Facilitators and barriers to the implementation of a Mobile Health Wallet for pregnancy-related health care: A qualitative study of stakeholders’ perceptions in Madagascar

Financial barriers are a major obstacle to accessing maternal health care services in low-resource settings. In Madagascar, less than half of live births are attended by skilled health staff. Although mobile money-based savings and payment systems are often used to pay for a variety of services, including health care, data on the implications of a dedicated mobile money wallet restricted to health-related spending during pregnancy–a mobile health wallet (MHW)–are not well understood. In cooperation with the Madagascan Ministry of Health, this study aims to elicit the perceptions, experiences, and recommendations of key stakeholders in relation to a MHW amid a pilot study in 31 state-funded health care facilities. We conducted a two-stage qualitative study using semi-structured in-depth interviews with stakeholders (N = 21) representing the following groups: community representatives, health care providers, health officials and representatives from phone provider companies. Interviews were conducted in Atsimondrano and Renivohitra districts, between November and December of 2017. Data was coded thematically using inductive and deductive approaches, and found to align with a social ecological model. Key facilitators for successful implementation of the MHW, include (i) close collaboration with existing communal structures and (ii) creation of an incentive scheme to reward pregnant women to save. Key barriers to the application of the MHW in the study zone include (i) disruption of informal benefits for health care providers related to the current cash-based payment system, (ii) low mobile phone ownership, (iii) illiteracy among the target population, and (iv) failure of the MHW to overcome essential access barriers towards institutional health care services such as fear of unpredictable expenses. The MHW was perceived as a potential solution to reduce disparities in access to maternal health care. To ensure success of the MHW, direct demand-side and provider-side financial incentives merit consideration

A Mobile Health Wallet for Pregnancy-Related Health Care in Madagascar: Mixed-Methods Study on Opportunities and Challenges

Background: Mobile savings and payment systems have been widely adopted to store money and pay for a variety of services, including health care. However, the possible implications of these technologies on financing and payment for maternal health care services-which commonly require large 1-time out-of-pocket payments-have not yet been systematically assessed in low-resource settings. Objective: The aim of this study was to determine the structural, contextual, and experiential characteristics of a mobile phone-based savings and payment platform, the Mobile Health Wallet (MHW), for skilled health care during pregnancy among women in Madagascar. Methods: We used a 2-stage cluster random sampling scheme to select a representative sample of women utilizing either routine antenatal (ANC) or routine postnatal care (PNC) in public sector health facilities in 2 of 8 urban and peri-urban districts of Antananarivo, Madagascar (Atsimondrano and Renivohitra districts). In a quantitative structured survey among 412 randomly selected women attending ANC or PNC, we identified saving habits, mobile phone use, media consumptions, and perception of an MHW with both savings and payment functions. To confirm and explain the quantitative results, we used qualitative data from 6 semistructured focus group discussions (24 participants in total) in the same population. Results: 59.3% (243/410, 95% CI 54.5-64.1) saved toward the expected costs of delivery and, out of those, 64.4% (159/247, 95% CI 58.6-70.2) used household cash savings for this purpose. A total of 80.3% (331/412, 95% CI 76.5-84.1) had access to a personal or family phone and 35.7% (147/412, 95% CI 31.1-40.3) previously used Mobile Money services. Access to skilled health care during pregnancy was primarily limited because of financial obstacles such as saving difficulties or unpredictability of costs. Another key barrier was the lack of information about health benefits or availability of services. The general concept of an MHW for saving toward and payment of pregnancy-related care, including the restriction of payments, was perceived as beneficial and practicable by the majority of participants. In the discussions, several themes pointed to opportunities for ensuring the success of an MHW through design features: (1) intuitive technical ease of use, (2) clear communication and information about benefits and restrictions, and (3) availability of personal customer support. Conclusions: Financial obstacles are a major cause of limited access to skilled maternal health care in Madagascar. An MHW for skilled health care during pregnancy was perceived as a useful and desirable tool to reduce financial barriers among women in urban Madagascar. The design of this tool and the communication strategy will likely be the key to success. Particularly important dimensions of design include technical user friendliness and accessible and personal customer service

Barriers and Delays in Tuberculosis Diagnosis and Treatment Services: Does Gender Matter?

Background:. Tuberculosis (TB) remains a global public health problem with known gender-related disparities. We reviewed the quantitative evidence for gender-related differences in accessing TB services from symptom onset to treatment initiation. Methods:. Following a systematic review process, we: searched 12 electronic databases; included quantitative studies assessing gender differences in accessing TB diagnostic and treatment services; abstracted data; and assessed study validity. We defined barriers and delays at the individual and provider/system levels using a conceptual framework of the TB care continuum and examined gender-related differences. Results:. Among 13,448 articles, 137 were included: many assessed individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial: 64% versus 36%; physical: 100% versus 0%; stigma: 85% versus 15%; health literacy: 67% versus 33%; and provider-/system-level: 100% versus 0%) and longer delays (presentation to diagnosis: 45% versus 0%) than men. Conclusions:. Many studies found no quantitative gender-related differences in barriers and delays limiting access to TB services. When differences were identified, women experienced greater barriers and longer delays than men

