Publications by authors named "Bart Criel"

111 Publications

How medical dominance and interprofessional conflicts undermine patient-centred care in hospitals: historical analysis and multiple embedded case study in Morocco.

BMJ Glob Health 2021 Jul;6(7)

Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Background: In Morocco's health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals.

Methods: We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of 'negotiated order' and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco.

Results: Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care.

Conclusion: The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.
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http://dx.doi.org/10.1136/bmjgh-2021-006140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8280911PMC
July 2021

Multilevel governance framework on grievance redressal for patient rights violations in India.

Health Policy Plan 2021 Jun 16. Epub 2021 Jun 16.

Health Equity Cluster, Institute of Public Health, 3009, II A Main, 17th Cross, KR road, Sidanna Layout, Banashankari stage II, Banashankari, Bengaluru, Karnataka-560070, India.

The notion of patient rights encompasses the obligations of the state and healthcare providers to respect the dignity, autonomy and equality of care-seeking individuals in healthcare processes. Functional patient grievance redressal systems are key to ensuring that the rights of individuals seeking healthcare are protected. We critically examined the published literature from high-income and upper-middle-income countries to establish an analytical framework on grievance redressal for patient rights violations in health facilities. We then used lawsuits on patient rights violations from the Supreme Court of India to analyse the relevance of the developed framework to the Indian context. With market perspectives pervading the health sector, there is an increasing trend of adopting a consumerist approach to protecting patient rights. In this line, avenues for grievance redressal for patient rights violations are gaining traction. Some of the methods and instruments for patient rights implementation include charters, ombudsmen, tribunals, health professional councils, separating rules for redressal and professional liability in patient rights violations, blame-free reporting systems, direct community monitoring and the court system. The grievance redressal mechanisms for patient rights violations in health facilities showcase multilevel governance arrangements with overlapping decision-making units at the national and subnational levels. The privileged position of medical professionals in multilevel governance arrangements for grievance redressal puts care-seeking individuals at a disadvantaged position during dispute resolution processes. Inclusion of external structures in health services and the healthcare profession and laypersons in the grievance redressal processes is heavily contested. Normatively speaking, a patient grievance redressal system should be accessible, impartial and independent in its function, possess the required competence, have adequate authority, seek continuous quality improvement, offer feedback to the health system and be comprehensive and integrated within the larger healthcare regulatory architecture.
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http://dx.doi.org/10.1093/heapol/czab066DOI Listing
June 2021

Multisectoral action for health in low-income and middle-income settings: how can insights from social science theories inform intragovernmental coordination efforts?

BMJ Glob Health 2021 05;6(5)

School of Public Health, Department of Health Policy Planning and Management, Makerere University College of Health Sciences, Kampala, Uganda.

There is consensus in global health on the need for multisectoral action (MSA) to address many contemporary development challenges, but there is limited action. Examples of issues that require coordinated MSA include the determinants of health conditions such as nutrition (malnutrition and obesity) and chronic non-communicable diseases. Nutrition, tobacco control and such public health issues are regulated separately by health, trade and treasury ministries. Those issues need to be coordinated around the same ends to avoid conflicting policies. Despite the need for MSA, why do we see little progress? We investigate the obstacles to and opportunities for MSA by providing a government perspective. This paper draws on four theoretical perspectives, namely (1) the political economy perspective, (2) principal-agent theory, (3) resource dependence theory and (4) transaction cost economics theory. The theoretical framework provides complementary propositions to understand, anticipate and prepare for the emergence and structuring of coordination arrangements between government organisations at the same or different hierarchical levels. The research on MSA for health in low/middle-income countries needs to be interested in a multitheory approach that considers several theoretical perspectives and the contextual factors underlying coordination practices.
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http://dx.doi.org/10.1136/bmjgh-2020-004064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8160194PMC
May 2021

[Study on the integration of mental health support into primary health care in Guinea].

Pan Afr Med J 2020 1;37:107. Epub 2020 Oct 1.

Ecole de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique.

Introduction: the low coverage of specialized mental health services and the shortage of human resources for mental health are enormous challenges for the health care system in Africa. The integration of mental health support into primary health care is a substantial and feasible complementary intervention to specialized services. We collected and analyzed data from 5 Health Care Centers (HCC) that had integrated this care package in Guinea.

Methods: we conducted a descriptive study of new cases of mental health issues between 2012 and 2017. The reasons for consultations and diagnoses were identified and analyzed on the basis of consultation registries and individual medical records.

Results: a total of 4.995 patients with mental health problems received consultations (2.8% of general consultations; 0.5 -7.7% according to the centers). The average age of patients was 27,9 years (± 16.1). The most common reasons for consultations were: insomnia 44.4% (n = 2081), seizures 39% (n = 1827), behavioral disorders 31.9% (n = 1263) and hallucinations 26.1% (n = 1224). The most common diagnoses were: epilepsy 36.8% (n = 1773) and psychotic disorders 33.5% (n = 1613). Eighty eight point four per cent (n = 4418) of patients received medical treatment, most often combined with psychological support.

Conclusion: this study highlights that in the Guinean context, where access to specialized mental health care is very limited, patients with mental ill, even with severe medical conditions, can be followed up in the health centers by non-specialized but trained mental health professionals.
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http://dx.doi.org/10.11604/pamj.2020.37.107.20351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757329PMC
January 2021

Improving primary care for diabetes and hypertension: findings from implementation research in rural South India.

BMJ Open 2020 12 15;10(12):e040271. Epub 2020 Dec 15.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Background: Chronic conditions are a leading cause of death and disability worldwide. Low-income and middle-income countries such as India bear a significant proportion of this global burden. Redesigning primary care from an acute-care model to a model that facilitates chronic care is a challenge and requires interventions at multiple levels.

Objectives: In this intervention study, we aimed to strengthen primary care for diabetes and hypertension at publicly funded primary healthcare centres (PHCs) in rural South India.

