Thresholds of morbidity among women in a peri-urban community of Maharashtra, India: conceptual and methodological issues.

While data on perceived morbidity often correlate poorly with clinical morbidity, they can provide an indicator for how women's concepts of health change in the context of larger transitions in gender and health systems. Drawing on multiple sources of data on perceived morbidity among women in a peri-urban settlement of Maharashtra, India, this article examines variations in women's thresholds for articulating illness conditions. Data on women's health were collected from married women aged 15-49, using four different instruments: focus group discussion guides; general illness narrative guidelines; individual open-ended questions about morbidity; and a highly structured checklist. Comparing the data and the assumptions underlying these instruments, the article identifies four different thresholds relating to situational, agency, prototypical and dimensional aspects of women's experience and subsequent reporting of morbidity

Engaging with HIV care systems: why space, time and social relations matter (editorial)

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Qualitative research to enhance the evaluation of results-based financing programmes: The promise and the reality

Paper prepared for the Health Results Innovation Trust Fund World Bank, Washington, DC, February, 2016This Discussion Paper presents the approach, findings, and recommendations from a desk review of the qualitative research conducted within Results-Based Financing programmes (RBF) under the Health Results Innovations Trust Fund (HRITF). The review included 17 studies conducted in Benin, Burundi, Cameroon, DRC, Ethiopia, Haiti, Kenya, Kyrgyzstan, Nigeria, Rwanda, Tajikistan, Tanzania, Zambia, and Zimbabwe. The studies reveal a body of high quality work that is consistent with the conceptual framework of RBF schemes, supported by political will, resources, and research capacity. Strengthening the added value of qualitative inquiry in on-going and future qualitative studies may be enabled by small shifts in thinking and practice, in line with a qualitative research paradigm. First, in order to better ground research in an existing country and system specific context, some interrogation of constructs and posited relationships in the existing conceptual framework for intervention/evaluation may be required. Second, to enable more in-depth and richer data that documents working practices and relations under RBF schemes, training of local researchers should place stronger emphasis on entry to the field, gaining trust, building rapport, and sustaining a dialogue with key informants. Third, smaller, more intensive and focused studies targeting fewer sites and smaller samples - but addressing a wider range of methods and informants within the health system - are likely to yield richer data that can support the understanding of how health workers and managers are responding to schemes, and what impact schemes have on service volumes and outputs.sch_iihpub4412pu

Changing men or changing health systems? A scoping review of interventions, services and programmes targeting men’s health in sub-Saharan Africa

From Springer Nature via Jisc Publications RouterHistory: received 2020-10-16, accepted 2021-03-17, registration 2021-03-17, pub-electronic 2021-03-31, online 2021-03-31, collection 2021-12Publication status: PublishedFunder: Joint Health Systems Research Initiative (MRC/ESRC/DfID/Wellcome Trust); Grant(s): Ref no: MR/S013253/1Karin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Karina Kielmann - ORCID: 0000-0001-5519-1658 https://orcid.org/0000-0001-5519-1658Background: Sex and gender have been shown to influence health literacy, health seeking behaviour, and health outcomes. However, research examining the links between gender and health has mainly focused on women’s health, which is a long-standing global health priority. We examine literature focused on the ‘missing men’ in global health research, in particular empirical studies that document interventions, programmes, and services targeting men’s health issues in Sub-Saharan Africa. Within these studies, we identify dominant conceptualisations of men and men’s health and how these have influenced the design of men’s health interventions and services. Methods: This is a scoping review of published and grey literature. Following comprehensive searches, we included 56 studies in the review. We conducted a bibliographic analysis of all studies and used inductive methods to analyse textual excerpts referring to conceptualizations of men and service design. An existing framework to categorise services, interventions, or programs according to their gender-responsiveness was adapted and used for the latter analysis. Results: From the included studies, we distinguished four principal ways in which men were conceptualized in programs and interventions: men are variously depicted as ‘gatekeepers’; ‘masculine’ men, ‘marginal’ men and as ‘clients. Additionally, we classified the gender-responsiveness of interventions, services or programmes described in the studies within the following categories: gender-neutral, −partnering, −sensitive and -transformative. Interventions described are predominantly gender-neutral or gender-partnering, with limited data available on transformative interventions. Health systems design features – focused mainly on achieving women’s access to, and uptake of services – may contribute to the latter gap leading to poor access and engagement of men with health services. Conclusion: This review highlights the need for transformation in sub-Saharan African health systems towards greater consideration of men’s health issues and health-seeking patterns.Funder: Joint Health Systems Research Initiative (MRC/ESRC/DfID/Wellcome Trust); Grant(s): Ref no: MR/S013253/1pubpu

