Equity of Inpatient Health Care in Rural Tanzania:\ud A Population- and Facility-Based Survey

To explore the equity of utilization of inpatient health care at rural Tanzanian health centers through the use of a short wealth questionnaire.Methods: Patients admitted to four rural health centers in the Kigoma Region of Tanzania from May 2008 to May 2009 were surveyed about their illness, asset ownership and demographics. Principal component analysis was used to compare the wealth of the inpatients to the wealth of the region’s general population, using data from a previous population-based survey. Among inpatients, 15.3% were characterized as the most poor, 19.6% were characterized as very poor, 16.5% were characterized as poor, 18.9% were characterized as less poor, and 29.7% were characterized as the least poor. The wealth distribution of all inpatients (p < 0.0001), obstetric inpatients (p < 0.0001), other inpatients (p < 0.0001), and fee-exempt inpatients (p < 0.001) were significantly different than the wealth distribution in the community population, with poorer patients underrepresented among inpatients. The wealth distribution of pediatric inpatients (p = 0.2242) did not significantly differ from the population at large. The findings indicated that while current Tanzanian health financing policies may have improved access to health care for children under five, additional policies are needed to further close the equity gap, especially for obstetric inpatients.\u

Shifting Visions: "Delegation" Policies and the Building of a "Rights-Based" Approach to Maternal Mortality

Rights-based approaches fold human rights principles into the ongoing work of health policy making and programming. The example of delegation of anesthesia provision for emergency obstetric care is used to demonstrate how a rights-based approach, applied to this problem in the context of high-mortality countries, requires decision makers to shift from an individual, ethics-based clinical perspective to a structural, rights-based public health perspective

Equity of inpatient health care in rural Tanzania: a population- and facility-based survey

Abstract Objective To explore the equity of utilization of inpatient health care at rural Tanzanian health centers through the use of a short wealth questionnaire. Methods Patients admitted to four rural health centers in the Kigoma Region of Tanzania from May 2008 to May 2009 were surveyed about their illness, asset ownership and demographics. Principal component analysis was used to compare the wealth of the inpatients to the wealth of the region's general population, using data from a previous population-based survey. Results Among inpatients, 15.3% were characterized as the most poor, 19.6% were characterized as very poor, 16.5% were characterized as poor, 18.9% were characterized as less poor, and 29.7% were characterized as the least poor. The wealth distribution of all inpatients (p < 0.0001), obstetric inpatients (p < 0.0001), other inpatients (p < 0.0001), and fee-exempt inpatients (p < 0.001) were significantly different than the wealth distribution in the community population, with poorer patients underrepresented among inpatients. The wealth distribution of pediatric inpatients (p = 0.2242) did not significantly differ from the population at large. Conclusion The findings indicated that while current Tanzanian health financing policies may have improved access to health care for children under five, additional policies are needed to further close the equity gap, especially for obstetric inpatients.http://deepblue.lib.umich.edu/bitstream/2027.42/112633/1/12939_2011_Article_251.pd

Moving Toward Patient-Centered Care in Africa: A Discrete Choice Experiment of Preferences for Delivery Care among 3,003 Tanzanian Women

Objective: In order to develop patient-centered care we need to know what patients want and how changing socio-demographic factors shape their preferences. Methods: We fielded a structured questionnaire that included a discrete choice experiment to investigate women’s preferences for place of delivery care in four rural districts of Pwani Region, Tanzania. The discrete choice experiment consisted of six attributes: kind treatment by the health worker, health worker medical knowledge, modern equipment and medicines, facility privacy, facility cleanliness, and cost of visit. Each woman received eight choice questions. The influence of potential supply- and demand- side factors on patient preferences was evaluated using mixed logit models. Results: 3,003 women participated in the discrete choice experiment (93% response rate) completing 23,947 choice tasks. The greatest predictor of health facility preference was kind treatment by doctor (β = 1.13, p<0.001), followed by having a doctor with excellent medical knowledge (β = 0.89 p<0.001) and modern medical equipment and drugs (β = 0.66 p<0.001). Preferences for all attributes except kindness and cost were changed with changes to education, primiparity, media exposure and distance to nearest hospital. Conclusions: Care quality, both technical and interpersonal, was more important than clinic inputs such as equipment and cleanliness. These results suggest that while basic clinic infrastructure is necessary, it is not sufficient for provision of high quality, patient-centered care. There is an urgent need to build an adequate, competent, and kind health workforce to raise facility delivery and promote patient-centered care

Pain in Children with Developmental Disabilities: Development and Preliminary Effectiveness of a Pain Training Workshop for Respite Workers

