Health Systems Research / recherche sur les systèmes de santé

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    Action Research for the Health and Safety of Domestic Workers in Montreal: Using Numbers to Tell Stories and Effect Change
    (2010) Hanley, J; Premji, S; Messing, K; Lippel, K
    In 2007, a Filipina organization in Quebec (PINAY) sought the help of university researchers to document the workplace health and safety experiences of domestic workers. Together, they surveyed 150 domestic workers and produced a report that generated interest from community groups, policy-makers, and the media. In this article, we—the university researchers—offer a case study of community-university action research. We share the story of how one project contributed to academic knowledge of domestic workers' health and safety experiences and also to a related policy campaign. We describe how Quebec workers' compensation legislation excludes domestic workers, and we analyze the occupational health literature related to domestic work. Striking data related to workplace accidents and illnesses emerged from the survey, and interesting lessons were learned about how occupational health questions should be posed. We conclude with a description of the successful policy advocacy that was possible as an outcome of this project.
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    Community Health Workers’ Perspectives on Their Contribution to Rural Health and Well-Being in Iran
    (2011) Javanparast, S; Baum, F; Labonte, R; Sanders, D
    Objectives. The activities of community health workers (CHWs) have been identified as key to improvements in the health of Iran's rural population. We explored the perceptions of CHWs regarding their contribution to rural health in Iran. Methods. Three research assistants familiar with the Iranian primary health care network conducted face-to-face interviews with CHWs in 18 provinces in Iran. Results. Findings showed that Iranian CHWs have an in-depth understanding of health, including its social determinants, and are responsible for a wide range of activities. Respondents reported that trust-based relationships with rural communities, an altruistic motivation to serve rural people, and sound health knowledge and skills are the most important factors facilitating successful implementation of the CHW program in Iran. By contrast, high workload and the lack of a support system were mentioned as barriers to effective performance. Conclusions. The CHW program in Iran is a compelling example of comprehensive primary health care, in that CHWs provide basic health care but also work with community members and other sectors to address the social determinants of health.
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    Policy review of the community health worker programme in Iran
    (2011) Javanparast, S.; Baum, F.; Labonte, R.; Sanders, D.; Heidari, G.
    Iran's Community Health Worker (CHW) programme survived as an integral element of the health system during a period when many other nations’ CHW programmes collapsed and therefore warrants detailed analysis of the policies supporting the programme. We draw on a wide range of information about the Iranian programme and from this analysis draw important lessons on how to improve rural population health outcomes through Primary Health Care.
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    Inequities in access to health care in South Africa
    (2011) Harris, B; Goudge, J; Ataguba, John; McIntyre, D; Nxumalo, N
    Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n=4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.
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    Access to health care services - an English policy perspective
    (2009) Goddard, M
    International trends highlight the confluence of economics, politics and legal considerations in the health policy process. Health Economics, Policy and Law serves as a forum for scholarship on health policy issues from these perspectives, and is of use to academics, policy makers and health care managers and professionals. HEPL is international in scope, publishes both theoretical and applied work, and contains articles on all aspects of health policy. Considerable emphasis is placed on rigorous conceptual development and analysis, and on the presentation of empirical evidence that is relevant to the policy process.
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    Challenges in developing community mental health services in Sri Lanka
    (2009) Fernando, S; Weerackody, C
    There are several issues to be faced in developing mental health services in South Asia if they are to be culturally and socially appropriate to the needs of the communities in the region. The meanings of mental health relevant to culturally appropriate service development can be obtained by exploring local notions of well-being, systems of care available to people and current practices among those seeking help for mental health problems. Participatory research carried out in communities in Sri Lanka affected by prolonged armed conflict and by the 2004 tsunami clarified the nature of well-being as perceived by communities themselves. Subsequent development of mental health services for Sri Lanka can be based on community consultation, using methodologies and interventions that involve the participation of the communities and their local institutions, and adapting relevant western approaches to the Sri Lankan context.