Job preferences among clinical officers in public sector facilities in rural Kenya: a discrete choice experiment

Background: Clinical officers (COs), a mid-level cadre of health worker, are the backbone of healthcare provision in rural Kenya. However, the vacancy rate for COs in rural primary healthcare facilities is high. Little is known about factors motivating COs' preferences for rural postings. Methods: A discrete choice experiment (DCE) questionnaire was used with 57 COs at public health facilities in nine districts of Nyanza Province, Kenya. The questionnaire was developed on the basis of formative qualitative interviews with COs (n = 5) and examined how five selected job attributes influenced COs' preferences for working in rural areas. Conditional logit models were employed to examine the relative importance of different job attributes. Results: Analysis of the qualitative data revealed five important job attributes influencing COs' preferences: quality of the facility, educational opportunities, housing, monthly salary and promotion. Analysis of the DCE indicated that a 1-year guaranteed study leave after 3 years of service would have the greatest impact on retention, followed by good quality health facility infrastructure and equipment and a 30% salary increase. Sub-group analysis shows that younger COs demonstrated a significantly stronger preference for study leave than older COs. Female COs placed significantly higher value on promotion than male COs. Conclusions: Although both financial incentives and non-financial incentives were effective in motivating COs to stay in post, the study leave intervention was shown to have the strongest impact on COs' retention in our study. Further research is required to examine appropriate interventions at each career stage that might boost COs' professional identity and status but without leading to larger deficits in the availability of generalist COs. 2016 Takemura et al.sch_iih14pub4260pub

‘We had to manage what we had on hand, in whatever way we could’: Adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa

In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors’ capacity to implement change in resourceconstrained facilities

Health workers' perceptions of private-not-for-profit health facilities' organizational culture and its influence on retention in Uganda

Background: An in-depth understanding of how organizational culture is experienced by health workers (HWs), and influences their decisions to leave their jobs is a fundamental, yet under-examined, basis for forming effective retention strategies. This research examined HWs ' working experiences and perceptions of organisational culture within private-not-for-profit, largely mission-based hospitals, and how this influenced retention. Methods: Thirty-two HWs, including managers, in 19 health facilities in Uganda were interviewed using a semi- structured topic guide. Interview transcripts were analysed using thematic content analysis. Results: Interviews showed that the organizational culture was predominantly hierarchical, with non-participative management styles which emphasized control and efficiency. HWs and managers held different perceptions of the organizational culture. While the managers valued results and performance, HWs valued team work, recognition and participative management. Conclusions: The findings of this study indicate that organizational culture influences retention of HWs in health facilities and provide a useful context to inform health care managers in the PNFP sub-sector in Uganda and similar contexts. To improve retention of HWs, a gradual shift in organizational culture will be necessary, focussing on the values, beliefs and perceptions which have the greatest influence on observable behaviour.sch_iih17 [809]pub5066pu

‘It has become everybody’s business and nobody’s business’: Policy actor perspectives on the implementation of TB infection prevention and control (IPC) policies in South African public sector primary care health facilities

