The role of the National Health insurance scheme in shaping equity of access to healthcare in Ghana

In light of recent emphasis on achieving Universal Health Coverage through social health insurance in low income countries, this thesis examined how the National Health Insurance Scheme in Ghana impacts on equity of access to healthcare in Tamale District of northern Ghana. Using mainly a qualitative approach, the thesis specifically examined whether the NHIS promotes equity in health insurance coverage and whether insured members are able to access healthcare equitably. Against this background, four broad findings were identified. Firstly, even though the NHIS improved insurance coverage in the Tamale District, enrolment was largely inequitable because most socially disadvantaged groups/individuals were less able to insure. This was mainly because such groups were predisposed to developing low willingness and low ability to enrol in the NHIS as a result of their individual and community characteristics as well as NHIS and healthcare system factors. Secondly, the NHIS improved the affordability of healthcare services and reduced the risk of catastrophic healthcare expenditure among insured members, particularly insured low income households. Thirdly, while the NHIS improved the financial resources of healthcare providers and the availability of medicines and medical supplies, it adversely impacted on the general quality of healthcare services mainly because the supply of healthcare resources failed to keep up with a high demand for healthcare services by insured members. Fourthly, the NHIS also improved the use of formal care, particularly among insured low income households due to their greater healthcare needs and previous inability to afford the cost of healthcare services. However, due to long waiting times associated with accessing NHIS healthcare, the improvement in financial access to healthcare by the NHIS failed to eradicate the use of ‘informal’ forms of care (e.g. drugstore, herbal/traditional medicine) among insured members. Based on these findings, this thesis concludes that the NHIS could enhance equity in access to care if there are opportunities created to enable socially disadvantaged groups to enrol in the scheme as well as improve the availability and quality of healthcare services for insured members

Analysis of Skills Needs in Repair Welding of Low-Alloy, High Tensile Steels Using the Manual Metal Arc Welding (MMAW) Process

There is actually critical skills gap in repair welding of low-alloy, high tensile steels among welding craftsmen within the Tamale metropolis. A skills gap is perceived to be the difference between the skills needed and the skills already acquired. This study seeks to analyze the skills gap in the repair welding of low-alloy, high tensile steels component parts in the informal sector within the metropolis, especially when using the MMAW process. A total of 120 questionnaires including structured interview were then administered to welding craftsmen. However, 111questionnaire were returned, representing a response rate of 92.5%. Welders perceive that a lot of repair welding is present in both automotive and structural steel industries (87.7%). The study was posed to determine whether welders were able to make the right choice of electrode for low-alloy steel welding. Also to find out whether level of education of the welder or age in the profession influences one’s ability to weld low-alloy steel successfully. The study revealed that those who could not identify the right electrode for low-alloy steel welding were at the higher side. The inferential statistics output indicated that quality of weld is independent of level of education, likewise age in the welding profession. It is therefore recommended that artisanal training be organized for welding craftsmen within the metropolis in order to address this critical gap.  Education institutions could take up this challenge to ensure that they offer the requisite skills to this category of welders who had not passed through technical education. It is also recommendable to ensure that repair welding of alloy steels in its entirety be given a place in the technical curriculum

Transforming social norms to end FGM in the EU: an evaluation of the REPLACE Approach