Design And Methods: The complexities of transforming the delivery of primary care motivated us to use a 'theory of change' approach to design, implement and evaluate the interventions. We used both quantitative and qualitative data collection methods. Data from patient records regarding processes of care, glycaemic and blood pressure control, interviews with patients, observations and field notes were used to analyse what changes occurred and why.

Interventions: We implemented the interventions for 9 months at three PHCs: (1) rationalise workflow to include essential tasks like counselling and measurement of blood pressure/blood glucose at each visit; (2) distribute clinical tasks among staff; (3) retain clinical records at the health facility and (4) capacity building of staff.

Results: We found that interventions were implemented at all three PHCs for the first 4 months but did not continue at two of the PHCs. This fadeout was most likely the result of staff transfers and a doctor's reluctance to share tasks. The availability of an additional staff member in the role of a coordinator most likely influenced the relative success of implementation at one PHC.

Conclusion: These findings draw attention to the need for building teams in primary care for managing chronic conditions. The role of a coordinator emerged as an important consideration, as did the need for a stable core of staff to provide continuity of care.
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http://dx.doi.org/10.1136/bmjopen-2020-040271DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745330PMC
December 2020

Team-based primary health care for non-communicable diseases: complexities in South India.

Health Policy Plan 2020 Nov;35(Supplement_2):ii22-ii34

Institute of Tropical Medicine, Nationalestraat 155, Antwerpen 2000, Belgium.

Chronic non-communicable diseases (NCDs), such as diabetes and cardiovascular diseases, have reached epidemic proportions worldwide. Health systems, especially those in low- and middle-income countries, such as India, struggle to deliver quality chronic care. A reorganization of healthcare service delivery is needed to strengthen care for chronic conditions. In this study, we evaluated the implementation of a package of tailored interventions to reorganize care, which were identified following a detailed analysis of gaps in delivering quality NCD care at the primary care level in India. Interventions included a redesign of the workflow at primary care clinics, a redistribution of tasks, the introduction of patient information records and the involvement of community health workers in the follow-up of patients with NCDs. An experimental case study design was chosen to study the implementation of the quality improvement measures. Three public primary care facilities in rural South India were selected. Qualitative methods were used to gain an in-depth understanding of the implementation process and outcomes of implementation. Observations, field notes and semi-structured interviews with staff at these facilities (n = 15) were thematically analysed to identify contextual factors that influenced implementation. Only one of the primary health centres implemented all components of the intervention by the end of 9 months. The main barriers to implementation were hierarchical arrangements that inhibited team-based care, the amount of time required for counselling and staff transfers. Team cohesion, additional staff and staff motivation seem to have facilitated implementation. This quality improvement research highlights the importance of building relational leadership to enable team-based care at primary care clinics in India. Redesigned organization of care and task redistribution is important solutions to deliver quality chronic care. However, implementing these will require capacity building of local primary care teams.
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http://dx.doi.org/10.1093/heapol/czaa121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646724PMC
November 2020

Towards a multilevel governance framework on the implementation of patient rights in health facilities: a protocol for a systematic scoping review.

BMJ Open 2020 10 15;10(10):e038927. Epub 2020 Oct 15.

Health Equity Cluster, Institute of Public Health, Bengaluru, India.

Introduction: Patient rights are "those rights that are attributed to a person seeking healthcare". Patient rights have implications for quality of healthcare and acts as a key accountability tool. It can galvanise structural improvements in the health system and reinforces ethical healthcare. States are duty bound to respect, protect and promote patient rights. The rhetoric on patient rights is burgeoning across the globe. With changing modes of governance arrangements, a number of state and non-state actors and institutions at various levels play a role in the design and implementation of (patient rights) policies. However, there is limited understanding on the multilevel institutional mechanisms for patient rights implementation in health facilities. We attempt to fill this gap by analysing the available scholarship on patient rights through a critical interpretive synthesis approach in a systematic scoping review.

Methods: The review question is 'how do the multilevel actors, institutional structures, processes interact and influence the patient rights implementation in healthcare facilities? How do they work at what level and in which contexts?" Three databases PubMed, LexisNexis and Web of Science will be systematically searched until 30 April 2020, for empirical and non-empirical literature in English from both lower middle-income countries and high-income countries. Targeted search will be performed in grey literature and through citation and reference tracking of key records. Using the critical interpretive synthesis approach, a multilevel governance framework on the implementation of patient rights in health facilities which is grounded in the data will be developed.

Ethics And Dissemination: The review uses published literature hence ethics approval is not required. The findings of the review will be published in a peer-reviewed journal.

Registration Number: PROSPERO 2020 CRD42020176939.
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http://dx.doi.org/10.1136/bmjopen-2020-038927DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7566736PMC
October 2020

Applying the Robson classification to routine facility data to understand the Caesarean section practice in conflict settings of South Kivu, eastern DR Congo.

PLoS One 2020 8;15(9):e0237450. Epub 2020 Sep 8.

Renforcement Institutionnel Pour des Politiques de Santé Basées sur l'Evidence, Democratic Republic of Congo, Lubumbashi, Democratic Republic of Congo.

Introduction: Sub-Saharan Africa has low Caesarean (CS) levels, despite a global increase in CS use. In conflict settings, the pattern of CS use is unclear because of scanty data. We aimed to examine the opportunity of using routine facility data to describe the CS use in conflict settings.

Methods: We conducted a facility-based cross-sectional study in 8 health zones (HZ) of South Kivu province in eastern DR Congo. We reviewed patient hospital records, maternity registers and operative protocol books, from January to December 2018. Data on direct conflict fatalities were obtained from the Uppsala Conflict Data Program. Based on conflict intensity and chronicity (expressed as a 6-year cumulative conflict death rate), HZ were classified as unstable (higher conflict death rate), intermediate and stable (lower conflict death rate). To describe the Caesarean section practice, we used the Robson classification system. Based on parity, history of previous CS, onset of labour, foetal lie and presentation, number of neonates and gestational age, the Robson classification categorises deliveries into 10 mutually exclusive groups. We performed a descriptive analysis of the relative contribution of each Robson group to the overall CS rate in the conflict stratum.

