants of health at universities and higher education institutions in India, China, Oman and Vietnam: a survey of needs, Health Research Policy and Systems, 15:76, DOI: 10.1186/s12961-017-0225-5

Research capacity is scarce in low- and middle-income country (LMIC) settings. Social determinants of health research (SDH) is an area in which research capacity is lacking, particularly in Asian countries. SDH research can support health decision-makers, inform policy and thereby improve the overall health and wellbeing of the population. In order to continue building this capacity, we need to know to what extent training exists and how challenges could be addressed from the perspective of students and staff. This paper aims to describe the challenges involved in training scholars to undertake research on the SDH in four Asian countries – China, India, Oman and Vietnam.

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Universal health coverage, economic slowdown and system resilience: Africa’s policy dilemma

Future Health Systems

Russo G, Bloom G and McCoy D (2017) Universal health coverage, economic slowdown and system resilience: Africa’s policy dilemma, BMJ Global Health, 2 (3), DOI: 10.1136/bmjgh-2017-00040

Achieving universal health coverage (UHC) has become a dominant policy preoccupation within the global health community. For Africa, progress towards UHC involves ambitious goals for expanding access to a range of effective health services, a substantial increase in health expenditure, and establishing a greater reliance on prepayment and pooling mechanisms to finance healthcare. According to one set of calculations, achieving UHC requires countries to spend at least $86 per capita in 2012 dollars on healthcare, and a minimum of 5% of Gross Domestic Product (GDP). Clearly, expanding the ‘fiscal space for health’ will be key to the success of UHC.

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Socioeconomic inequalities in under-five mortality in rural Bangladesh: evidence from seven national surveys spreading over 20 years

Future Health Systems

Chowdhury AH, Hanifi SMA, Mia MN and Bhuiya A (2017) Socioeconomic inequalities in under-five mortality in rural Bangladesh: evidence from seven national surveys spreading over 20 years, International Journal for Equity in Health (2017) 16:197, DOI: 10.1186/s12939-017-0693-9

Socioeconomic inequality in health and mortality remains a disturbing reality across nations including Bangladesh. Inequality drew renewed attention globally. Bangladesh though made impressive progress in health, it makes an interesting case for learning. This paper examined the trends and changing pattern of socioeconomic inequalities in under-five mortality in rural Bangladesh. It also examined whether mother’s education had any effect in reducing socioeconomic inequalities.

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Gender differentials in readiness and use of mHealth services in a rural area of Bangladesh

Future Health Systems

Khatun F, Heywood AE, Hanifi SM, Rahman MS, Ray PK, Liaw ST and Bhuiya A (2017) Gender differentials in readiness and use of mHealth services in a rural area of Bangladesh, BMC health services research, 17:573, DOI: 10.1186/s12913-017-2523-6

Traditional gender roles result in women lagging behind men in the use of modern technologies, especially in developing countries. Although there is rapid uptake of mobile phone use in Bangladesh, investigation of gender differences in the ownership, access and use of mobile phones in general and mHealth in particular has been limited. This paper presents gender differentials in the ownership of mobile phones and knowledge of available mHealth services in a rural area of Bangladesh.

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Learning by doing in practice: a roundtable discussion about stakeholder engagement in implementation research

Future Health Systems

Arwal SH, AulakhBK, Bumba A and Siddula A (2017) Learning by doing in practice: a roundtable discussion about stakeholder engagement in implementation research, Health Research Policy and Systems, 15(Suppl 2):105, DOI: 10.1186/s12961-017-0275-8

Researchers and policy-makers alike increasingly recognise the importance of engaging diverse perspectives in implementation research. This roundtable discussion presents the experiences and perspectives of three decision-makers regarding the benefits and challenges of their engagement in implementation research.

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Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda

Future Health Systems

Kananura RM, Ekirapa-Kiracho E, Paina L, Bumba A, Mulekwa G, Nakiganda-Busiku D, Oo HNL, Kiwanuka SN, George A and Peters DH (2017) Participatory monitoring and evaluation approaches that influence decision-making: lessons from a maternal and newborn study in Eastern Uganda, Health Research Policy and Systems, 15(Suppl 2):107, DOI: 10.1186/s12961-017-0274-9

The use of participatory monitoring and evaluation (M&E) approaches is important for guiding local decision-making, promoting the implementation of effective interventions and addressing emerging issues in the course of implementation. In this article, we explore how participatory M&E approaches helped to identify key design and implementation issues and how they influenced stakeholders’ decision-making in eastern Uganda.

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