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    Eliciting policymakers’ and stakeholders’ opinions to help shape health system research priorities in the Middle East and North Africa region
    (2010) El-Jardali, F; Makhoul, J; Jamal, D; Ranson, M K; Kronfol, N M
    Evidence-informed decisions can strengthen health systems. Literature suggests that engaging policymakers and other stakeholders in research priority-setting exercises increases the likelihood of the utilization of research evidence by policymakers. To our knowledge, there has been no previous priority-setting exercise in health policy and systems research in countries of the Middle East and North Africa (MENA) region. This paper presents the results of a recent research priority-setting exercise that identified regional policy concerns and research priorities related to health financing, human resources and the non-state sector, based on stakeholders in nine low and middle income countries (LMICs) of the MENA region. The countries included in this study were Algeria, Egypt, Jordan, Lebanon, Morocco, Palestine, Syria, Tunisia and Yemen. This multi-phased study used a combination of qualitative and quantitative research techniques. The overall approach was guided by the listening priority-setting approach, adapted slightly to accommodate the context of the nine countries. The study was conducted in four key phases: preparatory work, country-specific work, data analysis and synthesis, and validation and ranking. The study identified the top five policy-relevant health systems research priorities for each of the three thematic areas for the next 3–5 years. Study findings can help inform and direct future plans to generate, disseminate and use research evidence for LMICs in the MENA region. Our study process and results could help reduce the great chasm between the policy and research worlds in the MENA region. It is hoped that funding agencies and countries will support and align financial and human resources towards addressing the research priorities that have been identified.
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    Unequal access to ART: exploratory results from rural and urban case studies of ART use
    (2011) Cleary, S M; Birch, S; Moshabela, M; Schneider, H
    Introduction: South Africa has the world's largest antiretroviral treatment (ART) programme. While services in the public sector are free at the point of use, little is known about overall access barriers. This paper explores these barriers from the perspective of ART users enrolled in services in two rural and two urban settings. Methods: Using a comprehensive framework of access, interviews were conducted with over 1200 ART users to assess barriers along three dimensions: availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between sites were explored using multivariate linear and logistic regressions.Results: While availability access barriers in rural settings were found to be mitigated through a more decentralised model of service provision in one site, affordability barriers were considerably higher in rural versus urban settings. 50% of respondents incurred catastrophic healthcare expenditure and 36% borrowed money to cover these expenses in one rural site. On acceptability, rural users were less likely to report feeling respected by health workers. Stigma was reported to be lowest in the two sites with the most decentralised services and the highest coverage of those in need. Conclusions: While results suggest inequitable access to ART for rural relative to urban users, nurse-led services offered through primary healthcare facilities mitigated these barriers in one rural site. This is an important finding given current policy emphasis on decentralised and nurse-led ART in South Africa. This study is one of the first to present comprehensive evidence on access barriers to assist in the design of policy solutions.
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    Equity in the use of antiretroviral treatment in the public health care system in urban South Africa
    (2010) Cleary, S; Silal, S; Birch, S; Carrara, H; Pillay-Van Wyk, V
    Objectives: The scaling up of antiretroviral treatment (ART) for HIV-infected adults requires a sizeable investment of resources in the South African public health care system. It is important that these resources are used productively and in ways that reach those in need, irrespective of social status or personal characteristics. In this study we evaluate whether the distribution of ART services in the public system reflects the distribution of need among adults in the urban population. Methods: Data from a 2008 national survey were used to estimate the distribution of socioeconomic status (SES) and sex in HIV-positive adults in urban areas. These findings were compared to SES and sex distributions in 635 ART users within 6 urban public ART facilities. Results: Close to 40% of those with HIV are in the lowest SES quintile, while 67% are women. The distributions in users of ART are similar to these distributions in HIV-positive people. Conclusions: Patterns of ART use in study settings correspond to patterns of HIV in the urban population at the national level. This suggests that the South African ART programme is on track to ensure equitable delivery of treatment services in urban settings.