Results: Among the 29,600 deliveries reported by health facilities, 5,520 (18.6%) were by CS; 5,325 (96.5%) records were reviewed, of which 2,883 (54.1%) could be classified. The overall estimated population CS rate was 6.9%. The proportion of health facility deliveries that occurred in secondary hospitals was much smaller in unstable health zones (22.4%) than in intermediate (40.25) or stable health zones (43.0%). Robson groups 5 (previous CS, single cephalic, ≥ 37 weeks), 1 (nulliparous, single cephalic, ≥ 37 weeks, spontaneous labour) and 3 (multiparous, no previous CS, single cephalic, ≥ 37 weeks, spontaneous labour) were the leading contributors to the overall CS rate; and represented 75% of all CS deliveries. In unstable zones, previous CS (27.1%) and abnormal position of the fetus (breech, transverse lie, 3.3%) were much less frequent than in unstable and intermediate (44.3% and 6.0% respectively) and stable (46.7%and 6.2% respectively). Premature delivery and multiple pregnancy were more prominent Robson groups in unstable zones.

Conclusion: In South Kivu province, conflict exposure is linked with an uneven estimated CS rate at HZ level with at high-risks women in conflict affected settings likely to have lower access to CS compared to low-risk mothers in stable health zones.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237450PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7478810PMC
October 2020

Patient perspectives on interpersonal aspects of healthcare and patient-centeredness at primary health facilities: A mixed methods study in rural Eastern Uganda.

PLoS One 2020 30;15(7):e0236524. Epub 2020 Jul 30.

Department of Public Health-Health Systems and Equity Unit, Institute of Tropical Medicine, Antwerp, Belgium.

Introduction: Patient-centered care (PCC) is an approach to involve patients in health care delivery, to contribute to quality of care, and to strengthen health systems responsiveness. This article aims to highlight patient perspectives by showcasing their perceptions of their experience of PCC at primary health facilities in two districts in Uganda.

Methods: A mixed methods cross-sectional study was conducted in three public and two private primary health care facilities in rural eastern Uganda. In total, 300 patient exit survey questionnaires, 31 semi-structured Interviews (SSIs), 5 Focus Group Discussions (FGDs) and 5 feedback meetings were conducted. Data analysis was guided by a conceptual framework focusing on (1) understanding patients' health needs, preferences and expectations, (2) describing patients perceptions of their care experience according to five distinct PCC dimensions, and (3) reporting patient reported outcomes and their recommendations on how to improve quality of care.

Results: Patient expectations were shaped by their access to the facility, costs incurred and perceived quality of care. Patients using public facilities reported doing so because of their proximity (78.3% in public PHCs versus 23.3% in private PHCs) and because of the free services availed. On the other hand, patients attending private facilities did so because of their perception of better quality of care (84.2% in private PHCs versus 21.7% in public PHCs). Patients expectations of quality care were expressed as the availability of medication, shorter waiting times, flexible facility opening hours and courteous health workers. Analysis of the 300 responses from patients interviewed on their perception of the care they received, pointed to higher normalized scores for two out of the five PCC dimensions considered: namely, exploration of the patient's health and illness experience, and the quality of the relationship between patient and health worker (range 62.1-78.4 out of 100). The qualitative analysis indicated that patients felt that communication with health workers was enhanced where there was trust and in case of positive past experiences. Patients however felt uncomfortable discussing psychological or family matters with health workers and found it difficult to make decisions when they did not fully understand the care provided. In terms of outcomes, our findings suggest that patient enablement was more sensitive than patient satisfaction in measuring the effect of interpersonal patient experience on patient reported outcomes.

Discussion And Conclusion: Our findings show that Ugandan patients have some understanding of PCC related concepts and express a demand for it. The results offer a starting point for small scale PCC interventions. However, we need to be cognizant of the challenges PCC implementation faces in resource constrained settings. Patients' expectations in terms of quality health care are still largely driven by biomedical and technical aspects. In addition, patients are largely unaware of their right to participate in the evaluation of health care. To mitigate these challenges, targeted health education focusing on patients' responsibilities and patient's rights are essential. Last but not least, all stakeholders must be involved in developing and validating methods to measure PCC.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236524PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392339PMC
September 2020

An evaluation of self-management outcomes among chronic care patients in community home-based care programmes in rural Malawi: A 12-month follow-up study.

Health Soc Care Community 2021 Mar 16;29(2):353-368. Epub 2020 Jul 16.

Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa.

This paper investigates the impact of community home-based care (CHBC) on self-management outcomes for chronically ill patients in rural Malawi. A pre- and post-evaluation survey was administered among 140 chronically ill patients with HIV and non-communicable diseases, newly enrolled in four CHBC programmes. We translated, adapted and administered scales from the Stanford Chronic Disease Self-Management Programme to evaluate patient's self-management outcomes (health status and self-efficacy), at four time points over a 12-month period, between April 2016 and May 2017. The patient's drop-out rate was approximately 8%. Data analysis included descriptive statistics, tests of associations, correlations and pairwise comparison of outcome variables between time points, and multivariate regression analysis to explore factors associated with changes in self-efficacy following CHBC interventions. The results indicate a reduction in patient-reported pain, fatigue and illness intrusiveness, while improvements in general health status and quality of life were not statistically significant. At baseline, the self-efficacy mean was 5.91, which dropped to 5.1 after 12 months. Factors associated with this change included marital status, education, employment and were condition-related; whereby self-efficacy for non-HIV and multimorbid patients was much lower. The odds for self-efficacy improvement were lower for patients with diagnosed conditions of longer duration. CHBC programme support, regularity of contact and proximal location to other services influenced self-efficacy. Programmes maintaining regular home visits had higher patient satisfaction levels. Our findings suggest that there were differential changes in self-management outcomes following CHBC interventions. While self-management support through CHBC programmes was evident, CHBC providers require continuous training, supervision and sustainable funding to strengthen their contribution. Furthermore, sociodemographic and condition-related factors should inform the design of future interventions to optimise outcomes. This study provides a systematic evaluation of self-management outcomes for a heterogeneous chronically ill patient population and highlights the potential and relevant contribution of CHBC programmes in improving chronic care within sub-Saharan Africa.
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http://dx.doi.org/10.1111/hsc.13094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983972PMC
March 2021

Context matters: a qualitative study of the practicalities and dilemmas of delivering integrated chronic care within primary and secondary care settings in a rural Malawian district.

