Background: Sub-Saharan African country governments face challenges building robust health systems that can deliver essential and routine care consistently and well. Alongside the financial, logistical, and clinical challenges of delivering evidence-based interventions, planners and policymakers are increasingly pressed to be more responsive to stakeholders’ values and preferences in their decisionmaking. For example, mortality from postpartum hemorrhage can be prevented and treated with uterotonic drugs; however, Kenyan stakeholders may disagree how best to strategically address threats to availability, safety, and effectiveness of providing these life-saving medicines. A national community-based health program could deliver essential services where skilled health workers are scarce in Tanzania; however, community health workers, the government, and beneficiaries may value the program’s essential characteristics differently, including worker compensation, supervisory structures, training approaches to encourage retention, and which populations will be served. Systematically assessing preferences and priorities can be a valuable tool for health systems planners and policymakers for incorporating stakeholder voices into health programs.
Objectives: Characterize the range of quantitative stated-preference methods applications and approaches to health systems problems in sub-Saharan Africa through a systematic review of the scientific literature (Chapter 3); apply both qualitative and quantitative methods to two health systems problems in sub-Saharan Africa, 1) identify and prioritize strategies to promote uterotonic security in Kenya (Chapter 4); and 2) to identify, assess, and compare factors affecting stakeholders’ preferences for a national community-based health program throughout Tanzania (Chapter 5).
Methods: Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-offs (Chapter 3). Two studies were undertaken. In Kenya, key informants were interviewed to identify potential strategic focal areas to improve uterotonic security. Priorities were assessed among national stakeholders using conjoint analysis. Survey responses were regressed using a linear probability model (Chapter 4). In Tanzania, qualitative research engaging community health workers, governing authorities, and recent clients in four districts in Morogoro Region identified potential program characteristics. Experts were engaged to refine the experiment to align with current policy concerns. Preferences were elicited from community health workers, their governing authorities, and community members throughout Morogoro Region using best-worst scaling techniques. Preference estimates were generated using mixed logit regression (Chapter 5).
Results: Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based. Trade-offs fell into six health systems “building blocks:” service features (n=27), workforce incentives (n=17), product features (n=14), system priorities (n=14), insurance features (n=4), and research priorities (n=1). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Steps for attribute development were generally well described, and frequently included qualitative research (n=50, 65%). In Kenya, 23 informants were interviewed and 11 strategic focal areas were identified: polices and regulations, finance, advocacy and leadership, coordination, health supplies, human resource development, monitoring and evaluation, pharmaceutical quality assurance, service delivery, supply chain strengthening, and provider awareness. Survey respondents (n=66) included maternal health and pharmaceutical commodity experts from government, the public and private sectors. Pharmaceutical quality assurance (p<0.01) and supply chain strengthening (p<0.05) were the most prioritized areas. In Tanzania, interviews (community health workers, n=18; governing authorities, n=34) and discussions (client groups, n=8) yielded 19 potential program characteristics. Six attributes with three levels each were pre-tested and refined: incentives, supervision, eligibility, selection for training, services, and service venue. All survey respondents (community health workers (n=108), governing authorities (n=109), and community members (n=225) favored a community-based health program that provides a set salary (p<0.001), a package of services for the whole family (p<0.001), and disfavored requiring a Form 4 education (p<0.001). Governing authorities and community members preferred community health workers were bonded to service after training (p<0.001), while community health workers as a group were ambivalent.
Conclusions: Published stated-preference methods applications on sub-Saharan Africa health systems problems concerned primary health care for women, prevention and treatment of infectious diseases, and workforce development. Fewer studies concerned non-communicable diseases. In both the Kenya and Tanzania studies, a mixed methods approach demonstrated that identifying, assessing, and also comparing priorities using conjoint analysis or preferences using best-worst scaling techniques could be improved through qualitative research, pre-tests with relevant study audiences, and consultation with experts. Survey results from Kenya favor a uterotonic security strategy that emphasizes pharmaceutical quality assurance and supply chain strengthening above all other areas, reflecting ongoing concerns for both the quality and quantity of uterotonic drugs delivered. The national government should engage county governments to identify compatible priorities and consider lessons learned from commodity security approaches for national HIV/AIDS, malaria, childhood immunization, and family planning programs. Survey results from Tanzania suggest similar preferences among the three stakeholder groups that provide for a community-based health program that provides a regular salary to community health workers, does not require community health workers to have a Form 4 education, provides more comprehensive services in public fora and client homes. Our findings provide a consistent picture of stakeholder preferences and clear guidance to health policymakers and planners to implement a national, community-based health program in Tanzania
