Strengthening health system governance using health facility service charters: a mixed methods assessment of community experiences and perceptions in a district in Kenya.

BACKGROUND: Enhancing accountability in health systems is increasingly emphasised as crucial for improving the nature and quality of health service delivery worldwide and particularly in developing countries. Accountability mechanisms include, among others, health facilities committees, suggestion boxes, facility and patient charters. However, there is a dearth of information regarding the nature of and factors that influence the performance of accountability mechanisms, especially in developing countries. We examine community members' experiences of one such accountability mechanism, the health facility charter in Kericho District, Kenya. METHODS: A household survey was conducted in 2011 among 1,024 respondents (36% male, 64% female) aged 17 years and above stratified by health facility catchment area, situated in a division in Kericho District. In addition, sixteen focus group discussions were conducted with health facility users in the four health facility catchment areas. Quantitative data were analysed through frequency distributions and cross-tabulations. Qualitative data were transcribed and analysed using a thematic approach. RESULTS: The majority (65%) of household survey respondents had seen their local facility service charter, 84% of whom had read the information on the charter. Of these, 83% found the charter to be useful or very useful. According to the respondents, the charters provided useful information about the services offered and their costs, gave users a voice to curb potential overcharging and helped users plan their medical expenses before receiving the service. However, community members cited several challenges with using the charters: non-adherence to charter provisions by health workers; illegibility and language issues; lack of expenditure records; lack of time to read and understand them, often due to pressures around queuing; and socio-cultural limitations. CONCLUSION: Findings from this study suggest that improving the compliance of health facilities in districts across Kenya with regard to the implementation of the facility service charter is critical for accountability and community satisfaction with service delivery. To improve the compliance of health facilities, attention needs to be focused on mechanisms that help enforce official guidelines, address capacity gaps, and enhance public awareness of the charters and their use

Levels, trends and determinants of technical efficiency of general hospitals in Uganda: data envelopment analysis and Tobit regression analysis

General hospitals provide a wide range of primary and secondary healthcare services. They accounted for 38% of government funding to health facilities, 8.8% of outpatient department visits and 28% of admissions in Uganda in the financial year 2016/17. We assessed the levels, trends and determinants of technical efficiency of general hospitals in Uganda from 2012/13 to 2016/17. Methods We undertook input-oriented data envelopment analysis to estimate technical efficiency of 78 general hospitals using data abstracted from the Annual Health Sector Performance Reports for 2012/13, 2014/15 and 2016/17. Trends in technical efficiency was analysed using Excel while determinants of technical efficiency were analysed using Tobit Regression Model in STATA 15.1. Results The average constant returns to scale, variable returns to scale and scale efficiency of general hospitals for 2016/17 were 49% (95% CI, 44–54%), 69% (95% CI, 65–74%) and 70% (95% CI, 65–75%) respectively. There was no statistically significant difference in the efficiency scores of public and private hospitals. Technical efficiency generally increased from 2012/13 to 2014/15, and dropped by 2016/17. Some hospitals were persistently efficient while others were inefficient over this period. Hospital size, geographical location, training status and average length of stay were statistically significant determinants of efficiency at 5% level of significance. Conclusion The 69% average variable returns to scale technical efficiency indicates that the hospitals could generate the same volume of outputs using 31% (3439) less staff and 31% (3539) less beds. Benchmarking performance of the efficient hospitals would help to guide performance improvement in the inefficient ones. There is need to incorporate hospital size, geographical location, training status and average length of stay in the resource allocation formula and adopt annual hospital efficiency assessments

Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: Results of pre-COVID and COVID-19 lockdown stakeholder engagements