Introduction: Pain in children with intellectual disabilities (ID) is common and complex, yet there is no standard pain training for their secondary caregivers (ie, respite staff). Objectives: Determine perceived pain training needs/preferences of children\u27s respite staff (phase 1) and, use this information combined with extant research and guidelines to develop and pilot a training (phase 2). Methods: In phase 1, 22 participants responded to questionnaires and engaged in individual interviews/focus groups about their experiences with pain in children with ID, and perceived training needs/preferences. In phase 2, 50 participants completed knowledge measures and rated the feasibility of, and their own confidence and skill in, pain assessment and management for children with ID immediately before and after completing a pain training. They also completed a training evaluation. Results: Participants viewed pain training as beneficial. Their ideal training involved a half-day, multifaceted in-person program with a relatively small group of trainees incorporating a variety of learning activities, and an emphasis on active learning. Phase 2 results suggested that completion of the 3 to 3.5-hour pain training significantly increased respite workers\u27 pain-related knowledge (effect sizes: r=0.81 to 0.88), as well as their ratings of the feasibility of, and their own confidence and skill in, pain assessment and management in children with ID (effect sizes: r= 0.41 to 0.70). The training was rated favorably. Discussion: Training can positively impact respite workers\u27 knowledge and perceptions about pain assessment and management. As such, they may be better equipped to care for children with ID in this area

Community and health system intervention to reduce disrespect and abuse during childbirth in Tanga Region, Tanzania: A comparative before-and-after study

Background Abusive treatment of women during childbirth has been documented in low-resource countries and is a deterrent to facility utilization for delivery. Evidence for interventions to address women’s poor experience is scant. We assessed a participatory community and health system intervention to reduce the prevalence of disrespect and abuse during childbirth in Tanzania. Methods and findings We used a comparative before-and-after evaluation design to test the combined intervention to reduce disrespect and abuse. Two hospitals in Tanga Region, Tanzania were included in the study, 1 randomly assigned to receive the intervention. Women who delivered at the study facilities were eligible to participate and were recruited upon discharge. Surveys were conducted at baseline (December 2011 through May 2012) and after the intervention (March through September 2015). The intervention consisted of a client service charter and a facility-based, quality-improvement process aimed to redefine norms and practices for respectful maternity care. The primary outcome was any self-reported experiences of disrespect and abuse during childbirth. We used multivariable logistic regression to estimate a difference-in-difference model. At baseline, 2,085 women at the 2 study hospitals who had been discharged from the maternity ward after delivery were invited to participate in the survey. Of these, 1,388 (66.57%) agreed to participate. At endline, 1,680 women participated in the survey (72.29% of those approached). The intervention was associated with a 66% reduced odds of a woman experiencing disrespect and abuse during childbirth (odds ratio [OR]: 0.34, 95% CI: 0.21–0.58, p < 0.0001). The biggest reductions were for physical abuse (OR: 0.22, 95% CI: 0.05–0.97, p = 0.045) and neglect (OR: 0.36, 95% CI: 0.19–0.71, p = 0.003). The study involved only 2 hospitals in Tanzania and is thus a proof-of-concept study. Future, larger-scale research should be undertaken to evaluate the applicability of this approach to other settings. Conclusions After implementation of the combined intervention, the likelihood of women’s reports of disrespectful treatment during childbirth was substantially reduced. These results were observed nearly 1 year after the end of the project’s facilitation of implementation, indicating the potential for sustainability. The results indicate that a participatory community and health system intervention designed to tackle disrespect and abuse by changing the norms and standards of care is a potential strategy to improve the treatment of women during childbirth at health facilities. The trial is registered on the ISRCTN Registry, ISRCTN 48258486

Health care financing and utilization of maternal health services in developing countries

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/55454/1/Kruk et al financing maternal health.pd

Studying moderators of implementation: analysis from an intervention to reduce disrespect and abuse in facility-based childbirth

Background: Across the globe, women who deliver in health facilities report experiencing disrespect and abuse (D&A). In low- and middle-income countries, D&A is particularly catastrophic because it may cause women to opt against facility delivery, as well as violate their human rights. D&A is likely a frontline manifestation of multi-level problems in complex health systems; yet efforts to address D&A have typically focused on micro-levels - either health providers’ ethics or users’ demand for quality care. These have rarely achieved sustainable implementation mirroring clinical quality improvement challenges. Implementation science holds promise for investigating these challenges. The Consolidated Framework for Implementation Research (CFIR) assembles constructs from across the literature that can guide inquiry. Materials and methods: The Staha Project studies the magnitude and dimensions of D&A, and is testing mechanisms for its mitigation. It is based in two Tanzanian districts, with one assigned to intervention. Implementation is conducted by four facilities, catchment communities and local leadership. Implementation research includes patient and provider satisfaction surveys, observations, reports and qualitative interviews. Relevant CFIR constructs were selected to develop the lines of inquiry and as themes for qualitative analysis adapted iteratively based on data. We conducted descriptive analyses of quantitative data. Results: The intervention was developed through a participatory process grounded in baseline research to address meso- and micro-level drivers at the district level. A change process was elaborated including activation of a client service charter and a facility-based change process. Mutuality of respect emerged as the underlying value for the process. Results from the planning process and the first year of implementation will be presented using CFIR constructs. These will include findings related to the characteristics of the intervention, inner and outer settings, individual implementers and the process. Conclusions: The CFIR was a useful tool to establish lines of inquiry and frame analysis. Ongoing analysis permitted identification of areas for improvement. We found the strongest constructs were regarding the intervention, the individual, and the inner setting characteristics. The outer setting construct could be further developed, especially for interventions that go beyond health facilities

Community health workers and accountability: Reflections from an international "think-in"

Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a ‘think in’, held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger “accountability ecosystem.” This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs’ social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several propositions for further conceptual development and research related to the question of CHWs and accountability.publishedVersio