BMC Fam Pract 2020 06 8;21(1):101. Epub 2020 Jun 8.

Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Calle del Rossellón 132, ES-08036, Barcelona, Spain.

Background: With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level.

Methods: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo.

Results: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems.

Conclusion: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives.
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http://dx.doi.org/10.1186/s12875-020-01174-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282183PMC
June 2020

Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo.

PLoS One 2020 16;15(4):e0231660. Epub 2020 Apr 16.

School of Public Health and Tropical Medicine, Global Community Health and Behavioral Sciences, Tulane University, New Orleans, LA, United States of America.

Background: In their mission to achieve better access to quality healthcare services, mutual health organisations (MHOs) are not limited to providing health insurance. As democratically controlled member organisations, MHOs aim to make people's voices heard. At national level, they seek involvement in the design of social protection policies; at local level, they seek to improve responsiveness of healthcare services to members' needs and expectations.

Methods: In this qualitative study, we investigated whether MHOs in the Democratic Republic of Congo (DRC) succeed in defending members' rights by improving healthcare quality while minimising expenses. The data originate from an earlier in-depth investigation conducted in the DRC in 2016 of the performance of 13 MHOs. We re-analysed this existing dataset and more specifically investigated actions that the MHOs undertook to improve quality and affordability of healthcare provision for their members, using a framework for analysis based on Hirschman's exit-voice theory. This framework distinguishes four mechanisms for MHO members to use in influencing providers: (1) 'exit' or 'voting with the feet'; (2) 'co-producing a long voice route' or imposing rules through strategic purchasing; (3) 'guarding over the long voice route of accountability' or pressuring authorities to regulate and enforce regulations; and (4) 'strengthening the short voice route' by transforming the power imbalance at the provider-patient interface.

Results: All studied MHOs used these four mechanisms to improve healthcare provision. Most healthcare providers, however, did not recognise their authority to do so. In the DRC, controlling quality and affordability of healthcare is firmly seen as a role for the health authorities, but the authorities only marginally take up this role. Under current circumstances, the power of MHOs in the DRC to enhance quality and affordability of healthcare is weak.

Conclusion: On their own, mutual health organisations in the DRC do not have sufficient power to influence the practices of healthcare providers. Greater responsiveness of the health services to MHO members requires cooperation of all actors involved in healthcare delivery to create an enabling environment where voices defending people's rights are heard.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231660PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162613PMC
July 2020

Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa.

Health Res Policy Syst 2020 Feb 19;18(1):25. Epub 2020 Feb 19.

Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.

Background: Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country's efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems.

Methods: We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process.

Results: An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change.

Conclusion: Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level.
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http://dx.doi.org/10.1186/s12961-020-0531-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031916PMC
February 2020

Integration of mental health care in private not-for-profit health centres in Guinea, West Africa: a systemic entry point towards the delivery of more patient-centred care?

BMC Health Serv Res 2020 Jan 28;20(1):61. Epub 2020 Jan 28.

Institute of Tropical Medicine, Antwerp, Belgium.

Background: Patient-centred care is an essential component of quality of health care. We hypothesize that integration of a mental health care package into versatile first-line health care services can strengthen patient participation, an important dimension of patient-centred care. The objective of this study is to analyse whether consultations conducted by providers in facilities that integrated mental health care score higher in terms of patient participation.

Methods: This study was conducted in Guinea in 12 not-for-profit health centres, 4 of which had integrated a mental health care package (MH+) and 8 had not (MH-). The study involved 450 general curative consultations (175 in MH+ and 275 in MH- centres), conducted by 18 care providers (7 in MH+ and 11 in MH- centres). Patients were interviewed after the consultation on how they perceived their involvement in the consultation, using the Patient Participation Scale (PPS). The providers completed a self-administered questionnaire on their perception of patient's involvement in the consultation. We compared scores of the PPS between MH+ and MH- facilities and between patients and providers.

Results: The mean PPS score was 24.21 and 22.54 in MH+ and MH- health centres, respectively. Participation scores depended on both care providers and the health centres they work in. The patients consulting an MH+ centre were scoring higher on patient participation score than the ones of an MH- centre (adjusted odds ratio of 4.06 with a 95% CI of 1.17-14.10, p = 0.03). All care providers agreed they understood the patients' concerns, and patients shared this view. All patients agreed they wanted to be involved in the decision-making concerning their treatment; providers, however, were reluctant to do so.

Conclusion: Integrating a mental health care package into versatile first-line health services can promote more patient-centred care.
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http://dx.doi.org/10.1186/s12913-020-4914-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6986146PMC
January 2020

Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry.

PLoS One 2019 28;14(8):e0221649. Epub 2019 Aug 28.

Department of Public Health-Health Systems and Equity unit, Institute of Tropical Medicine, Antwerp, Belgium.

Background: Patient-centered care (PCC) offers opportunities for African health systems to improve quality of care. Nonetheless, PCC continually faces implementation challenges. In 2015, Uganda introduced PCC as a concept in their national quality improvement guidelines. In order to investigate whether and how this is implemented in practice, this study aims to identify relevant stakeholders' views on the current quality of primary health care services and their understanding of PCC. This is an important step in understanding how the concept of PCC can be implemented in a resource constrained, sub-Saharan context like Uganda.

Methods: This qualitative study was conducted in Uganda at national, district and facility level, with a focus on three public and three private health centres. Data collection consisted of in-depth interviews (n = 49); focus group discussions (n = 7); and feedback meetings (n = 14) across the four main categories of stakeholders identified: patients/communities, health workers, policy makers and academia. Interviews and discussions explored stakeholder perceptions on the interpersonal aspects of quality primary health care and meanings attached to the concept of PCC. A content analysis of Ugandan policy documents mentioning PCC was also conducted. Thematic content analysis was conducted using NVivo 11 to organize and analyze the data.