Introduction: With COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider access to healthcare before and during COVID-19 with those working and living in slum communities.Methods: In seven slums in Bangladesh, Kenya, Nigeria and Pakistan, we explored stakeholder perspectives and experiences of healthcare access for non-COVID-19 conditions in two periods: pre-COVID-19 and during COVID-19 lockdowns.Results: Between March 2018 and May 2020, we engaged with 860 community leaders, residents, health workers and local authority representatives. Perceived common illnesses in all sites included respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension. Pre-COVID, stakeholders described various preventive, diagnostic and treatment services, including well-used antenatal and immunisation programmes and some screening for hypertension, tuberculosis, HIV and vectorborne disease. In all sites, pharmacists and patent medicine vendors were key providers of treatment and advice for minor illnesses. Mental health services and those addressing gender-based violence were perceived to be limited or unavailable. With COVID-19, a reduction in access to healthcare services was reported in all sites, including preventive services. Cost of healthcare increased while household income reduced. Residents had difficulty reaching healthcare facilities. Fear of being diagnosed with COVID-19 discouraged healthcare seeking. Alleviators included provision of healthcare by phone, pharmacists/drug vendors extending credit and residents receiving philanthropic or government support; these were inconsistent and inadequate.Conclusion: Slum residents\u27 ability to seek healthcare for non-COVID-19 conditions has been reduced during lockdowns. To encourage healthcare seeking, clear communication is needed about what is available and whether infection control is in place. Policymakers need to ensure that costs do not escalate and unfairly disadvantage slum communities. Remote consulting to reduce face-to-face contact and provision of mental health and gender-based violence services should be considered

Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan : results of pre-COVID and COVID-19 lockdown stakeholder engagements

Abstract Introduction With COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider access to healthcare before and during COVID-19 with those working and living in slum communities. Methods In seven slums in Bangladesh, Kenya, Nigeria and Pakistan, we explored stakeholder perspectives and experiences of healthcare access for non-COVID-19 conditions in two periods: pre-COVID-19 and during COVID-19 lockdowns. Results Between March 2018 and May 2020, we engaged with 860 community leaders, residents, health workers and local authority representatives. Perceived common illnesses in all sites included respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension. Pre-COVID, stakeholders described various preventive, diagnostic and treatment services, including well-used antenatal and immunisation programmes and some screening for hypertension, tuberculosis, HIV and vectorborne disease. In all sites, pharmacists and patent medicine vendors were key providers of treatment and advice for minor illnesses. Mental health services and those addressing gender-based violence were perceived to be limited or unavailable. With COVID-19, a reduction in access to healthcare services was reported in all sites, including preventive services. Cost of healthcare increased while household income reduced. Residents had difficulty reaching healthcare facilities. Fear of being diagnosed with COVID-19 discouraged healthcare seeking. Alleviators included provision of healthcare by phone, pharmacists/drug vendors extending credit and residents receiving philanthropic or government support; these were inconsistent and inadequate. Conclusion Slum residents’ ability to seek healthcare for non-COVID-19 conditions has been reduced during lockdowns. To encourage healthcare seeking, clear communication is needed about what is available and whether infection control is in place. Policymakers need to ensure that costs do not escalate and unfairly disadvantage slum communities. Remote consulting to reduce face-to-face contact and provision of mental health and gender-based violence services should be considered

Pharmacies in informal settlements : a retrospective, cross-sectional household and health facility survey in four countries

Background Slums or informal settlements characterize most large cities in LMIC. Previous evidence suggests pharmacies may be the most frequently used source of primary care in LMICs but that pharmacy services are of variable quality. However, evidence on pharmacy use and availability is very limited for slum populations. Methods We conducted household, individual, and healthcare provider surveys and qualitative observations on pharmacies and pharmacy use in seven slum sites in four countries (Nigeria, Kenya, Pakistan, and Bangladesh). All pharmacies and up to 1200 households in each site were sampled. Adults and children were surveyed about their use of healthcare services and pharmacies were observed and their services, equipment, and stock documented. Results We completed 7692 household and 7451 individual adults, 2633 individual child surveys, and 157 surveys of pharmacies located within the seven sites. Visit rates to pharmacies and drug sellers varied from 0.1 (Nigeria) to 3.0 (Bangladesh) visits per person-year, almost all of which were for new conditions. We found highly variable conditions in what constituted a “pharmacy” across the sites and most pharmacies did not employ a qualified pharmacist. Analgesics and antibiotics were widely available but other categories of medications, particularly those for chronic illness were often not available anywhere. The majority of pharmacies lacked basic equipment such as a thermometer and weighing scales. Conclusions Pharmacies are locally and widely available to residents of slums. However, the conditions of the facilities and availability of medicines were poor and prices relatively high. Pharmacies may represent a large untapped resource to improving access to primary care for the urban poor

