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

Experiences of migrant parents of children with special health and welfare needs in Nordic countries: a scoping review

Study aim: The objective of this scoping review was to explore and summarise emerging themes in existing studies on personal experiences of migrant parents of children with special health and welfare needs and their interaction with health and welfare services in the Nordic countries. Methods: A comprehensive and systematic search for relevant articles in electronic databases was conducted in PubMed, PsycINFO and Web of Science between 2 April 2023 and 31 May 2023. The scoping review followed identified guidelines in conducting scoping reviews. Out of the initial 1836 study results, 62 studies were read and assessed as full text and a total of 13 studies met the inclusion criteria. Results: Using thematic analysis, three key thematic categories were identified: (a) Initial responses to having a child with health and welfare challenges; (b) encountering the Nordic health and welfare services; (c) implications on social inclusion. The challenges to participation faced by migrants threatened their wellbeing, impacted their relationships and influenced their coping strategies and opportunities for social inclusion. Conclusions: The Nordic countries have accessible, affordable and well-equipped infrastructure for health and welfare services compared with the home countries of most migrants. Future research is necessary to explore alternative strategies and spaces to promote participation and involvement of migrant parents of children with special health and welfare needs to inform public health and welfare services development and research.publishedVersio

Voluntary sector's role and relevance as alternative arenas for promotion of health and social inclusion of migrant parents and families of children with special health and welfare needs in Norway

Migrant families of children with special health and welfare needs such as mental, developmental, and physical disabilities face significant barriers to health and welfare services. This could result in social inequalities and exclusion. The aim of this article was to explore the role and relevance of voluntary sector in promoting health and social inclusion of migrant families of children with special health and welfare needs in Norway. The study is based on a qualitative participatory research design using co-production and interdisciplinary research methodologies. A total of 15 voluntary sector employees participated in semi-structured qualitative interviews. We found three major themes to summarise the role of voluntary sector: 1) Providing arenas for social inclusion and belonging; 2) Facilitating access to public health and welfare services; and 3) Provision of complementary health and welfare services. Results indicate that voluntary services use more informal community centered caring approaches and are supplementary to public health and welfare services. An exploration of more opportunities for participation of migrant families of children with special health and welfare needs in the development of services and collaboration between voluntary services and public welfare providers may foster inclusion and could be of relevance to future welfare research and practice.publishedVersio

Experiences of municipal­ psychologists on their role in local public health work

Background: Municipal psychologists (MPs) in Norway are mandated to contribute to public health work through mental health promotion and preventive efforts. However, the literature indicates that MPs spend most of their time on clinical work. This study aimed to explore the role and situatedness of MPs in public health work, from their perspective. Method: A qualitative design was used, involving 12 semi-structured interviews with MPs from 8 different municipalities in the greater Oslo region. Data were analysed using thematic analysis. Results: Participants reported challenges related to a lack of role clarity, leading to difficulties in balancing clinical and public health work. Collaborative challenges across sectors and services also constituted major findings. Despite this, MPs remained convinced that their competencies are needed and relevant in municipal public health work. Conclusion: The roles of MPs need to be clearly defined. Official guidelines for their roles should be developed, and MPs should be formally included in municipal public health teams. Furthermore, legislation regarding psychological expertise in the Public Health Act can create a clear mandate for MPs and grant them greater authority. Keywords: mental health, prevention, municipal psychologists, new public management, self-determination theoryExperiences of municipal­ psychologists on their role in local public health workpublishedVersio

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

Introducing payment for performance in the health sector of Tanzania- the policy process

Background: Prompted by the need to achieve progress in health outcomes, payment for performance (P4P) schemes are becoming popular policy options in the health systems in many low income countries. This paper describes the policy process behind the introduction of a payment for performance scheme in the health sector of Tanzania illuminating in particular the interests of and roles played by the Government of Norway, the Government of Tanzania and the other development partners. Methods: The study employed a qualitative research design using in-depth interviews (IDIs), observations and document reviews. Thirteen IDIs with key-informants representing the views of ten donor agencies and government departments influential in the process of introducing the P4P scheme in Tanzania were conducted in Dar es Salaam, Tanzania and Oslo, Norway. Data was collected on the main trends and thematic priorities in development aid policy, countries and actors perceived to be proponents and opponents to the P4P scheme, and P4P agenda setting in Tanzania. Results: The initial introduction of P4P in the health sector of Tanzania was controversial. The actors involved including the bilateral donors in the Health Basket Fund, the World Bank, the Tanzanian Government and high level politicians outside the Health Basket Fund fought for their values and interests and formed alliances that shifted in the course of the process. The process was characterized by high political pressure, conflicts, changing alliances, and, as it evolved, consensus building. Conclusion: The P4P policy process was highly political with external actors playing a significant role in influencing the agenda in Tanzania, leaving less space for the Government of Tanzania to provide leadership in the process. Norway in particular, took a leading role in setting the agenda. The process of introducing P4P became long and frustrating causing mistrust among partners in the Health Basket Fund

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