Karina Kielmann - ORCID: 0000-0001-5519-1658 https://orcid.org/0000-0001-5519-1658South Africa is increasingly offering screening, diagnosis and treatment of tuberculosis (TB), and especially drug-resistant TB, at the primary care level. Nosocomial transmission of TB within primary health facilities is a growing concern in South Africa, and globally. We explore here how TB infection prevention and control (IPC) policies, historically focused on hospitals, are being implemented within primary care facilities. We spoke to 15 policy actors using in-depth interviews about barriers to effective TB-IPC and opportunities for improving implementation. We identified four drivers of poor policy implementation: fragmentation of institutional responsibility and accountability for TB-IPC; struggles by TB-IPC advocates to frame TB-IPC as an urgent and addressable policy problem; barriers to policy innovation from both a lack of evidence as well as a policy environment dependent on ‘new’ evidence to justify new policy; and the impact of professional medical cultures on the accurate recognition of and response to TB risks. Participants also identified examples of TB-IPC innovation and described conditions necessary for these successes. TB-IPC is a long-standing, complex health systems challenge. As important as downstream practices like mask-wearing and ventilation are, sustained, effective TB-IPC ultimately requires that we better address the upstream barriers to TB-IPC policy formulation and implementation.The support of the Economic and Social Research Council (IK) is gratefully acknowledged. The project is partly funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with other funders including support from the GCRF. Grant reference: ES/P008011/1https://doi.org/10.1080/17441692.2020.183993216pubpub1

Health systems’ responses to the roll-out of antiretroviral therapy (ART) in India: a comparison of two HIV high-prevalence settings

The government of India launched the free anti-retroviral therapy (ART) initiative in 2004 and the programme has since scaled up expansion in a phased manner. Programme authorities acknowledge problems in scale-up, yet discussions have been restricted to operational constraints, with little consideration for how local health system responses to HIV/AIDS influence the delivery of ART. This paper draws on the perspectives of key informants and people living with HIV (PLHIV) to compare delivery of ART in two ART centres in the States of Maharashtra and Andhra Pradesh at two distinct points of time. In 2005, data were collected through key informant interviews (KIIs) using interview guides and a survey of PLHIV using a semi-structured interview schedule. Differences were observed in the functioning and resources of the two centres, indicating different levels of preparedness which in turn influenced PLHIV's pathways in accessing ART. We examine these differences in the light of programme leadership, ownership and the roles of public, private and non-governmental organisation actors in HIV care. KIIs conducted during a follow-up visit in 2009 focused on changes in ART delivery. Many operational problems had been resolved; however, new challenges were emerging as a result of the increased patient load. An understanding of how ART programmes evolve within local health systems has bearing on future developments of the ART programme and must include a consideration of the wider socio-political environment within which HIV programmes are embedded

Balancing authority, deference and trust across the public-private divide in health care: Tuberculosis health visitors in western Maharashtra, India

While concepts such as 'partnership' are central to the terminology of private-public mix (PPM), little attention has been paid to how social relations are negotiated among the diverse actors responsible for implementing these inter-sectoral arrangements. India's Revised National Tuberculosis Control Programme (RNTCP) has used intermediary agents to facilitate the involvement of private providers in the expansion of Directly Observed Therapy, Short-Course (DOTS). We examine the roles of tuberculosis health visitors (TB HVs) in mediating working relationships among private providers, programme staff and patients that underpin a PPM-DOTS launched by the RNTCP in western Maharashtra. In addition to observations and informal interactions with the programme and participating health providers, researchers conducted in-depth interviews with senior programme officers and eight TB HVs. Framed by a political discourse of clinical governance, working relationships within the PPM are structured by the pluralistic context, social and professional hierarchies and paternalism of health care in India. TB HVs are at the nexus of these relationships, yet remain undervalued partly because accountability is measured through technical rather than social outcomes of the 'partnership'. Close attention to the dynamics of power relations in working practices within the health system can improve accountability and sustainability of partnerships. 2014 2014 The Author(s). Published by Taylor & Francis.sch_iih9pub3557pub