BUREAUCRATS AS PURCHASERS OF HEALTH SERVICES: LIMITATIONS OF THE PUBLIC SECTOR FOR CONTRACTING

Contracting out of health services increasingly involves a new role for governments as purchasers of services. To date, emphasis has been on contractual outcomes and the contracting process, which may benefit from improvements in developing countries, has been understudied. This article uses evidence from wide scale NGO contracting in Pakistan and examines the performance of government purchasers in managing the contracting process; draws comparisons with NGO managed contracting; and identifies purchaser skills needed for contracting NGOs. We found that the contracting process is complex and government purchasers struggled to manage the contracting process despite the provision of well-designed contracts and guidelines. Weaknesses were seen in three areas: (i) poor capacity for managing tendering; (ii) weak public sector governance resulting in slow processes, low interest and rent seeking pressures; and (iii) mistrust between government and the NGO sector. In comparison parallel contracting ventures managed by large NGOs generally resulted in faster implementation, closer contractual relationships, drew wider participation of NGOs and often provided technical support. Our findings do not dilute the importance of government in contracting but front the case for an independent purchasing agency, for example an experienced NGO, to manage public sector contracts for community based services with the government role instead being one f larger oversight. © 2011 John Wiley & Sons, Ltd.

What can we learn on public accountability from non-health disciplines: a meta-narrative review.

OBJECTIVE: In health, accountability has since long been acknowledged as a central issue, but it remains an elusive concept. The literature on accountability spans various disciplines and research traditions, with differing interpretations. There has been little transfer of ideas and concepts from other disciplines to public health and global health. In the frame of a study of accountability of (international) non-governmental organisations in local health systems, we carried out a meta-narrative review to address this gap. Our research questions were: (1) What are the main approaches to accountability in the selected research traditions? (2) How is accountability defined? (3) Which current accountability approaches are relevant for the organisation and regulation of local health systems and its multiple actors? SETTING: The search covered peer-reviewed journals, monographs and readers published between 1992 and 2012 from political science, public administration, organisational sociology, ethics and development studies. 34 papers were selected and analysed. RESULTS: Our review confirms the wide range of approaches to the conceptualisation of accountability. The definition of accountability used by the authors allows the categorisation of these approaches into four groups: the institutionalist, rights-based, individual choice and collective action group. These four approaches can be considered to be complementary. CONCLUSIONS: We argue that in order to effectively achieve public accountability, accountability strategies are to be complementary and synergistic

Data for: "Stigmatized by association: challenges for abortion service providers in Ghana"

Unsafe abortion is an issue of public health concern and contributes significantly to maternal morbidity and mortality globally. Abortion evokes religious, moral, ethical, socio-cultural and medical concerns which mean it is highly stigmatized and this poses a threat to both providers and researchers. This study examined the challenges to providing safe abortion services from the perspective of health providers in Ghana. In-depth interviews were performed with obstetrician/gynaecologists, nurse-midwives and pharmacists (n = 36) in three (3) hospitals and five (5) health centres in the capital city in Ghana

Stigmatized by association: challenges for abortion service providers in Ghana.

BACKGROUND: Unsafe abortion is an issue of public health concern and contributes significantly to maternal morbidity and mortality globally. Abortion evokes religious, moral, ethical, socio-cultural and medical concerns which mean it is highly stigmatized and this poses a threat to both providers and researchers. This study sought to explore challenges to providing safe abortion services from the perspective of health providers in Ghana. METHODS: A descriptive qualitative study using in-depth interviews was conducted. The study was conducted in three (3) hospitals and five (5) health centres in the capital city in Ghana. Participants (n?=?36) consisted of obstetrician/gynaecologists, nurse-midwives and pharmacists. RESULTS: Stigma affects provision of safe-abortion services in Ghana in a number of ways. The ambiguities in Ghanaian abortion law and lack of overt institutional support for practitioners increased reluctance to openly provide for fear of stigmatisation and legal threat. Negative provider attitudes that stigmatised women seeking abortion care were frequently driven by socio-cultural and religious norms that highly stigmatise abortion practice. Exposure to higher levels of education, including training overseas, seemed to result in more positive, less stigmatising views towards the need for safe abortion services. Nevertheless, physicians open to practicing abortion were still very concerned about stigma by association. CONCLUSIONS: Stigma constitutes an overarching impediment for abortion service provision. It affects health providers providing such services and even researchers who study the subject. Exposure to wider debate and education seem to influence attitudes and values clarification training may prove useful. Proper dissemination of existing guidelines and overt institutional support for provision of safe services also needs to be rolled out

Integrated care: learning between high-income, and low- and middle-income country health systems.

Over the past decade, discussion of integrated care has become more widespread and prominent in both high- and low-income health care systems (LMICs). The trend reflects the mismatch between an increasing burden of chronic disease and local health care systems which are still largely focused on hospital-based treatment of individual clinical episodes and also the long-standing proliferation of vertical donor-funded disease-specific programmes in LMICs which have disrupted horizontal, or integrated, care. Integration is a challenging concept to define, in part because of its multiple dimensions and varied scope: from integrated clinical care for individual patients to broader systems integration-or linkage-involving a wide range of interconnected services (e.g. social services and health care). In this commentary, we compare integrated care in high- and lower-income countries. Although contexts may differ significantly between these settings, there are many common features of how integration has been understood and common challenges in its implementation. We discuss the different approaches to, scope of, and impacts of, integration including barriers and facilitators to the processes of implementation. With the burden of disease becoming more alike across settings, we consider what gains there could be from comparative learning between these settings which have constituted two separate strands of research until now

Globalisation and transitions in abortion care in Ghana.

