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Background: This paper discusses the stages of health system resilience (HSR) and the factors underlying differences in HSR during the covid-19 pandemic, especially the vaccination challenge. We studied the relationship between vaccination strategies and macro-context backgrounds in 21 Latin American countries. Our objective was to capture the impact of those aspects in the SR and identify potential improvements for future crises and for vaccination programs in general. Methods: The study uses mixed-methods research to provide insights into how the countries' backgrounds and vaccination strategies impact the HSR. Particularly, we used explanatory sequential mixed methods, which entails a quantitative-qualitative two-phase sequence. The quantitative phase was conducted using cluster and variance analysis, in which the HSR was measured using as a proxy the covid-19 vaccination outcomes in three cut-offs of reaching 25%, 50%, and 75% of population coverage. This approach allows us to discriminate covid-19 vaccination progress by stages and contrast it to the qualitative stage, in which we performed a country-case analysis of the background conditions and the changes in vaccination strategies that occurred during the corresponding dates. Results: The paper provides a rich comparative case analysis of countries, classifying them by early, prompt, and delayed performers. The results show that differences in vaccination performance are due to flexibility in adapting strategies, cooperation, and the ability to design multilevel solutions that consider the needs of various actors in the health ecosystem. These differences vary depending on the vaccination stage, which suggests the importance of acknowledging learning, diffusion, and feedback processes at the regional level. Conclusions: We identified the importance of societal well-being as an ideal country antecedent for high and sustained levels of performance in covid-19 vaccination. Whereas in other countries where the set-up and beginning phases were rough, the value of the operational decisions and the learning on the move regarding their own and their peers' trajectories were crucial and were reflected in performance improvement. A contribution of this study is that the above-mentioned analysis was done using vaccination coverage cut-off points that allow a performance view that takes into consideration the stages of the vaccination progress and the learning process that goes with it. As well as framing this into the HSR shock cycles that allow to differentiate the stages of resilience on which countries must act. [ABSTRACT FROM AUTHOR]

Background: In Guatemala, Indigenous women have a maternal mortality ratio over twice that of non-Indigenous women. Long-standing marginalization of Indigenous groups and three decades of civil war have resulted in persistent linguistic, economic, cultural, and physical barriers to maternity care. Curamericas/Guatemala facilitated the development of three community-built, -owned, and -operated birthing centers, Casas Maternas Rurales (referred to here as Community Birthing Centers), where auxiliary nurses provided physically accessible and culturally acceptable clinical care. The objective of this paper is to assess the management of complications and the decision-making pathways of Birthing Center staff for complication management and referral. This is the sixth paper in the series of 10 articles. Birthing centers are part of the Expanded Census-based, Impact-oriented Approach, referred to as CBIO+. Methods: We undertook an explanatory, mixed-methods study on the handling of pregnancy complications at the Birthing Centers, including a chart review of pregnancy complications encountered among 1,378 women coming to a Birthing Center between 2009 and 2016 and inductively coded interviews with Birthing Center staff. Results: During the study period, 1378 women presented to a Birthing Center for delivery-related care. Of the 211 peripartum complications encountered, 42.2% were successfully resolved at a Birthing Center and 57.8% were referred to higher-level care. Only one maternal death occurred, yielding a maternal mortality ratio of 72.6 maternal deaths per 100,000 live births. The qualitative study found that staff attribute their successful management of complications to frequent, high-quality trainings, task-shifting, a network of consultative support, and a collaborative atmosphere. Conclusion: The Birthing Centers were able to resolve almost one-half of the peripartum complications and to promptly refer almost all of the others to a higher level of care, resulting in a maternal mortality ratio less than half that for all Indigenous Guatemalan women. This is the first study we are aware of that analyzes the management of obstetrical complications in such a setting. Barriers to providing high-quality maternity care, including obtaining care for complications, need to be addressed to ensure that all pregnant women in such settings have access to a level of care that is their fundamental human right. [ABSTRACT FROM AUTHOR]