Pharmacies in informal settlements : a retrospective, cross-sectional household and health facility survey in four countries

Background Slums or informal settlements characterize most large cities in LMIC. Previous evidence suggests pharmacies may be the most frequently used source of primary care in LMICs but that pharmacy services are of variable quality. However, evidence on pharmacy use and availability is very limited for slum populations. Methods We conducted household, individual, and healthcare provider surveys and qualitative observations on pharmacies and pharmacy use in seven slum sites in four countries (Nigeria, Kenya, Pakistan, and Bangladesh). All pharmacies and up to 1200 households in each site were sampled. Adults and children were surveyed about their use of healthcare services and pharmacies were observed and their services, equipment, and stock documented. Results We completed 7692 household and 7451 individual adults, 2633 individual child surveys, and 157 surveys of pharmacies located within the seven sites. Visit rates to pharmacies and drug sellers varied from 0.1 (Nigeria) to 3.0 (Bangladesh) visits per person-year, almost all of which were for new conditions. We found highly variable conditions in what constituted a “pharmacy” across the sites and most pharmacies did not employ a qualified pharmacist. Analgesics and antibiotics were widely available but other categories of medications, particularly those for chronic illness were often not available anywhere. The majority of pharmacies lacked basic equipment such as a thermometer and weighing scales. Conclusions Pharmacies are locally and widely available to residents of slums. However, the conditions of the facilities and availability of medicines were poor and prices relatively high. Pharmacies may represent a large untapped resource to improving access to primary care for the urban poor

Analysis of OpenStreetMap data quality at different stages of a participatory mapping process : evidence from slums in Africa and Asia

This paper examines OpenStreetMap data quality at different stages of a participatory mapping process in seven slums in Africa and Asia. Data were drawn from an OpenStreetMap-based participatory mapping process developed as part of a research project focusing on understanding inequalities in healthcare access of slum residents in the Global South. Descriptive statistics and qualitative analysis were employed to examine the following research question: What is the spatial data quality of collaborative remote mapping achieved by volunteer mappers in morphologically complex urban areas? Findings show that the completeness achieved by remote mapping largely depends on the morphology and characteristics of slums such as building density and rooftop architecture, varying from 84 in the best case, to zero in the most difficult site. The major scientific contribution of this study is to provide evidence on the spatial data quality of remotely mapped data through volunteer mapping efforts in morphologically complex urban areas such as slums; the results could provide insights into how much fieldwork would be needed in what level of complexity and to what extent the involvement of local volunteers in these efforts is required

The prevalence and socio-demographic associations of household food insecurity in seven slum sites across Nigeria, Kenya, Pakistan, and Bangladesh. A cross-sectional study

Although the proportion of people living in slums is increasing in low- and middle-income countries and food insecurity is considered a severe hazard for health, there is little research on this topic. This study investigated and compared the prevalence and socio-demographic associations of household food insecurity in seven slum settings across Nigeria, Kenya, Pakistan, and Bangladesh. Data were taken from a cross-sectional, household-based, spatially referenced survey conducted between December 2018 and June 2020. Household characteristics and the extent and distribution of food insecurity across sites was established using descriptive statistics. Multivariable logistic regression of data in a pooled model including all slums (adjusting for slum site) and site-specific analyses were conducted. In total, a sample of 6,111 households were included. Forty-one per cent (2,671) of all households reported food insecurity, with varying levels between the different slums (9-69%). Household head working status and national wealth quintiles were consistently found to be associated with household food security in the pooled analysis (OR: 0·82; CI: 0·69-0·98 & OR: 0·65; CI: 0·57-0·75) and in the individual sites. Households which owned agricultural land (OR: 0·80; CI: 0·69-0·94) were less likely to report food insecurity. The association of the household head's migration status with food insecurity varied considerably between sites. We found a high prevalence of household food insecurity which varied across slum sites and household characteristics. Food security in slum settings needs context-specific interventions and further causal clarification