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    Disability management experts and the impact of jurisdiction on practice: an Ontario example
    (2010) Bernhard, Dörte; MacEachen, Ellen; Lippel, Katherine
    Introduction: The role, tasks and competencies of disability management professionals (DMPs) have increasingly become a focus of research in the last decade. However, the legal context in which DMPs work, how this affects their daily practice, and how this impacts their training curricula, has been neglected. This omission is problematic given that international training programs of disability management (DM) operate across different jurisdictions. Our study describes DMPs' practice in Ontario, Canada and considers jurisdiction-specific elements of disability management practice. Methods: The study is based on seven interviews and a focus group with five participants, who are either certified disability management professionals or who are involved with DMPs' training, as well as documentary analysis of the legal context of these professionals' practice. Results: The study shows how DMPs' practice is affected by the local legal context. The jurisdiction's socio-political framework requires DMPs to distinguish between occupational and non-occupational cases, a distinction which affects their practice and their recommendations to employers. This is in contrast to DM training which emphasises equal treatment of all people with disabilities. Conclusions: The research suggests that disability management practices may differ from one jurisdiction to the next and therefore emphasises the need to consider socio-political aspects in DMPs' practice as well as in the development of training programmes and cross-jurisdictional research.
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    Law of Workplace Bullying: an international overview
    (2010) Lippel, Katherine
    This issue brings together eight contributions from legal scholars and specialists in workplace bullying from four continents, who report on the state of the law governing a specific form of workplace abuse alternatively described as workplace bullying, psychological harassment, moral harassment, victimization, or mobbing.
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    Primary eye care in sub-Saharan African: do we have the evidence needed to scale up training and service delivery?
    (2010) Courtright, P; Seneadza, A; Mathenge, W; Eliah, E; Lewallen, S
    The models for addressing the delivery of an eye-care service in sub-Saharan Africa have seen considerable revision in the last 30 years, and the on-going challenges, as well as the future needs, will probably require many more changes and new systems. There is a need to assess the different models that are currently employed, in order to ensure that all potential contributions to the elimination of avoidable blindness are used; the evolving concept of primary eye care (PEC) requires such assessment. For the current review, the published literature on eye care provided by general front-line healthworkers was screened for articles that provided evidence of the impact of such PEC on the general delivery of eye care in sub-Saharan Africa. Of the 103 relevant articles detected, only three provided evidence of the effectiveness of PEC and the authors of all three of these articles suggested that such eye care was not meeting the needs or expectations of the target populations, the trainers, or programmes of eye care. Among the main problems identified were a lack of a clear definition of the scope of practice for PEC, the need for clarifying the specific skills that a front-line healthworker could perform correctly, and the changing needs and expectations for the delivery of an eye-care service in Africa. If PEC is to become adequately grounded in Africa, the generation of further evidence of the effectiveness and limitations of such care would be a prudent move.
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    Access as a policy-relevant concept in low- and middle-income countries
    (2009) McIntyre, D; Thiede, M; Birch, S
    Although access to health care is frequently identified as a goal for health care policy, the precise meaning of access to health care often remains unclear. We present a conceptual framework that defines access to health care as the empowerment of an individual to use health care and as a multidimensional concept based on the interaction (or degree of fit) between health care systems and individuals, households, and communities. Three dimensions of access are identified: availability, affordability, and acceptability, through which access can be evaluated directly instead of focusing on utilisation of care as a proxy for access. We present the case for the comprehensive evaluation of health care systems as well as the dimensions of access, and the factors underlying each dimension. Such systemic analyses can inform policy-makers about the ‘fit’ between needs for health care and receipt of care, and provide the basis for developing policies that promote improvements in the empowerment to use care.
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    Multi-faceted approach to promote knowledge translation platforms in eastern Mediterranean countries: climate for evidence-informed policy
    (2012-05) El-Jardali, Fadi; Ataya, Nour; Jamal, Diana; Jaafar, Maha
    Senior policymakers, stakeholders and researchers from Algeria, Bahrain, Egypt, Iran, Jordan, Lebanon, Oman, Sudan, Syria, Tunisia, and Yemen participated in this study. Despite the complexity of policymaking processes in countries from this region, the absence of a structured process for decision making, and the limited engagement of policymakers and researchers in knowledge translation (KT) activities, there are windows of opportunity for moving towards more evidence informed policymaking. A recurring positive theme was the development of new national strategic plans. Findings emphasized the complexity of policymaking. Donors, political regimes, economic goals and outdated laws were identified as key drivers.