I Buy Medicines From the Streets Because I Am Poor: A Qualitative Account on why the Informal Market for Medicines Thrive in Ivory Coast

The informal market for medicines has been growing. In Ivory Coast, this informal market is an unofficial core part of the health system. Given the risks associated with the informal market for medicines, it is important to understand why this market continues to grow. It becomes even more important in the context of COVID-19, as a huge chunk of falsified medical products end up at the informal market. A qualitative case study design was chosen for this study, with in-depth interviews (IDIs) and focus group discussions (FGDs) being the methods for data collection. 20 IDIs and 3 FGDs were conducted. Participants in this study are sellers, buyers, and pharmaceutical experts. We found out that the informal market for medicines thrives because it is highly accessible, convenient, affordable, and that it is used for various social, cultural, and religious reasons. The study concludes that although this informal market presents a clear danger to public health, it is thriving. For authorities to address this public health challenge, there is need for a holistic and multi-pronged approach, which includes addressing health systems factors and strengthening regulatory framework.publishedVersio

Strengthening cultural competence in health professionals through partnerships: A case study of a health collaborative exchange between Malawi and Norway in trauma care and emergency medicine

North-South partnerships have been identified as one way of solving some of the challenges in health sectors globally. Norway and Malawi have one such partnership in trauma and emergence care. Lack of trauma care and emergency medicine is a major public health concern worldwide. This results in substantial loss to individual, families, and society. The study follows this partnership between Norway and Malawi, investigating on its socio-cultural benefits, and on how this contributes to the health professionals’ cultural competence. A qualitative case study was chosen for this study, 20 semi-structured interviews were conducted with health professionals and coordinators of the program. Interviews were conducted digitally using platforms such as Zoom and WhatsApp. Interviews were collected between the period of December 2020and February 2021. We found out that exchange participants from both countries largely reported positive experiences. Their experiences centred around their interactions and encounters with patients, patients’ relatives, and colleagues at host institutions. Participants reported a better understanding on health seeking behaviours in different contexts, the importance of communication with both patients and colleagues, and teamwork. In addition, the study revealed the importance on perceptions around identities such as race and gender and how these impact on health professionals’ interactions with patients. We also found out that although working in a different socio cultural environment was reported as challenging, it was experienced as enriching and rewarding in terms of building and developing cultural competence. The study concludes that North-South health professionals exchange partnerships can be a viable vehicle for developing and naturing cultural competence in health professionals, however, such programs need to invest in preparing the exchange participants to be ready for the challenges that lies ahead in host institutions and countries.publishedVersio

Beyond the glass ceiling: an exploration of the experiences of female corporate organizational leaders in Ghana

Although an increase in the inclusion of women in the global labor market has been reported in recent times, existing literature show that women are still heavily underrepresented in organizational leadership positions. Many studies in this area mainly focused on perceived barriers to women’s ascend to leadership positions, while little attention is paid to insights into the lived experiences of women who have already managed to assume leadership positions. This study was conducted to plug this gap in the literature. We interviewed 10 women corporate organizational leaders in Ghana to share their lived experiences as female leaders within the Ghanaian context. Our findings reveal that women still face several challenges even after breaking the glass ceiling to attain leadership positions in corporate organizations in Ghana. The main challenges were raised around the issue of gender, discrimination, age, their roles as mothers and wives. On the other hand, their positions also came with benefits and opportunities such as improved financial status, a command for respect as well as increasing their social and business networking capacity. More importantly, age although a disadvantage for the young women leaders, it was seen as a resource for older women as it enhances their respect and seen as performance of motherhood roles in this Ghanaian context. The study concludes that although women leaders’ experiences are largely negative, older women leaders seemed to utilize their positions actively and creatively and perform pseudo-motherhood roles which in turn helps them in the performance of their leadership roles.publishedVersio

Assessing performance enhancing tools: experiences with the open performance review and appraisal system (OPRAS) and expectations towards payment for performance (P4P) in the public health sector in Tanzania