Background: Health inequalities are persistent and widening with transformative policy change needed. Radically shifting policy to tackle upstream causes of inequalities is likely to require public participation to provide a mandate, evidence and to address questions of co-design, implementation and acceptability. The aim of this paper is to explore perceptions among policy actors on why and how the public should be involved in policymaking for health inequalities. Methods: In 2019–2020, we conducted exploratory, in-depth, semi-structured interviews with 21 Scottish policy actors from a range of public sector bodies and agencies and third sector organisations that work in, or across, health and non-health sectors. Data were analysed thematically and used to examine implications for the development of participatory policymaking. Results: Policy actors viewed public participation in policymaking as intrinsically valuable for democratic reasons, but the main, and more challenging, concern was with how it could affect positive policy change. Participation was seen as instrumental in two overlapping ways: as evidence to improve policies to tackle health inequalities and to achieve public acceptance for implementing more transformative policies. However, our analysis suggests a paradox: whilst policy actors place importance on the instrumental value of public participation, they simultaneously believe the public hold views about health inequalities that would prevent transformative change. Finally, despite broad agreement on the need to improve public participation in policy development, policy actors were uncertain about how to make the necessary changes due to conceptual, methodological and practical challenges. Conclusions: Policy actors believe in the importance of public participation in policy to address health inequalities for intrinsic and instrumental reasons. Yet, there is an evident tension between seeing public participation as a route to upstream policies and a belief that public views might be misinformed, individualistic, short-term or self-interested and doubts about how to make public participation meaningful. We lack good insight into what the public think about policy solutions to health inequalities. We propose that research needs to shift from describing the problem to focusing more on potential solutions and outline a potential way forward to undertake effective public participation to tackle health inequalities. [ABSTRACT FROM AUTHOR]

Background: This paper uses the concepts of organisational culture and organisational trust to explore the Implementation of equity-oriented policies -- the Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems' people-centeredness and "software". Methods: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. Results: Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Conclusions: Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected. [ABSTRACT FROM AUTHOR]

Background: Equity and justice in healthcare payment form an integral part of health policy and planning. In the majority of low and middle-income countries (LMICs), healthcare inequalities are further aggravated by Out of Pocket Expenditure (OOPE). This paper examines the pattern of health equity and regional disparities in healthcare spending among Indian states by applying Andersen's behavioural model of healthcare utilization. Methods: The present study uses data from the 66th quinquennial round of Consumer Expenditure Survey, of the National Sample Survey Organization (NSSO), conducted in 2009-10 by Ministry of Statistics and Programme Implementation (MoSPI), Government of India (GoI). To measure equity and regional disparities in healthcare expenditure, states have been categorized under three heads on the basis of monthly OOPE i.e., Category A (OOPE > =INR 100); Category B (OOPE between INR 50 to 99) and Category C (OOPE < INR 50). Multiple Generalised Linear Regression Model (GLRM) has been employed to explore the effect of various socio-economic covariates on the level of OOPE. Results: The gap in the ratio of average healthcare spending between the poorest and richest households was maximum in Category A states Category B (richest/poorest = 14.60), followed by (richest/poorest 11.70) and Category C (richest/poorest 11.40). Results also indicate geographical concentration of lower level healthcare spending among Indian states (e.g., Odisha, Chhattisgarh and all the north-eastern states). Results from the multivariate analysis suggest that people residing in urban areas, having higher economic status, belonging to non-Muslim communities, non-Scheduled Tribes (STs), and non-poor households spend more on healthcare than their counterparts. Conclusions: In spite of various efforts by the government to reduce the burden of healthcare spending, widespread inequalities in healthcare expenditure are prevalent. Households with high healthcare needs (SCs/STs, and the poor) are in a more disadvantaged position in terms of spending on health care. It has also been observed that spending on healthcare was comparatively lower among backward or isolated states. No doubt, the overall social security measures should be enhanced, but at the same time, looking at the regional differences, more priority should be assigned to the disadvantaged states to reduce the burden of OOPE. It is proposed that there is need to increase government spending, especially for the disadvantaged states and population, to minimise the burden of OOPE. [ABSTRACT FROM AUTHOR]