Causal effect of children's secondary education on parental health outcomes: findings from a natural experiment in Botswana

Objectives A growing literature highlights the intergenerational transmission of human capital from parents to children. However, far less is known about ‘upward transmission’ from children to parents. In this study, we use a 1996 Botswana education policy reform as a natural experiment to identify the causal effect of children’s secondary schooling on their parents’ health. Setting Botswana’s decennial census (2001 and 2011). Data were obtained through the Integrated Public Use Microdata Series and are 10% random samples of the complete population in each of these census years. Participants Survey respondents who were citizens born in Botswana, at least 18 years old at the time of the census and born in or after 1975 (n=89 721). Primary and secondary outcome measures Parental survival and disability at the time of the census, separately for mothers and fathers. Results The 1996 reform caused a large increase in grade 10 enrolment, inducing an additional 0.4 years of schooling for the first cohorts affected (95% CI 0.3 to 0.5, p<0.001). The reform, however, had no effect on parental survival and disability by the time exposed child cohorts reach age 30. Results were robust to a wide array of sensitivity analyses.publishedVersio

Causal effect of children's secondary education on parental health outcomes: findings from a natural experiment in Botswana

Objectives A growing literature highlights the intergenerational transmission of human capital from parents to children. However, far less is known about ' upward transmission' from children to parents. In this study, we use a 1996 Botswana education policy reform as a natural experiment to identify the causal effect of children's secondary schooling on their parents' health. Setting Botswana's decennial census (2001 and 2011). Data were obtained through the Integrated Public Use Microdata Series and are 10% random samples of the complete population in each of these census years. Participants Survey respondents who were citizens born in Botswana, at least 18 years old at the time of the census and born in or after 1975 (n=89 721). Primary and secondary outcome measures Parental survival and disability at the time of the census, separately for mothers and fathers. Results The 1996 reform caused a large increase in grade 10 enrolment, inducing an additional 0.4 years of schooling for the first cohorts affected (95% CI 0.3 to 0.5, p<0.001). The reform, however, had no effect on parental survival and disability by the time exposed child cohorts reach age 30. Results were robust to a wide array of sensitivity analyses. Conclusions This study found little evidence that parents' survival and disability were affected by their offspring's educational attainment in Botswana. Parents' health may not be necessarily affected by increasing their offspring's educational attainment

Anaemia among men in India: a nationally representative cross-sectional study

Summary Background Population-based studies on anaemia in India have mostly focused on women and children, with men with anaemia receiving much less attention despite anaemia's adverse effect on health, wellbeing, and economic productivity. This study aimed to determine the national prevalence of anaemia among men in India; how the prevalence of anaemia in men varies across India among states and districts and by sociodemographic characteristics; and whether the geographical and sociodemographic variation in the prevalence of anaemia among men is similar to that among women to inform whether anaemia reduction efforts for men should be coupled with existing efforts for women. Methods In this cross-sectional study, we analysed data from a nationally representative household survey carried out from January, 2015, to December, 2016, among men aged 15–54 years and women aged 15–49 years in all 29 states and seven Union Territories of India. Haemoglobin concentration was measured using the portable HemoCue Hb 201+ (HemoCue AB, Angelholm, Sweden) and a capillary blood sample. In addition to disaggregating anaemia prevalence (separately in men and women) by state and age group, we used mixed-effects Poisson regression to determine individual-level and district-level predictors of anaemia. Findings 106 298 men and 633 305 women were included in our analysis. In men, the prevalence of any anaemia was 23·2% (95% CI 22·7–23·7), moderate or severe anaemia was 5·1% (4·9–5·4), and severe anaemia was 0·5% (0·5–0·6). An estimated 21·7% (20·9–22·5) of men with any degree of anaemia had moderate or severe anaemia compared with 53·2% (52·9–53·5) of women with any anaemia. Men aged 20–34 years had the lowest probability of having anaemia whereas anaemia prevalence among women was similar across age groups. State-level prevalence of any anaemia in men varied from 9·2% (7·7–10·9) in Manipur to 32·9% (31·0–34·7) in Bihar. The individual-level predictors of less household wealth, lower education, living in a rural area, smoking, consuming smokeless tobacco, and being underweight and the district-level predictors of living in a district with a lower rate of primary school completion, level of urbanisation, and household wealth were all associated with a higher probability of anaemia in men. Although some important exceptions were noted, district-level and state-level prevalence of anaemia among men correlated strongly with that among women. Interpretation Anaemia among men in India is an important public health problem. Because of the similarities in the patterns of geographical and sociodemographic variation of anaemia between men and women, future efforts to reduce anaemia among men could target similar population groups as those targeted in existing efforts to reduce anaemia among women. Funding Alexander von Humboldt Foundation

"Because at school, you can become somebody" - the perceived health and economic returns on secondary schooling in rural Burkina Faso