Background: Despite numerous campaigns and interventions to end female genital mutilation (FGM), the practice persists across the world, including the European Union (EU). Previous interventions have focused mainly on awareness raising and legislation aimed at criminalizing the practice. Limited evidence exists on the effectiveness of interventions due in part to the lack of systematic evaluation of projects. This paper presents an evaluation of the REPLACE Approach, which is a new methodology for tackling FGM based on community-based behaviour change and intervention evaluation. Methods: We developed, trialed and evaluated the REPLACE Approach through extensive engagement with eight FGM affected African diaspora communities in five EU countries. We employed qualitative and quantitative tools to obtain data to inform the development, implementation and evaluation of the Approach. These included communitybased participatory action research, questionnaires and community readiness assessments. The research took place between 2010 and 2016. Results: Findings suggested that the Approach has the capability for building the capacities of FGM affected communities to overturn social norms that perpetuate the practice. We observed that community-based action research is a useful methodology for collecting data in FGM intervention settings as it allows for effective community engagement to identify, educate and motivate influential community members to challenge the practice, as well as obtaining useful information on the beliefs and norms that shape the practice. We also found that community readiness assessments, pre and post intervention, were useful for tailoring interventions appropriately and for evaluating changes in attitudes and behaviour that may have resulted from the interventions. Conclusion: This evaluation has demonstrated that the REPLACE Approach has the potential, over time, to bring about changes in norms and attitudes associated with FGM. Its strengths lay in the engagement with influential community members, in building the capacity and motivation of community members to undertake change, in recognising contextual differences in the barriers and enablers of FGM practice and in tailoring interventions to local community readiness to change, and then evaluating interventions to re-inform implementation. The next steps would therefore be to implement the Approach over a longer time frame to assess if it results in measurable change in behaviour

Factors Influencing the Efficiency of Public Hospitals in Saudi Arabia: A Qualitative Study Exploring Stakeholders' Perspectives and Suggestions for Improvement

Objective: Despite an extensive literature on efficiency, qualitative evidence on the drivers of hospital efficiency is scant. This study examined the factors that influence the efficiencies of health service provision in public hospitals in the Kingdom of Saudi Arabia (KSA) and their potential remedies. Design: We employed a qualitative design involving semi-structured interviews conducted between July and September 2019. Participants were purposively selected and included policymakers and hospital managers drawn from districts, regional and national levels. Data were analyzed in Nvivo 12 based on a thematic approach. Setting: Key informants of Ministry of health in the KSA. Results: Respondents identified a range of different factors across the community, facility and the wider health system that influence inefficiencies in public hospitals in KSA. Ineffective hospital management, lack of strategic planning and goals, weak administrative leadership, and absence of monitoring hospital performance was noted to have a profound impact on hospital efficiency. The conditions of healthcare staff in respect to both skills, authority and psychological factors were considered to influence the efficiency level. Further, lack of appropriate data for decision making due to the absence of an appropriate health informatics system was regarded as a factor of inefficiency. At the community level, respondents described inadequate information on the healthcare needs and expectations of patients and the wider community as significant barriers to the provision of efficient services. To improve hospital efficiencies, respondents recommended that service delivery decisions are informed by data on community health needs; capacity strengthening and effective supervision of hospital staff; and judicious resource allocation. Conclusion: The study demonstrates that inefficiencies in health services remain a critical challenge in public hospitals in KSA. Extensive awareness-raising and training on efficient resource utilization among key health systems stakeholders are imperative to improving hospital performance. More research is needed to strengthen knowledge on hospital efficiency in light of the limited data on the topic in KSA and the wider Gulf region

Factors influencing the efficiency of public hospitals in Saudi Arabia: a qualitative study exploring stakeholders' perspectives and suggestions for improvement

Objective: Despite an extensive literature on efficiency, qualitative evidence on the drivers of hospital efficiency is scant. This study examined the factors that influence the efficiencies of health service provision in public hospitals in the Kingdom of Saudi Arabia (KSA) and their potential remedies. Design: We employed a qualitative design involving semi-structured interviews conducted between July and September 2019. Participants were purposively selected and included policymakers and hospital managers drawn from districts, regional and national levels. Data were analyzed in Nvivo 12 based on a thematic approach. Setting: Key informants of Ministry of health in the KSA. Results: Respondents identified a range of different factors across the community, facility and the wider health system that influence inefficiencies in public hospitals in KSA. Ineffective hospital management, lack of strategic planning and goals, weak administrative leadership, and absence of monitoring hospital performance was noted to have a profound impact on hospital efficiency. The conditions of healthcare staff in respect to both skills, authority and psychological factors were considered to influence the efficiency level. Further, lack of appropriate data for decision making due to the absence of an appropriate health informatics system was regarded as a factor of inefficiency. At the community level, respondents described inadequate information on the healthcare needs and expectations of patients and the wider community as significant barriers to the provision of efficient services. To improve hospital efficiencies, respondents recommended that service delivery decisions are informed by data on community health needs; capacity strengthening and effective supervision of hospital staff; and judicious resource allocation. Conclusion: The study demonstrates that inefficiencies in health services remain a critical challenge in public hospitals in KSA. Extensive awareness-raising and training on efficient resource utilization among key health systems stakeholders are imperative to improving hospital performance. More research is needed to strengthen knowledge on hospital efficiency in light of the limited data on the topic in KSA and the wider Gulf region