Background: Geographical distribution of healthcare resources is an important dimension of healthcare access. Little work has been published on healthcare resource allocation patterns in China, despite public equity concerns. Methods: Using national data from 2043 counties, this paper investigates the geographic distribution of hospital beds at the county level in China. We performed Gini coefficient analysis to measure inequalities and ordinary least squares regression with fixed provincial effects and additional spatial specifications to assess key determinants. Results: We found that provinces in west China have the least equitable resource distribution. We also found that the distribution of hospital beds is highly spatially clustered. Finally, we found that both county-level savings and government revenue show a strong positive relationship with county level hospital bed density. Conclusions: We argue for more widespread use of disaggregated, geographical data in health policy-making in China to support the rational allocation of healthcare resources, thus promoting efficiency and equity. [ABSTRACT FROM AUTHOR]

Introduction The health of Indigenous Australians is worse than that of other Australians. Most of the determinants of health are preventable and the poor health outcomes are inequitable. The Australian Government recently pledged to close that health gap. One possible way is to improve the priority setting process to ensure transparency and the use of evidence such as epidemiology, equity and economic evaluation. The purpose of this research was to elicit the perceptions of Indigenous and non-Indigenous decision-makers on several issues related to priority setting in Indigenous-specific health care services. Specifically, we aimed to: 1. identify the criteria used to set priorities in Indigenous-specific health care services; 2. determine the level of uptake of economic evaluation evidence by decision-makers and how to improve its uptake; and 3. identify how the priority setting process can be improved from the perspective of decisionmakers. Methods We used a paper survey instrument, adapted from Mitton and colleagues' work, and a faceto- face interview approach to elicit decision-makers' perceptions in Indigenous-specific health care in Victoria, Australia. We used mixed methods to analyse data from the survey. Responses were summarised using descriptive statistics and content analysis. Results were reported as numbers and percentages. Results The size of the health burden; sustainability and acceptability of interventions; historical trends/patterns; and efficiency are key criteria for making choices in Indigenous health in Victoria. There is a need for an explicit priority setting approach, which is systematic, and is able to use available data/evidence, such as economic evaluation evidence. The involvement of Indigenous Australians in the process would potentially make the process acceptable. Conclusions An economic approach to priority setting is a potentially acceptable and useful tool for Aboriginal Community Controlled Health Services (ACCHS). It has the ability to use evidence and ensure due process at the same time. The use of evidence can ensure that health outcomes for Indigenous peoples can be maximised - hence, increase the potential for 'closing the gap' between Indigenous and other Australians. [ABSTRACT FROM AUTHOR]

Introduction Access to quality maternal health services mainly depends on existing policies, regulations, skilled and knowledge, perceptions, and economic power and motivation of service givers and target users. Critics question policy recommending involvement of traditional birth attendants (TBAs) in emergency obstetric care (EmoC) services in developing countries. Objectives This paper reports about knowledge and practices of TBAs on EmoC in Kigoma Rural District, Tanzania and discusses policy implications on involving TBAs in maternal health services. Methods 157 TBAs were identified from several villages in 2005, interviewed and observed on their knowledge and practice in relation to EmoC. Quantitative and qualitative techniques were used for data collection and analysis depending on the nature of the information required. Findings Among a total of 157 TBAs approached, 57.3% were aged 50+ years while 50% had no formal education. Assisting mothers to deliver without taking their full pregnancy history was confessed by 11% of all respondents. Having been attending pregnant women with complications was experienced by 71.2% of all respondents. Only 58% expressed adequate knowledge on symptoms and signs of pregnancy complications. Lack of knowledge on possible risk of HIV infections while assisting childbirth without taking protective gears was claimed by 5.7% of the respondents. Sharing the same pair of gloves between successful deliveries was reported to be a common practice by 21.1% of the respondents. Use of unsafe delivery materials including local herbs and pieces of cloth for protecting themselves against HIV infections was reported as being commonly practiced among 27.6% of the respondents. Vaginal examination before and during delivery was done by only a few respondents. Conclusion TBAs in Tanzania are still consulted by people living in underserved areas. Unfortunately, TBAs' inadequate knowledge on EmOC issues seems to have contributed to the rising concerns about their competence to deliver the recommended maternal services. Thus, the authorities seeming to recognize and promote TBAs should provide support to TBAs in relation to necessary training and giving them essential working facilities, routine supportive supervision and rewarding those seeming to comply with the standard guidelines for delivering EmoC services. [ABSTRACT FROM AUTHOR]