Findings And Conclusion: While Ugandan stakeholder groups have varying perceptions of PCC, they agree on the following: the need to involve patients in making decisions about their health, the key role of healthcare workers in that endeavor, and the importance of context in designing and implementing solutions. For that purpose, three avenues are recommended: Firstly, fora that include a wide range of stakeholders may offer a powerful opportunity to gain an inclusive vision on PCC in Uganda. Secondly, efforts need to be made to ensure that improved communication and information sharing-important components of PCC-translate to actual shared decision making. Lastly, the Ugandan health system needs to strengthen its engagement of the transformation from a community health worker system to a more comprehensive community health system. Cross-cutting the entire analysis, is the need to address, in a culturally-sensitive way, the many structural barriers in designing and implementing PCC policies. This is essential in ensuring the sustainable and effective implementation of PCC approaches in low- and middle-income contexts.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221649PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6713356PMC
March 2020

Distribution and quality of emergency obstetric care service delivery in the Democratic Republic of the Congo: it is time to improve regulatory mechanisms.

Reprod Health 2019 Jul 15;16(1):102. Epub 2019 Jul 15.

Kinshasa School of Public Health, University of Kinshasa, P.O. Box: 11850, Kinshasa I, Kinshasa, Democratic Republic of the Congo.

Background: The Demographic and Health Survey 2013-14 indicated that the Democratic Republic of the Congo (DRC) is still challenged by high maternal and neonatal mortality. The aim of this study was to assess the availability, quality and equity of emergency obstetric care (EmOC) in the DRC.

Methods: A cross-sectional survey of 1,568 health facilities selected by multistage random sampling in 11 provinces of the DRC was conducted in 2014. Data were collected through interviews, document reviews, and direct observation of service delivery. Collected data included availability, quality, and equity of EmOC depending on the location (urban vs. rural), administrative identity, type of facility, and province. Associations between variables were tested by Pearson's chi-squared test using an alpha significance level of 0.05.

Results: A total of 1,555 health facilities (99.2%) were surveyed. Of these, 9.1% provided basic EmOC and 2.9% provided comprehensive EmOC. The care was unequally distributed across the provinces and urban vs. rural areas; it was more available in urban areas, with the provinces of Kinshasa and Nord-Kivu being favored compared to other provinces. Caesarean section and blood transfusions were provided by health centers (6.5 and 9.0%, respectively) and health posts (2.3 and 2.3%, respectively), despite current guidelines disallowing the practice. None of the facilities provided quality EmOC, mainly due to the lack of proper standards and guidelines.

Conclusions: The distribution and quality of EmOC are problematic. The lack of regulation and monitoring appears to be a key contributing factor. We recommend the Ministry of Health go beyond merely granting funds, and also ensure the establishment and monitoring of appropriate standard operating procedures for providers.
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http://dx.doi.org/10.1186/s12978-019-0772-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6631736PMC
July 2019

[Integrating mental health in community health centers in Guinea].

Sante Publique 2019 Marc Apr;31(2):305-313

This study investigates effects of integrating mental health on staff attitudes in 5 community health centers in Guinea: more specifically, on destigmatizing mental health problems and on adopting patient-centered care approaches. It is based on semi-structured interviews with 27 health workers from health centers having integrated mental health care (Santé Mentale +, with acronym SM+); and, as a comparison group, with 11 health workers working in facilities that do not have integrated mental health (SM-). Attitudinal change among SM+ health workers contrasts sharply with the stigmatizing discourse of SM- health workers. The former, strengthened by their successes in treating mental health patients, have overcome their fears and developed positive attitudes vis-à-vis mental health patients. Furthermore, part of the SM+ workers discovered and adopted a patient-centered approach to care, whereas others remained confined to a biomedical logic. A facilitating factor of change has been the organization of an in-service training program (joint consultations, teamwork and community action) taking into account health workers' emotional needs and providing patient-centered role models. However, this training set-up only functioned optimally in the non-bureaucratic organizational context of a community health center staffed with a stable and qualified team. Our study indicates that, beyond improved access to psychiatric care, integrating mental health in health centers can also reinforce the quality of the therapeutic relationship in general. The contents and modalities of the training program in mental health are crucial; but so is the way the health services are being organized.
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http://dx.doi.org/10.3917/spub.192.0305DOI Listing
January 2021

Patient-provider perspectives on self-management support and patient empowerment in chronic care: A mixed-methods study in a rural sub-Saharan setting.

J Adv Nurs 2019 Nov 21;75(11):2980-2994. Epub 2019 Jul 21.

Unit of Equity and Health, Department of Public Health, Institute of Tropical Medicine. Nationalestraat, Antwerp, Belgium.

Aim: To explore how provision of self-management support to chronically-ill patients in resource-limited settings contributes to patient empowerment in chronic care.

Design: Concurrent descriptive mixed methods research.

Methods: A survey of 140 patients with chronic conditions administered at four time-points in 12 months. We conducted 14 interviews and four focus-group discussions with patients (N = 31); 13 healthcare provider interviews; and observations of four patient-support group meetings. Data were collected between April 2016 - May 2017 in rural Malawi. Qualitative data were analysed using a thematic approach and descriptive statistical analysis performed on survey data.

Results: Healthcare professionals facilitated patient empowerment through health education, although literacy levels and environmental factors affected self-management guidance. Information exchanged during patient-provider interactions varied and discussions centred around medical aspects and health promoting behaviour. Less than 40% of survey patients prepared questions prior to clinic consultations. Health education was often unstructured and delegated to non-physician providers, mostly untrained in chronic care. Patients accessed psychosocial support from volunteer-led community home-based care programmes. HIV support-groups regularly interacted with peers and practical skills exchanged in a supportive environment, reinforcing patient's self-mangement competence and proactiveness in health care.

Conclusion: For optimal self-management, reforms at inter-personal and organizational level are needed including; mutual patient-provider collaboration, diversifying access to self-management support resources and restructuring patient support-groups to cater to diverse chronic conditions.

