Assessing access barriers to maternal health care: measuring bypassing to identify health centre needs in rural Uganda.

BACKGROUND: In low income countries, several barriers exist to the use of health services for child delivery, including distance, transportation, informal costs or low perceived quality. Yet there is rarely information about which barriers are more or less important to the use of a given health facility. This study assessed the relative importance of different barriers to maternal health facility use in rural Uganda through the use of simple indicators based on locally available data. METHODS: Data from public health facilities performing deliveries in a rural district were used along with census information to construct a set of indicators useful for diagnosing barriers to delivery service use. Indicators included the number of facility-based deliveries per 1000 women served, the proportion of users from a facility's local area, and a new indicator, the 'bypassing ratio', defined as the number of women from a facility's local area who delivered in other facilities, divided by the number of local women using the facility itself. RESULTS: Numbers of deliveries varied greatly between facilities of the same level. A few very low use facilities saw over 75% of women come from the local area, while other facilities services attracted a large majority of women from other areas. The phenomenon of bypassing provides additional insight into the relative importance of distance or transport as opposed to internal facility factors preventing use. CONCLUSIONS: Simple and easily replicable tools are essential to assist health managers to identify communities and facilities needing improvements in access to delivery care. The methods developed in this paper could be utilized by local officials in other areas to assist planning and improvement of both maternal care and other health services

Overcoming access barriers for facility-based delivery in low-income settings: insights from Bangladesh and Uganda.

Women in both Bangladesh and Uganda face a number of barriers to delivery in professional health facilities, including costs, transportation problems, and sociocultural norms to deliver at home. Some women in both the countries manage to overcome these barriers. This paper reports on a comparative qualitative study investigating how some women and their families were able to use professional delivery services. The study provides insights into the decision-making processes and overcoming access barriers. Husbands were found to be particularly important in Uganda, while, in Bangladesh, a number of individuals could influence care-seeking, including unqualified local healers or traditional birth attendants. In both the settings, cost and transport barriers were often overcome through social networks. Social prohibitions on birth in the health facility did not feature strongly in women's accounts, with several Ugandan women explaining that friends or peers also used facilities, while, in Bangladesh, perceived complications apparently justified the use of professional medical care. Investigating the ways in which some women can overcome common barriers can help inform policy and planning to increase the use of health facilities for child delivery

Innovative responses for preventing HIV transmission: The protective value of population-wide interruptions of risk activity.

Concurrent partnering contributes to high HIV prevalence. This is in part due to the natural history of the virus. After transmission, an individual’s viral load spikes in a period of ‘acute infection’ during which they are highly infectious. Models estimate that around 10 - 45% of HIV acquisition arises from sex with an individual in the acute infection period.&#x0D; If everyone in a population abstained from high-risk sex for a given period of time, in theory the viral loads of all recent seroconverters should pass through the acute infection period. When risk behaviour resumed there would be almost no individuals in the high-viraemic phase, thereby reducing infectivity, and HIV incidence would fall. &#x0D; Recurring population-wide shifts in risk behaviour are not unheard of. Many, in fact, occur as part of existing religious observances. The month of Ramadan in Muslim communities is perhaps one of the most obvious cases. Ramadan sees significant behaviour changes. In addition to fasting from sunrise to sunset, observant individuals abstain from coitus during daylight hours. There is anecdotal evidence that risky sexual behaviours are also significantly reduced over this period. In Indonesia, for instance, it was reported that research with sex workers was not possible during Ramadan because people ‘abstained from sex from one end of the month to the other … Many sex workers returned to home villages during this time.’ &#x0D; This article argues that a population-wide interruption of risk behaviour for a set period of time could reduce HIV incidence and make a significant contribution to prevention efforts. It calls for mathematical modelling of periodic risk behaviour interruptions, as well as encouragement of policy interventions to develop campaigns of this nature. A policy response, such as a ‘safe sex/no sex’ campaign in a cohesive population, deserves serious consideration as an HIV prevention intervention. In some contexts, periods of abstinence from risk behaviour could also be linked to existing religious practices to provide policy options.</jats:p

What constitutes “good” evidence for public health and social policy-making? From hierarchies to appropriateness

Within public health, and increasingly other areas of social policy, there are widespread calls to increase or improve the use of evidence for policy-making. Often these calls rest on an assumption that increased evidence utilisation will be a more efficient or effective means of achieving social goals. Yet a clear elucidation of what can be considered ?good evidence? for policy is rarely articulated. Many of the current discussions of best practise in the health policy sector derive from the evidence-based medicine (EBM) movement, embracing the ?hierarchy of evidence? that places experimental trials as pre-eminent in terms of methodological quality. However, a number of problems arise if these hierarchies are used to rank or prioritise policy relevance. Challenges in applying evidence hierarchies to policy questions arise from the fact that the EBM hierarchies rank evidence of intervention effect on a specified and limited number of outcomes. Previous authors have noted that evidence forms at the top of such hierarchies typically serve the needs and realities of clinical medicine, but not necessarily public policy. We build on past insights by applying three disciplinary perspectives from political science, the philosophy of science and the sociology of knowledge to illustrate the limitations of a single evidence hierarchy to guide health policy choices, while simultaneously providing new conceptualisations suited to achieve health sector goals. In doing so, we provide an alternative approach that re-frames ?good? evidence for health policy as a question of appropriateness. Rather than adhering to a single hierarchy of evidence to judge what constitutes ?good? evidence for policy, it is more useful to examine evidence through the lens of appropriateness. The form of evidence, the determination of relevant categories and variables, and the weight given to any piece of evidence, must suit the policy needs at hand. A more robust and critical examination of relevant and appropriate evidence can ensure that the best possible evidence of various forms is used to achieve health policy goals

Strengthening the research to policy and practice interface: exploring strategies used by research organisations working on sexual and reproductive health and HIV/AIDS

This commentary introduces the HARPS supplement on getting research into policy and practice in sexual and reproductive health (SRH). The papers in this supplement have been produced by the Sexual Health and HIV Evidence into Practice (SHHEP) collaboration of international research, practitioner and advocacy organizations based in research programmes funded by the UK Department for International Development

Appeals to evidence for the resolution of wicked problems: the origins and mechanisms of evidentiary bias

Wicked policy problems are often said to be characterized by their ‘intractability’, whereby appeals to evidence are unable to provide policy resolution. Advocates for ‘Evidence Based Policy’ (EBP) often lament these situations as representing the misuse of evidence for strategic ends, while critical policy studies authors counter that policy decisions are fundamentally about competing values, with the (blind) embrace of technical evidence depoliticizing political decisions. This paper aims to help resolve these conflicts and, in doing so, consider how to address this particular feature of problem wickedness. Specifically the paper delineates two forms of evidentiary bias that drive intractability, each of which is reflected by contrasting positions in the EBP debates: ‘technical bias’ - referring to invalid uses of evidence; and ‘issue bias’ - referring to how pieces of evidence direct policy agendas to particular concerns. Drawing on the fields of policy studies and cognitive psychology, the paper explores the ways in which competing interests and values manifest in these forms of bias, and shape evidence utilization through different mechanisms. The paper presents a conceptual framework reflecting on how the nature of policy problems in terms of their complexity, contestation, and polarization can help identify the potential origins and mechanisms of evidentiary bias leading to intractability in some wicked policy debates. The discussion reflects on whether being better informed about such mechanisms permit future work that may lead to strategies to mitigate or overcome such intractability in the future