Background Health workers’ motivation is a key determinant of the quality of health services, and poor motivation has been found to be an obstacle to service delivery in many low-income countries. In order to increase the quality of service delivery in the public sector in Tanzania, the Open Performance Review and Appraisal System (OPRAS) has been implemented, and a new results-based payment system, Payment for performance (P4P) is introduced in the health sector. This article addresses health workers’ experiences with OPRAS, expectations towards P4P and how lessons learned from OPRAS can assist in the implementation of P4P. The broader aim is to generate knowledge on health workers’ motivation in low-income contexts. Methods A qualitative study design has been employed to elicit data on health worker motivation at a general level and in relation to OPRAS and P4P in particular. Focus group discussions (FGDs) and in-depth interviews (IDIs) have been conducted with nursing staff, clinicians and administrators in the public health sector in a rural district in Tanzania. The study has an ethnographic backdrop based on earlier long-term fieldwork in Tanzania. Results Health workers evaluated OPRAS and P4P in terms of the benefits experienced or expected from complying with the tools. The study found a general reluctance towards OPRAS as health workers did not see OPRAS as leading to financial gains nor did it provide feedback on performance. Great expectations were expressed towards P4P due to its prospects of topping up salaries, but the links between the two performance enhancing tools were unclear. Conclusions Health workers respond to performance enhancing tools based on whether the tools are found appropriate or yield any tangible benefits. The importance placed on salary and allowances forms the setting in which OPRAS operates. The expected addition to the salary through P4P has created a vigorous discourse among health workers attesting to the importance of the salary for motivation. Lessons learned from OPRAS can be utilized in the implementation of P4P and can enhance our knowledge on motivation and performance in the health services in low-income contexts such as Tanzania.publishedVersio

When Incentives Work too well: Locally Implemented Pay for Performance (P4P) and Adverse Sanctions towards Home Birth in Tanzania - A Qualitative Study.

Despite limited evidence of its effectiveness, performance-based payments (P4P) are seen by leading policymakers as a potential solution to the slow progress in reaching Millennium Development Goal 5: improved maternal health. This paper offers insights into two of the aspects that are lacking in the current literature on P4P, namely what strategies health workers employ to reach set targets, and how the intervention plays out when implemented by local government as part of a national programme that does not receive donor funding. A total of 28 in-depth interviews (IDIs) with 25 individuals were conducted in Mvomero district over a period of 15 months in 2010 and 2011, both before and after P4P payments. Seven facilities, including six dispensaries and one health centre, were covered. Informants included 17 nurses, three clinical officers, two medical attendants, one lab technician and two district health administrators. Health workers reported a number of strategies to increase the number of deliveries at their facility, including health education and cooperation with traditional health providers. The staff at all facilities also reported that they had told the women that they would be sanctioned if they gave birth at home, such as being fined or denied clinical cards and/or vaccinations for their babies. There is a great uncertainty in relation to the potential health impacts of the behavioural changes that have come with P4P, as the reported strategies may increase the numbers, but not necessarily the quality. Contrary to the design of the P4P programme, payments were not based on performance. We argue that this was due in part to a lack of resources within the District Administration, and in part as a result of egalitarian fairness principles. Our results suggest that particular attention should be paid to adverse effects when using external rewards for improved health outcomes, and secondly, that P4P may take on a different form when implemented by local implementers without the assistance of professional P4P specialists

Pay for performance in Maternal Health in Tanzania perceptions,expectations and experiences in Mvomero district

In 2008, Tanzania was one of the 11 countries responsible for 65% of all maternal deaths in the world. The Ministry of Health and Social Welfare of Tanzania in 2008 acknowledged lack of commendable progress in reducing maternal deaths. At the heart of the lack of progress are challenges in human resources for health, including poor motivation among health workers.\ud In 2009, the Government of Tanzania decided to introduce P4P in mother, newborn and child health (MNCH), in order to bring down the MMR and accelerate progress towards Millennium Development Goals 5&4 addressing mother and child health. Pay for performance links incentives with performance and assumes that better health worker performance improves acceptability, utilisation and quality of health services. The study explores how service provision and the use of incentives in maternal health is perceived by health practitioners and community members\ud The study was carried out in Mvomero district in Tanzania, at 5 health facilities. The study‟s approach was qualitative. Twelve in-depth interviews were conducted with health workers and 3 focus group discussions were also conducted with community members. A number of perceived barriers to the access of health services were reported. The barriers existed on both the provider and the user side. By and large, provider side factors seemed to play a major role in the low-utilisation of health services and of these, supply shortages were the mostly cited impediment to the provision of health services. Health workers reported dissatisfaction and demotivation with the current working conditions citing mainly the perceived unfair remuneration system and supply shortages as major factors.\ud Mixed views to the use of incentives in health care were reported. There were some concerns that P4P might undermine the quality of health services by promoting unethical behaviours such cheating, emphasis on quantity against quality or prioritisation of rewarded services. On the other hand P4P was perceived to have the potential of increasing health worker motivation, cooperation and teamwork at facility level.\ud The study concluded that in view of health workers and community members‟ perceptions and experiences related to incentives and service provision, steps should be taken to ensure that the conditions for successful implementation should be in place before the P4P programme is scaled up. This involves ensuring the availability of basic equipments, staff and routines at facility level.\u