Introduction: Research on the intimate partnerships of female sex workers (FSWs) tends to focus on the risks associated with these relationships. This paper takes as its starting point that the situation of FSWs is better understood by including knowledge of the benefits of their intimate partnerships. Specifically, we employ the conceptual framework provided by emergent research examining intimacy as a complex fusion of affective and instrumental dimensions among sex workers. This perspective allows us to frame information about FSWs' intimate partnerships within a behaviour-structural approach that is helpful for identifying how intimate partnerships can be a source of both benefit as well as increased risk to FSWs. Methods: Our results are based on a mixed-methods study carried out in the summer of 2011 in Kibera, Kenya. We conducted face-to-face interviews (n=30) with a non-probability sample of FSWs stratified by age who self-identified as Human Immune Virus positive (HIV+). We asked about participants' involvement in current and past intimate partnerships, and whether these relationships had a positive or negative impact on their health and well?being. Results: Participants currently in intimate partnerships had fewer clients and thus lower incomes than those without intimate partnerships. Participants presently with partners were also more likely to receive some financial support from partners, to report lower intimate partner violence, and to narrate higher partner emotional support and greater assistance with medications. These participants were also more likely to have disclosed their sex work and HIV+ statuses to their partners. Intimate partnerships, on the other hand, showed increased risk of economic vulnerability and emotional dependence for FSWs. This became especially problematic for those participants in fragile relationships. Despite these variations, none of the differences between the two groups were statistically significant. Conclusions: Intimacy and transactional relations are bound up with one another and intersect with the structural realities and vulnerabilities; this is the case for sex workers in well-resourced and resourced-constrained countries alike. Rather than treating intimate partnerships as distinct from transactional relationships, FSWs' relationships should be viewed on a continuum of risk and support. [ABSTRACT FROM AUTHOR]

Introduction: The prevalence of undernutrition, which is closely associated with socioeconomic and sanitation conditions, is often higher among indigenous than non-indigenous children in many countries. In Brazil, in spite of overall reductions in the prevalence of undernutrition in recent decades, the nutritional situation of indigenous children remains worrying. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first study to evaluate a nationwide representative sample of indigenous peoples. This paper presents findings from this study on the nutritional status of indigenous children < 5 years of age in Brazil. Methods: A multi-stage sampling was employed to obtain a representative sample of the indigenous population residing in villages in four Brazilian regions (North, Northeast, Central-West, and Southeast/South). Initially, a stratified probabilistic sampling was carried out for indigenous villages located in these regions. Households in sampled villages were selected by census or systematic sampling depending on the village population. The survey evaluated the health and nutritional status of children < 5 years, in addition to interviewing mothers or caretakers. Results: Height and weight measurements were taken of 6,050 and 6,075 children, respectively. Prevalence rates of stunting, underweight, and wasting were 25.7%, 5.9%, and 1.3%, respectively. Even after controlling for confounding, the prevalence rates of underweight and stunting were higher among children in the North region, in low socioeconomic status households, in households with poorer sanitary conditions, with anemic mothers, with low birthweight, and who were hospitalized during the prior 6 months. A protective effect of breastfeeding for underweight was observed for children under 12 months. Conclusions: The elevated rate of stunting observed in indigenous children approximates that of non-indigenous Brazilians four decades ago, before major health reforms greatly reduced its occurrence nationwide. Prevalence rates of undernutrition were associated with socioeconomic variables including income, household goods, schooling, and access to sanitation services, among other variables. Providing important baseline data for future comparison, these findings further suggest the relevance of social, economic, and environmental factors at different scales (local, regional, and national) for the nutritional status of indigenous peoples. [ABSTRACT FROM AUTHOR]