Impact: Our study provides insights and framing of self-management support and empowerment for patients in long-term care in sub-Saharan Africa. Lessons drawn could feed into designing and delivering responsive chronic care interventions.
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http://dx.doi.org/10.1111/jan.14116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6900026PMC
November 2019

Models of care for chronic conditions in low/middle-income countries: a 'best fit' framework synthesis.

BMJ Glob Health 2018 30;3(6):e001077. Epub 2018 Dec 30.

Department of Health Financing, Institute of Tropica Medicine, Antwerp, Belgium.

Management of chronic conditions is a challenge for healthcare delivery systems world over and especially for low/middle-income countries (LMIC). Redesigning primary care to deliver quality care for chronic conditions is a need of the hour. However, much of the literature is from the experience of high-income countries. We conducted a synthesis of qualitative findings regarding care for chronic conditions at primary care facilities in LMICs. The themes identified were used to adapt the existing chronic care model (CCM) for application in an LMIC using the 'best fit' framework synthesis methodology. Primary qualitative research studies were systematically searched and coded using themes of the CCM. The results that could not be coded were thematically analysed to generate themes to enrich the model. Search strategy keywords were: primary health care, diabetes mellitus type 2, hypertension, chronic disease, developing countries, low, middle-income countries and LMIC country names as classified by the World Bank. The search yielded 404 articles, 338 were excluded after reviewing abstracts. Further, 42 articles were excluded based on criteria. Twenty-four studies were included for analysis. All themes of the CCM, identified a priori, were represented in primary studies. Four additional themes for the model were identified: a focus on the quality of communication between health professionals and patients, availability of essential medicines, diagnostics and trained personnel at decentralised levels of healthcare, and mechanisms for coordination between healthcare providers. We recommend including these in the CCM to make it relevant for application in an LMIC.
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http://dx.doi.org/10.1136/bmjgh-2018-001077DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326308PMC
December 2018

Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India.

BMC Health Serv Res 2019 Jan 18;19(1):44. Epub 2019 Jan 18.

Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerpen, Belgium.

Background: Chronic diseases have emerged as the leading cause of death globally, and 20% of Indians are estimated to suffer from a chronic condition. Care for chronic diseases poses a major public health challenge, especially when health care delivery has been geared traditionally towards acute care. In this study, we aimed to better understand how primary care for diabetes and hypertension is currently organised in first-line health facilities in rural India, and propose evidence-based ways forward for strengthening local health systems to address chronic problems.

Methods: We used qualitative and quantitative methods to gain insight into how care is organised and how patients and providers manage within this delivery system. We conducted in-depth interviews with the medical doctors working in three private clinics and in three public primary health centres. We also interviewed 24 patients with chronic diseases receiving care in the two sub-sectors. Non-participant observations and facility assessments were performed to triangulate the findings from the interviews.

Results: The current delivery system has many problems impeding the delivery of quality care for chronic conditions. In both the public and private facilities studied, the care processes are very doctor-centred, with little room for other health centre staff. Doctors face very high workloads, especially in the public sector, jeopardising proper communication with patients and adequate counselling. In addition, the health information system is fragmented and provides little or no support for patient follow-up and self-management. The patient is largely left on their own in trying to make sense of their condition and in finding their way in a complex and scattered health care landscape.

Conclusions: The design and organisation of care for persons with chronic diseases in India needs to be rethought. More space and responsibility should be given to the primary care level, and relatively less to the more specialised hospital level. Furthermore, doctors should consider delegating some of their tasks to other staff in the first-line health facility to significantly reduce their workload and increase time available for communication. The health information system needs to be adapted to better ensure continuity of care and support self-management by patients.
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http://dx.doi.org/10.1186/s12913-019-3876-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6339380PMC
January 2019

Qualitative exploration of sociocultural determinants of health inequities of Dalit population in Dhaka City, Bangladesh.

BMJ Open 2018 12 14;8(12):e022906. Epub 2018 Dec 14.

Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.

Objectives: In recent years, Bangladesh has made remarkable advances in health outcomes; however, the benefits of these gains are unequally shared among citizens and population groups. Dalits ( sweepers), a marginalised traditional working community, have relatively poor access to healthcare services. This study sought to explore the sociopolitical and cultural factors associated with health inequalities among Dalits in an urban setting.

Design: An exploratory qualitative study design was adopted. Fourteen in-depth interviews, five focus group discussions and seven key informant interviews were conducted. The acquired data were analysed using an iterative approach which incorporated deductive and inductive methods in identifying codes and themes.

Settings: This study was conducted in two sweeper communities in Dhaka city.

Participants: Participants were Dalit men and women (in-depth interviews, mean age±SD 30±10; and focus group discussions), and the community leaders and non-governmental organisation workers (key informant interviews).

Results: The health status of members of these Dalit groups is determined by an array of social, economic and political factors. Dalits (untouchables) are typically considered to fall outside the caste-based social structure and existing vulnerabilities are embedded and reinforced by this identity. Dalits' experience of precarious access to healthcare or poor healthcare is an important manifestation of these inequalities and has implications for the economic and social life of Dalit populations living together in geographically constrained spaces.

Conclusions: The provision of clinical healthcare services alone is insufficient to mitigate the negative effects of discriminations and to improve the health status of Dalits. A better understanding of the precise influences of sociocultural determinants of health inequalities is needed, together with the identification of the strategies and programmes needed to address these determinants with the aim of developing more inclusive health service delivery systems.
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http://dx.doi.org/10.1136/bmjopen-2018-022906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6303619PMC
December 2018

Moving to a strong(er) community health system: analysing the role of community health volunteers in the new national community health strategy in Malawi.

BMJ Glob Health 2018 16;3(Suppl 3):e000996. Epub 2018 Nov 16.

Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.