Results-Based Financing (RBF) in the health sector of a low-income country. From agenda setting to implementation: The case of Tanzania

Background: During the last decade there has been growing concern about lack of results in the health sector of many low-income countries. Prompted by a need to achieve progress, Results-Based Financing (RBF) has become an increasingly popular policy option and has been seen as a solution for the unmet Millennium Development Goals 4 and 5, for child health and maternal health. RBF pays for results of chosen health indicators rather than inputs and therefore appealing to both recipient and donor countries. In 2015, over 30 low-income countries with the majority in sub-Saharan Africa including Tanzania were implementing RBF programmes to improve health services provision. Tanzania implemented a provider side RBF, aiming to motivate health workers by paying them financial incentives based on predetermined performance targets. Despite the widespread uptake of RBF in low-income contexts, there is little evidence to support that it works. Studies on RBF show mixed results and most of these studies focus on aspects of effectiveness and efficiency of these programmes. What is explored less are the policy processes that lead to the introduction of RBF programmes in low-income countries and how RBF affects the working environment and the interaction between health workers and health service users. This may in turn affect the overall success of RBF programmes. Aim: The study aim to generate policy relevant knowledge on processes leading up to the introduction of RBF in a resource constrained health sector, and the challenges related to its implementation. To achieve this, the study investigates the roles played by both internal and external policy actors in the RBF policy process in Tanzania. It further critically examines the experiences of health workers with RBF and how they responded to it, paying particular attention to the social and cultural context. Methods: A qualitative case study design was used in the study. Data was collected in Mvomero and Rufiji districts and Dar es Salaam in Tanzania and in Oslo in Norway. The study followed both the local Tanzanian RBF programme in Mvomero and the donor-funded Pwani pilot in Rufiji district. In-depth interviews (IDIs), focus group discussions (FGDs), policy document reviews and participation in RBF meetings were the main methods for data collection. A total of 70 IDIs and 27 FGDs were conducted between 2010 and 2013. Field notes and informal conversations during fieldwork were other very important sources of data for the study. Results: The introduction of RBF in Tanzania was controversial. The process was long and contested. The actors, both external and internal, fought for their values and interests. It resulted in tensions, mistrust and frustrations in the health sector partnership, and in the end, Tanzania did not get space to act as an agent of her own development. The results further showed that the two RBF programmes that were implemented in Tanzania, one which received donor support and another which did not, were implemented differently. The locally funded RBF diverted from its programme design and paid health workers flat bonus regardless of performance. This was partly due to lack of capacity and partly due to concerns for equity and fairness. The donor funded RBF adhered to its design, including paying health workers according to performance and contribution towards RBF performance indicators that is, Reproductive and Child Health (RCH) staff, working directly with RBF performance indicators were paid more bonuses than non RCH staff. This system of payment was reported to be unfair and it was revealed that it had affected social relations at health facilities. Leadership at health facilities was concerned this would lead to the disruption of work and preferred a flat rate with a similar logic as in the local RBF programme. Moreover, the study revealed that in the local RBF programme, health workers used coercive strategies in order to meet RBF performance targets. It was noted that these strategies are detrimental to health outcomes. Discussion The study showed that understanding processes behind the implementation of RBF is important as these help to explain why RBF programmes may fail or succeed. Additionally, the study revealed that RBF programmes can affect social relations among health workers and with health service users. The Tanzanian experience presents a picture where the country was overwhelmed by external influence in the RBF policy process and in the end could not follow its own development trajectory. As the theory of partnership in development aid posits, donor countries prefer an instrumental version of partnership, which entails imposition of their priorities, while disregarding country ownership. When Tanzania chose to follow her own path by launching a local RBF programme, partners in the Health Basket Fund withdrew their funding. Tanzania went ahead with the local RBF programme, but with little success. Payment in the programme used flat rates, partly due to lack of resources and partly due to the concern of fairness. The donor-funded RBF was better managed and resourced but the payment system of bonuses, which paid health workers differently by their centrality to performance indicators, was reported as fundamentally unfairness as predicted by workplace social justice theory, the Referent Cognitions Theory. Health workers changed their behaviors in response to RBF, as presumed by the Principal- Agent Theory. In both districts, RBF negatively affected social relations among health workers and with their patients. It was revealed that RBF can lead to the use of coercive strategies as a means to reach performance targets in resource constrained settings. RBF has the potential of disrupting social relations, teamwork and intrinsic motivation among health workers. The Self-Determination Theory and Bourdieu’s concept of capital elucidates on how RBF is potentially detrimental to social relations and intrinsic motivation of health workers. Therefore the study recommends that caution is needed when implementing RBF programmes in low-income contexts, and that particular attention has to be paid to policy processes, social-cultural and contextual factors