Introduction: The residents of many Australian rural and remote communities do not have the essential infrastructure and services required to support healthy living conditions and community members choosing healthy lifestyle options. Improving these social determinants of health is seen to offer real opportunities to improve health among such disadvantaged populations. In this paper, we describe the development and trialling of a tool to measure, monitor and evaluate key social determinants of health at community level. Methods: The tool was developed and piloted through a multi-phase and iterative process that involved a series of consultations with community members and key stakeholders and trialling the tool in remote Indigenous communities in the Northern Territory of Australia. Results: The indicators were found to be robust, and by testing the tool on a number of different levels, face validity was confirmed. The scoring system was well understood and easily followed by Indigenous and non-Indigenous study participants. A facilitated small group process was found to reduce bias in scoring of indicators. Conclusion: The Healthy Community Assessment Tool offers a useful vehicle and process to help those involved in planning, service provision and more generally promoting improvements in community social determinants of health. The tool offers many potential uses and benefits for those seeking to address inequities in the social determinants of health in remote communities. Maximum benefits in using the tool are likely to be gained with cross-sector involvement and when assessments are part of a continuous quality improvement program. [ABSTRACT FROM AUTHOR]

Introduction: Indigenous Australians experience more aggressive cancers and higher cancer mortality rates than other Australians. Cancer patients undergoing treatment are likely to access health services (e.g. social worker, cancer helpline, pain management services). To date Indigenous cancer patients' use of these services is limited. This paper describes the use of health services by Indigenous cancer patients. Methods: Indigenous cancer patients receiving treatment were recruited at four major Queensland public hospitals (Royal Brisbane Women's Hospital, Princess Alexandra, Cairns Base Hospital and Townsville Hospital). Participants were invited to complete a structured questionnaire during a face-to-face interview which sought information about their use of community and allied health services. Results: Of the 157 patients interviewed most were women (54.1%), of Aboriginal descent (73.9%), lived outer regional areas (40.1%) and had a mean age of 52.2 years. The most frequent cancer types were breast cancer (22.3%), blood related (14.0%), lung (12.1%) and gastroenterological (10.8%). More than half of the participants reported using at least one of the 'Indigenous Health Worker/Services' (76.4%), 'Allied Health Workers/Services' (72.6%) and 'Information Sources' (70.7%). Younger participants 19-39 years were more likely to use information sources (81.0%) than older participants who more commonly used community services (48.8%). The cancer patients used a median of three health services groups while receiving cancer treatment. Conclusions: Indigenous cancer patients used a range of health services whilst receiving treatment. Indigenous Health Workers/Services and Allied Health Workers/Services were the most commonly used services. However, there is a need for further systematic investigation into the health service utilization by Indigenous cancer patients. [ABSTRACT FROM AUTHOR]

Background: Health is recognized as a fundamental right in Brazil's constitution. In the absence of a clearly defined benefit packages of healthcare services that are financed under the Unified Health System (Sistema Único de Saúde, SUS), courts have become important in adjudicating coverage decisions. Empirical assessments of equity and the right to health tend to focus on simple measures of access. However, these empirical perspectives belie the significant inequalities and rights violations that arise in the case of more complex health needs such as cancer. To shed light on these issues, this paper focuses on the care pathways for breast and cervical cancer and explores access and quality issues that arise at different points along the care pathway with implications for the realization of the right to health in Brazil. Method: A mixed method approach is used. The analysis is primarily based on a quantitative analysis of national representative administrative data principally from the cervical and breast cancer information systems and the hospital cancer registry. To gain more insights into the organization of cancer care, qualitative data was collected from the state of Bahia, through document analysis, direct observation, roundtable discussions with health workers (HWs), and structured interviews with health care administrators. Results: The paper reveals that the volume of completed screening exams is well below the estimated need, and a tendency toward lower breast cancer screening rates in poorer states and for women in the lowest income brackets. Only 26% of breast cancer cases and 29% of cervical cancer cases are diagnosed at an early stage (stage 0 or I), thereby reducing the survival prospects of patients. Waiting times between confirmed diagnosis and treatment are long, despite new legislation that guarantees a maximum of 60 days. The waiting times are significantly longer for patients that follow the recommended patient pathways, and who are diagnosed outside the hospital. Conclusion: The study reveals that there are large variations between states and patients, where the poorest states and patients fare worse on key indicators. More broadly, the paper shows the importance of collecting data both on patient characteristics and health system performance and carry out detailed health system analysis for exposing, empirically, rights violations and for identifying how they can be addressed. [ABSTRACT FROM AUTHOR]