Since the Alma Ata Declaration in 1978, community health volunteers (CHVs) have been at the forefront, providing health services, especially to underserved communities, in low-income countries. However, consolidation of CHVs position within formal health systems has proved to be complex and continues to challenge countries, as they devise strategies to strengthen primary healthcare. Malawi's community health strategy, launched in 2017, is a novel attempt to harmonise the multiple health service structures at the community level and strengthen service delivery through a team-based approach. The core community health team (CHT) consists of health surveillance assistants (HSAs), clinicians, environmental health officers and CHVs. This paper reviews Malawi's strategy, with particular focus on the interface between HSAs, volunteers in community-based programmes and the community health team. Our analysis identified key challenges that may impede the strategy's implementation: (1) inadequate training, imbalance of skill sets within CHTs and unclear job descriptions for CHVs; (2) proposed community-level interventions require expansion of pre-existing roles for most CHT members; and (3) district authorities may face challenges meeting financial obligations and filling community-level positions. For effective implementation, attention and further deliberation is needed on the appropriate forms of CHV support, CHT composition with possibilities of co-opting trained CHVs from existing volunteer programmes into CHTs, review of CHT competencies and workload, strengthening coordination and communication across all community actors, and financing mechanisms. Policy support through the development of an addendum to the strategy, outlining opportunities for task-shifting between CHT members, CHVs' expected duties and interactions with paid CHT personnel is recommended.
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http://dx.doi.org/10.1136/bmjgh-2018-000996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6254745PMC
November 2018

Développement des Zones de Santé d'Apprentissage et de Recherche en République Démocratique du Congo : enseignements utiles d'une évaluation qualitative des expériences antérieures en Afrique Subsaharienne.

Glob Health Promot 2020 Jun 15;27(2):139-148. Epub 2018 Oct 15.

Institut de Médecine Tropicale Prince Leopold, Santé Publique, Anvers, Flandre, Belgique.

Trois Zones d'Apprentissage et de Recherche (ZAR) sont développées par le programme RIPSEC en République Démocratique duCongo (RDC). Cette stratégie consiste à utiliser un district sanitaire comme substrat pour former des managers des districts de santé et mener des recherches sur les systèmes de santé. L'objet de cet article est d'explorer les principes, les effets et les conditions de succès de cette stratégie à travers une évaluation qualitative des expériences ZAR antérieures en Afrique Subsaharienne. Elle concerne quatre expériences, deux menées au Niger, une en RDC et une au Congo-Brazzaville. Les données proviennent des témoignages de responsables du développement des expériences, présentés dans un séminaire en 2014 et approfondis par des entretiens en 2015, et des publications traitant des expériences. Les faits communs aux quatre expériences sont la diffusion nationale et souvent internationale des bonnes pratiques et des modèles organisationnels, leur développement inscrit dans le long-terme et l'implication des managers des ZAR dans tous les volets de leur transformation. Le centrage de la recherche sur les problèmes de la ZAR et la promotion de la réflexivité dans les décisions managériales sont importants pour cette transformation. L'utilisation des résultats par le programme RIPSEC, les logiques imbriquées dans le concept ZAR et l'apport potentiel de l'implication d'écoles de santé publiques nationales dans leur développement sont ensuite discutés. La validité de l'étude est limitée mais renforcer le leadership des managers des districts sanitaires est un défi fréquent pour les systèmes de santé aux ressources limitées. Cet article peut aider à développer une stratégie pour le renforcer.
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http://dx.doi.org/10.1177/1757975918784537DOI Listing
June 2020

[Stigmatisation of mental illness by medical students in Conakry, Guinea].

Sante Publique 2018 March April;30(2):253-261

Introduction: Stigmatisation of mental illness constitutes a major problem in the development of mental healthcare programs, especially when it originates from health professionals themselves. The aim of this research is to investigate possible attitudes of stigmatisation among first and final year medical students registered at the University of Conakry faculty of medicine in Guinea-Conakry (West Africa).

Methods: Focus group discussions identified students' attitudes and perceptions in relation to mental illness, their explanatory models, their opinions concerning traditional and modern therapeutic practices with regard to mental illness, and their interest to possibly incorporate psychiatry in their future medical practice.

Results: Many students explicitly regret the stigmatisation of mental health patients, but nevertheless share the general population's prevailing attitudes of discrimination. The dominant stereotype of mental illness is that of madness, although final year medical students describe a more diverse spectrum of mental health problems. There is strong adherence to secular occult explanations of mental illness and advocacy for traditional medicine in addressing these illnesses, including among final year medical students.

Discussion: No student would opt for psychiatry as a specialisation, although some expressed interest in integrating psychiatry into their future medical practice. However, this research indicates that stigmatising attitudes are not cut in stone. Under the impetus of specific teaching programmes, attitudes can evolve to create room for tolerance and compassion.
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http://dx.doi.org/10.3917/spub.182.0253DOI Listing
November 2018

Patients experiences of self-management and strategies for dealing with chronic conditions in rural Malawi.

PLoS One 2018 2;13(7):e0199977. Epub 2018 Jul 2.

Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Faculty of Sciences, Vrije Universiteit, Amsterdam, The Netherlands.

Background: The high burden of chronic communicable diseases such as HIV/AIDS, and an escalating rise of non-communicable diseases (NCDs) in Malawi and other sub-Saharan African countries, calls for a shift in how health care services are designed and delivered. Patient-centred care and patient self-management are critical elements in chronic care, and are advocated as universal strategies. In sub-Saharan Africa, there is need for more evidence around the practice of patient self-management, and how to best support patients with chronic conditions in the African context. Our study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource-constrained setting in Malawi.

Methods: This is primarily a qualitative study, involving patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients (from the third of four-part data collection series), 14 in-depth interviews, and four focus-group discussions with patients (n = 31 respondents). A framework approach was used for qualitative analysis, and descriptive statistical analysis was performed on survey data.

Results: Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included: 1) ability to acquire appropriate disease knowledge; 2) poverty level; 3) the presence of support from family caregivers and community-based support initiatives; 4) the nature of one's social relations; and 5) the ability to deal with stressors and stigma. NCD and HIV comorbid patients were more disadvantaged in their access to care, as they experienced frequent drug stock-outs and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of (multiple) care challenges.