I Buy Medicines From the Streets Because I Am Poor: A Qualitative Account on why the Informal Market for Medicines Thrive in Ivory Coast

The informal market for medicines has been growing. In Ivory Coast, this informal market is an unofficial core part of the health system. Given the risks associated with the informal market for medicines, it is important to understand why this market continues to grow. It becomes even more important in the context of COVID-19, as a huge chunk of falsified medical products end up at the informal market. A qualitative case study design was chosen for this study, with in-depth interviews (IDIs) and focus group discussions (FGDs) being the methods for data collection. 20 IDIs and 3 FGDs were conducted. Participants in this study are sellers, buyers, and pharmaceutical experts. We found out that the informal market for medicines thrives because it is highly accessible, convenient, affordable, and that it is used for various social, cultural, and religious reasons. The study concludes that although this informal market presents a clear danger to public health, it is thriving. For authorities to address this public health challenge, there is need for a holistic and multi-pronged approach, which includes addressing health systems factors and strengthening regulatory framework

I Buy Medicines From the Streets Because I Am Poor: A Qualitative Account on why the Informal Market for Medicines Thrive in Ivory Coast

The informal market for medicines has been growing. In Ivory Coast, this informal market is an unofficial core part of the health system. Given the risks associated with the informal market for medicines, it is important to understand why this market continues to grow. It becomes even more important in the context of COVID-19, as a huge chunk of falsified medical products end up at the informal market. A qualitative case study design was chosen for this study, with in-depth interviews (IDIs) and focus group discussions (FGDs) being the methods for data collection. 20 IDIs and 3 FGDs were conducted. Participants in this study are sellers, buyers, and pharmaceutical experts. We found out that the informal market for medicines thrives because it is highly accessible, convenient, affordable, and that it is used for various social, cultural, and religious reasons. The study concludes that although this informal market presents a clear danger to public health, it is thriving. For authorities to address this public health challenge, there is need for a holistic and multi-pronged approach, which includes addressing health systems factors and strengthening regulatory framework

Strengthening cultural competence in health professionals through partnerships: A case study of a health collaborative exchange between Malawi and Norway in trauma care and emergency medicine

North-South partnerships have been identified as one way of solving some of the challenges in health sectors globally. Norway and Malawi have one such partnership in trauma and emergence care. Lack of trauma care and emergency medicine is a major public health concern worldwide. This results in substantial loss to individual, families, and society. The study follows this partnership between Norway and Malawi, investigating on its socio-cultural benefits, and on how this contributes to the health professionals’ cultural competence. A qualitative case study was chosen for this study, 20 semi-structured interviews were conducted with health professionals and coordinators of the program. Interviews were conducted digitally using platforms such as Zoom and WhatsApp. Interviews were collected between the period of December 2020and February 2021. We found out that exchange participants from both countries largely reported positive experiences. Their experiences centered around their interactions and encounters with patients, patients’ relatives, and colleagues at host institutions. Participants reported a better understanding on health seeking behaviors in different contexts, the importance of communication with both patients and colleagues, and teamwork. In addition, the study revealed the importance on perceptions around identities such as race and gender and how these impact on health professionals’ interactions with patients. We also found out that although working in a different socio-cultural environment was reported as challenging, it was experienced as enriching and rewarding in terms of building and developing cultural competence. The study concludes that North-South health professionals exchange partnerships can be a viable vehicle for developing and naturing cultural competence in health professionals, however, such programs need to invest in preparing the exchange participants to be ready for the challenges that lies ahead in host institutions and countries