BACKGROUND: Access to safe abortion is a globally contested policy and social justice issue - contested because of its religious and moral dimensions regarding the right to life and personhood of a foetus vs. the rights of women to make decisions about their own bodies. Many nations have agreed to address the health consequences of unsafe abortion, though stopped short of committing to providing comprehensive services. Ghana has a relatively liberal abortion law dating from 1985 and has ratified most international agreements on provision of care. Policy implementation has been very slow, but modest efforts are now being made to reduce maternal mortality caused by unsafe abortions. Understanding whether globalisation has played a role in this transition to practice is important to institutionalise the transition in Ghana and to learn lessons for other countries seeking to implement policies, but analysis is lacking. METHODS: Drawing on 58 in-depth key informant interviews and policy document analysis we describe the development of de jure law and policies on comprehensive abortion care in Ghana, de facto interpretation and implementation of those policies, and assess what role globalization played in the transition in abortion care in Ghana. RESULTS: We found that an accumulation of global influences has converged to start a transition in the culture of abortion care and service provision in Ghana, from a restrictive interpretation of the law to facilitating more widespread access to legal, safe abortion services through development of policies and guidelines and a slow change in attitudes and practices of health providers. These global influences can be categorised as: a global governance architecture of reproductive rights-obligations which creates pressure on signatory governments to act; and global communication of ideas and mobility of health providers (particularly through cross-cultural training opportunities and interaction with international NGOs) which facilitate global cultural interaction on the benefits of safe abortion services for reducing consequences of unsafe abortions. CONCLUSION: Globalisation of information, debate and training experience as well as of international rights frameworks can together create a powerful force for good to protect women and their children from the needless pain and death resulting from unsafe abortions

One stop crisis centres: A policy analysis of the Malaysian response to intimate partner violence

BACKGROUND: This article aims to investigate the processes, actors and other influencing factors behind the development and the national scale-up of the One Stop Crisis Centre (OSCC) policy and the subsequent health model for violence-response. METHODS: Methods used included policy analysis of legal, policy and regulatory framework documents, and in-depth interviews with key informants from governmental and non-governmental organisations in two States of Malaysia. RESULTS: The findings show that women's NGOs and health professionals were instrumental in the formulation and scaling-up of the OSCC policy. However, the subsequent breakdown of the NGO-health coalition negatively impacted on the long-term implementation of the policy, which lacked financial resources and clear policy guidance from the Ministry of Health. CONCLUSION: The findings confirm that a clearly-defined partnership between NGOs and health staff can be very powerful for influencing the legal and policy environment in which health care services for intimate partner violence are developed. It is critical to gain high level support from the Ministry of Health in order to institutionalise the violence-response across the entire health care system. Without clear operational details and resources policy implementation cannot be fully ensured and taken to scale

The risks of partner violence following HIV status disclosure, and health service responses: narratives of women attending reproductive health services in Kenya.

INTRODUCTION: For many women living with HIV (WLWH), the disclosure of positive status can lead to either an extension of former violence or new conflict specifically associated with HIV status disclosure. This study aims to explore the following about WLWH: 1. the women's experiences of intimate partner violence (IPV) risks following disclosure to their partners; 2. an analysis of the women's views on the role of health providers in preventing and addressing IPV, especially following HIV disclosure. METHODS: Thirty qualitative interviews were conducted with purposively selected WLWH attending clinics in Kenya. Data were coded using NVivo 9 and analyzed thematically. RESULTS: Nearly one third of the respondents reported experiencing physical and/or emotional violence inflicted by their partners following the sero-disclosure, suggesting that HIV status disclosure can be a period of heightened risk for partner stigma and abuse, and financial withdrawal, and thus should be handled with caution. Sero-concordance was protective for emotional and verbal abuse once the partner knew his positive status, or knew the woman knew his status. Our results show acceptance of the role of the health services in helping prevent and reduce anticipated fear of partner stigma and violence as barriers to HIV disclosure. Some of the approaches suggested by our respondents included couple counselling, separate counselling sessions for men, and facilitated disclosure. The women's narratives illustrate the importance of integrating discussions on risks for partner violence and fear of disclosure into HIV counselling and testing, helping women develop communication skills in how to disclose their status, and reducing fear about marital separation and break-up. Women in our study also confirmed the key role of preventive health services in reducing blame for HIV transmission and raising awareness on HIV as a chronic disease. However, several women reported receiving no counselling on safe disclosure of HIV status. CONCLUSION: Integration of partner violence identification and care into sexual, reproductive and HIV services for WLWH could be a way forward. The health sector can play a preventive role by sensitizing providers to the potential risks for partner violence following disclosure and ensuring that the women's decision to disclose is fully informed and voluntary