Conclusion: Our findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. We recommend expanding current peer-patient and support group initiatives to patients with NCDs, and further investments in the decentralisation of integrated health services to primary care level in Malawi.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199977PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028088PMC
January 2019

The Social Nature of Perceived Illness Representations of Perinatal Depression in Rural Uganda.

Int J Environ Res Public Health 2018 06 7;15(6). Epub 2018 Jun 7.

Health Systems and Equity Unit, Department of Public Health, Institute of Tropical Medicine at Antwerp, Nationalestraat 155, 2000 Antwerp, Belgium.

While the global health community advocates for greater integration of mental health into maternal health agendas, a more robust understanding of perinatal mental health, and its role in providing integrated maternal health care and service delivery, is required. The present study uses the Illness Representation Model, a theoretical cognitive framework for understanding illness conceptualisations, to qualitatively explore multiple stakeholder perspectives on perinatal depression in rural Uganda. A total of 70 in-depth interviews and 9 focus group discussions were conducted with various local health system stakeholders, followed by an emergent thematic analysis using NVivo 11. Local communities perceived perinatal depression as being both the fault of women, and not. It was perceived as having socio-economic and cultural causal factors, in particular, as being partner-related. In these communities, perinatal depression was thought to be a common occurrence, and its negative consequences for women, infants and the community at large were recognised. Coping and help-seeking behaviours prescribed by the participants were also primarily socio-cultural in nature. Placing the dynamics and mechanisms of these local conceptualisations of perinatal depression alongside existing gaps in social and health care systems highlights both the need of, and the opportunities for, growth and prioritisation of integrated perinatal biomedical, mental, and social health programs in resource-constrained settings.
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http://dx.doi.org/10.3390/ijerph15061197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6025508PMC
June 2018

A critique of the Uganda district league table using a normative health system performance assessment framework.

BMC Health Serv Res 2018 05 10;18(1):355. Epub 2018 May 10.

Public Health Department, Institute of Tropical Medicine, 155 Nationalestraat, 2000, Antwerp, Belgium.

Background: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality.

Methods: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis.

Results: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range.

Conclusions: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.
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http://dx.doi.org/10.1186/s12913-018-3126-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946482PMC
May 2018

The complex challenge of providing patient-centred perinatal healthcare in rural Uganda: A qualitative enquiry.

Soc Sci Med 2018 05 21;205:82-89. Epub 2018 Mar 21.

Equity and Health Unit, Department of Public Health, Institute of Tropical Medicine at Antwerp, Belgium.

Rationale: Increasing research and reflections on quality of healthcare across the perinatal period slowly propels the global community to lobby for improved standards of quality perinatal healthcare, especially in low- and middle-income countries.

Objective: The purpose of this qualitative study was to obtain a deeper understanding of how interpersonal dimensions of the quality of care relate to real-life experiences of perinatal care, in a resource-constrained local health system.

Methods: In total, 41 in-depth interviews and five focus group discussions (N = 34) were conducted with perinatal women and local health system health professionals living and working in rural Uganda. Data analysis used an emergent and partially inductive, thematic framework based on the grounded theory approach.

Results: The results indicated that interpersonal aspects of quality of perinatal care and service delivery are largely lacking in this low-resource setting. Thematic analysis showed three interrelated process aspects of quality of perinatal care: negative reported patient-provider interactions, the perceptions shaping patient-provider interactions, and emergent consequences arising out of these processes of care. Further reflections expose the central, yet often-unheeded, role of perinatal women's agency in their own health seeking behaviours and overall well-being, as well as that of underlying practical norms surrounding health worker attitudes and behaviours.

Conclusion: These findings highlight the complexity of patient-centred perinatal healthcare provision in rural Uganda and point to the relevance of linking the interpersonal dimensions of quality of care to the larger systemic and structural dimensions of perinatal healthcare.
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http://dx.doi.org/10.1016/j.socscimed.2018.03.029DOI Listing
May 2018

Effects of demand-side incentives in improving the utilisation of delivery services in Oyam District in northern Uganda: a quasi-experimental study.

BMC Pregnancy Childbirth 2017 Dec 19;17(1):431. Epub 2017 Dec 19.

Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.

Background: We evaluated the effects and financial costs of two interventions with respect to utilisation of institutional deliveries and other maternal health services in Oyam District in Uganda.

Methods: We conducted a quasi-experimental study involving intervention and comparable/control sub-counties in Oyam District for 12 months (January-December 2014). Participants were women receiving antenatal care, delivery and postnatal care services. We evaluated two interventions: the provision of (1) transport vouchers to women receiving antenatal care and delivering at two health centres (level II) in Acaba sub-county, and (2) baby kits to women who delivered at Ngai Health Centre (level III) in Ngai sub-county. The study outcomes included service coverage of institutional deliveries, four antenatal care visits, postnatal care, and the percentage of women 'bypassing' maternal health services inside their resident sub-counties. We calculated the effect of each intervention on study outcomes using the difference in differences analysis. We calculated the cost per institutional delivery and the cost per unit increment in institutional deliveries for each intervention.

Results: Overall, transport vouchers had greater effects on all four outcomes, whereas baby kits mainly influenced institutional deliveries. The absolute increase in institutional deliveries attributable to vouchers was 42.9%; the equivalent for baby kits was 30.0%. Additionally, transport vouchers increased the coverage of four antenatal care visits and postnatal care service coverage by 60.0% and 49.2%, respectively. 'Bypassing' was mainly related to transport vouchers and ranged from 7.2% for postnatal care to 11.9% for deliveries. The financial cost of institutional delivery was US$9.4 per transport voucher provided, and US$10.5 per baby kit. The incremental cost per unit increment in institutional deliveries in the transport-voucher system was US$15.9; the equivalent for the baby kit was US$30.6.

Conclusion: The transport voucher scheme effectively increased utilisation of maternal health services whereas the baby-kit scheme was only effective in increasing institutional deliveries. The transport vouchers were less costly than the baby kits in the promotion of institutional deliveries. Such incentives can be sustainable if the Ministry of Health integrates them in the health system.
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http://dx.doi.org/10.1186/s12884-017-1623-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5737523PMC
December 2017
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