“Deadly”, “fierce”, “shameful”: notions of antiretroviral therapy, stigma and masculinities intersecting men’s life-course in Blantyre, Malawi

Abstract: Background: Stigma and masculinity represent persistent barriers in delivering successful HIV interventions to men. Our study examined community perceptions of HIV and anti-retroviral therapy (ART) and their implications for men on ART across the life course in Blantyre, Malawi. Methods: Our qualitative study is based on 72 face-to-face semi-structured interviews. Participants were selected purposively and included men on ART (with suppressed and unsuppressed viral loads), adult male community members irrespective of HIV status and other HIV stakeholders such as health personnel and program implementers. Interviews were conducted in Chichewa and English, transcribed verbatim and analyzed thematically in NVivo 12. We applied the socio-ecological model as our theoretical framework as well as a “life-course” perspective. Results: Our findings highlight lingering negative perceptions towards ART in general and towards PLHIV irrespective of viral load suppression. With intersecting notions of masculinity and stigma, men’s descriptions of anticipated stigma in their relationships and when visiting health facilities dominated. Stigma was experienced at the personal, interpersonal, facility and community level. Yet, men living with HIV were perceived differently throughout the life-course, with young sexually active men seen as the most stigmatized group and older men seen as drawing resilience from a greater range of masculine norms. Some men of all ages displayed “transformative” masculinities independent of stigma and community expectations. Conclusions: We propose the “life-course” as a useful concept for studies on masculinity, HIV and stigma. Considering gendered constructions of “respectable” midlife-older age vis-à-vis younger age, and how they influence stigma as well as uptake and adherence to ART might lead to more targeted services for men that build on “transformative masculinities”

Engendering health systems in response to national rollout of dolutegravir-based regimens among women of childbearing potential: a qualitative study with stakeholders in South Africa and Uganda

Background In the era of rapid dolutegravir rollout, concerns about neural tube defects have complicated the health systems response among women of childbearing potential. This qualitative study, which was nested within the DolPHIN-2 clinical trial, examined the current and future health system opportunities and challenges associated with the transition to dolutegravir-based regimen as first line antiretroviral therapy among women of childbearing potential in South Africa and Uganda .   Method Semi-structured in-depth interviews with members of antiretroviral therapy guideline development groups and affiliates were conducted. Thirty-one participants were purposively selected for the study, including senior officials from the Ministry of Health and National Drug Regulatory Authority in Uganda and South Africa as well as health sector development partners, activists, researchers and health workers. A thematic approach was used to analyse the data.   Findings Despite differences in health system contexts, several common challenges and opportunities were identified with the transition among women of childbearing potential in South Africa and Uganda.  In both contexts national stakeholders identified challenges with ensuring gender equity in roll out due to the potential teratogenicity of dolutegravir, paucity of data on dolutegravir use in pregnancy, potential stock out of effective contraceptives, poorly integrated contraception services, and limited pharmacovigilance in pregnancy.  Participants identified opportunities that could be harnessed to accelerate the transition, including high stakeholder interest and commitment to transition, national approval and licensure of a generic tenofovir/lamivudine/dolutegravir regimen, availability of a network of antiretroviral therapy providers, and strong desire among women for newer and more tolerable regimens.      Conclusion The transition to dolutegravir-based regimens has the potential to strengthen health systems in low- and middle-income countries to engender equitable access to optimised antiretroviral regimen among women. There is the need for a multi-sectoral effort to harness the opportunities of the health systems to addresses the bottlenecks to the transition and initiate extensive community engagement alongside individual and institutional capacity strengthening. Improvements in pregnancy pharmacovigilance and counselling and family planning services are critical to ensuring a successful transition among women of childbearing potential