Background The perceived returns on schooling are critical in schooling decision-making but are not well understood. This study examines the perceived returns on secondary schooling in Burkina Faso, where secondary school completion is among the lowest globally (<10%). Methods We conducted a two-staged qualitative study using semi-structured interviews (N = 49). In the first stage, we sampled students, dropouts, parents and teachers from a random sample of five schools (n = 39). In the second stage, we interviewed key informants knowledgeable of the school context using snowball sampling (n = 10). Systematic analysis was based on a grounded theory approach with a reading of transcripts, followed by coding of the narratives in NVivo 12. Results Respondents nearly universally perceived health benefits to schooling. In particular, key health benefits included improved sexual and reproductive health outcomes, hygiene knowledge and practices, as well as better interactions with the formal health system. Common economic returns on schooling included improved employment opportunities and the provision of support to family members, in addition to generally attaining success and recognition. Indirect and long-term health returns, however, were infrequently mentioned by respondents. Conclusions While respondents reported nearly universally short-term health benefits to schooling, responses with regard to economic as well as indirect and long-term health benefits were more ambiguous. Future intervention studies on the perceived returns on formal education are needed to inform policy and reach education and health targets in the region

A qualitative and quantitative performance evaluation of Swaziland’s Rural Health Motivator program

Background: Community health workers (CHWs) are increasingly used to increase access to primary healthcare, and considered to be a key health worker cadre to achieve the UNAIDS 90-90-90 target. Despite the recent policy interest in effectively designing, implementing, and evaluating new CHW programs, there is limited evidence on how long-standing CHW programs are performing. Using the CHW Performance Logic model as an evaluation framework, this study aims to assess the performance of Swaziland’s long-standing national CHW program, called the rural health motivator (RHM) program. Methods: This study was carried out in the Manzini and Lubombo regions of Swaziland. We conducted a survey of 2,000 households selected through two-stage cluster random sampling and a survey among a stratified simple random sample of 306 RHMs. Additionally, semi-structured qualitative interviews were conducted with 25 RHMs. Results: While RHMs are instructed to visit every household assigned to them at least once a month, only 15.7% (95% CI: 11.4 – 20.4%) of RHMs self-reported to be meeting this target. Less than half (46.3%; 95% CI: 43.4 – 49.6%) of household survey respondents, who reported to have ever been visited by a RHM, rated their overall satisfaction with RHM services as eight or more points on a 10-point scale (ranging from “very dissatisfied” to “very satisfied”). A theme arising from the qualitative interviews was that community members only rarely seek care from RHMs, with care-seeking tending to be constrained to emergency situations. Conclusions: The RHM program does not meet some of its key performance objectives. Two opportunities to improve RHM performance identified by the evaluation were increasing RHM's stipend and improving the supply of equipment and material resources needed by RHMs to carry out their tasks

Improving the performance of community health workers in Swaziland: findings from a qualitative study

Background: The performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre. Methods: The CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance. Results: Across the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: i) increased monetary compensation of CHWs, ii) a more reliable supply of equipment and consumables, iii) additional training, and iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance. Conclusions: While this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers

Proportion of foetal and placental implantation abnormalities in Madagascar: A cross-sectional study of 35,919 women at public-sector primary healthcare facilities in central and southern Madagascar, 2017–2020

Background Like other countries in sub-Saharan Africa, Madagascar has a high burden of maternal and neonatal mortality. However, as the proportion of foetal and placental abnormalities among the Malagasy population is unknown, strategies aimed at reducing maternal and neonatal mortality are challenging to define and implement. Methods We conducted a multi-year, cross-sectional study using secondary NGO data on obstetric ultrasound, including patient records of all pregnant women who received an obstetric ultrasound screening between July 1st, 2017, and September 30th, 2020, at 62 public-sector primary care facilities in urban and rural regions of Madagascar. We analysed demographic characteristics and determined the prevalence of foetal and placental abnormalities. Results The dataset included 38,688 ultrasound screening reports from 35,919 women, where 2,587/35,919 (7.20%) women had more than one ultrasound exam. Most women (68.63%, 26,550/38,688) received their first ultrasound during the third trimester of pregnancy. Foetal malpresentation at 36 weeks of gestation or later was diagnosed in 5.48% (176/3,211) of women with the breech presentation being most common (breech 3.99%, 128/3,211; transverse 0.84%, 27/3,211; mobile 0.5%, 16/3,211; oblique 0.16%, 5/3,211). Placenta previa was found in 2.31% (875/38,755) and multiple gestations in 1.03% (370/35,919) cases. Around one in every 150 women (0.66%, 234/38,702) had amniotic fluid disorders. Conclusion The proportion of foetal and placental abnormalities detected by obstetric ultrasound is consistent with findings from other countries in sub-Saharan Africa. In contrast to current WHO recommendations, pregnant women, particularly those from rural, resource-constrained settings attend obstetric ultrasound screenings most commonly during their third trimester of pregnancy