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Social inequalities are intensifying globally and widening divisions are linked to civil unrest. Disadvantaged ethnic and religious groups experience poor access to, representation in and outcomes from public services such as healthcare and education. As mechanisms for social participation and citizenship, public services are key to inclusive and sustainable societies. In this paper we present results of a systematic review on strategies for the inclusion of minority ethnic and religious communities, often neglected populations in term of sustainable development activity. We focus on four public service areas: education, health, local government and police services and identify evidence gaps. Our overall aim is to raise awareness and provoke debate, reflection and subsequently action towards the inclusion of disadvantaged ethnic and religious minorities within public services. Public service inclusion strategies were identified through a global evidence review and four country specific reviews conducted by the Socially Inclusive Cities Network – academics, NGOs, policy – makers and practitioners from India, Kenya, Nigeria, Vietnam and the UK. Published evidence was supplemented by country-based and international workshops involving over 230 relevant stakeholders. We specifically explored intersectional experience relating to gender, age and migration status. 56 publications were identified for the global review, mostly in health and education. Macro (social and political), meso (institutional) and micro (individual) arena were identified as three distinct but interconnected levels through which exclusion is operationalized. Three overarching frameworks appeared key to successful ethnic and religious inclusion initiatives: accounting for social context; multiple strategies for system reform; and collaboration with disadvantaged communities. Inclusion strategies that address macro, meso and micro level drivers of exclusion are needed to achieve the aspirations of SDG 10. Involving affected communities is key to their success. more...

This study examines perceptions of institutional delivery among married couples and older women in the Tangkhul Nagas tribe living in two villages of Ukhrul district Manipur India. One village has a Primary Health Center with good road connectivity only 25 kilometers from the capital city of Manipur. The other village is located in an isolated area of the hilly region with no modern amenities or infrastructure. The nearest health facility is 10 kilometers away. Findings indicate a resistance to the insistence on Caesarean section deliveries by health professionals and a preference for traditional birth attendants. more...

Background: Global progress in reducing maternal mortality requires improving access to maternal and child health services for the most vulnerable groups. This article reports results of implementation research that aimed to increase the acceptability of village-based ethnic minority midwives (EMMs) by local communities in Vietnam through implementing an integrated interventions package. Methods: The study was carried out in 2 provinces in Vietnam, Dien Bien and Kon Tum. A quasi-experimental survey with pretest/posttest design was adopted, which included 6 months of intervention implementation. The interventions package included introductory “launch” meetings, monthly review meetings at community health centers, and 5-day refresher training for EMMs. A mixed-methods approach was used involving both quantitative and qualitative data. A structured questionnaire was used in the pre- and posttest surveys, complemented by in-depth interviews and focus group discussions with EMMs, relatives of pregnant women, community representatives, and health managers. Results: Introductions of EMMs to their local communities by local authorities and supervision of performance of EMMs contributed to significant increases in utilization of services provided by EMMs, from 58.6% to 87.7%. Key facilitators included information on how to contact EMMs, awareness of services provided by EMMs, and trust in services provided by EMMs. The main barriers to utilization of EMM services, which may affect sustainability of the EMM scheme, were low self-esteem of EMMs and small allowances to EMMs, which also affected the recognition of EMMs in the community. Conclusions: Providing continuous support and integration of EMMs within frontline service provision and ensuring adequate local budget for monthly allowances are the key factors that should allow sustainability of the EMM scheme and continued improvement of access to maternal and child health care among poor ethnic minority people living in mountainous areas in Vietnam. more...

Responsiveness is a key objective of national health systems. Responsive health systems anticipate and adapt to existing and future health needs, thus contributing to better health outcomes. Of all the health systems objectives, responsiveness is the least studied, which perhaps reflects lack of comprehensive frameworks that go beyond the normative characteristics of responsive services. This paper contributes to a growing, yet limited, knowledge on this topic. Herewith, we review the current frameworks for understanding health systems responsiveness and drawing on these, as well as key frameworks from the wider public services literature, propose a comprehensive conceptual framework for health systems responsiveness. This paper should be of interest to different stakeholders who are engaged in analysing and improving health systems responsiveness. Our review shows that existing knowledge on health systems responsiveness can be extended along the three areas. First, responsiveness entails an actual experience of people's interaction with their health system, which confirms or disconfirms their initial expectations of the system. Second, the experience of interaction is shaped by both the people and the health systems sides of this interaction. Third, different influences shape people's interaction with their health system, ultimately affecting their resultant experiences. Therefore, recognition of both people and health systems sides of interaction and their key determinants would enhance the conceptualisations of responsiveness. Our proposed framework builds on, and advances, the core frameworks in the health systems literature. It positions the experience of interaction between people and health system as the centrepiece and recognises the determinants of responsiveness experience both from the health systems (eg, actors, processes) and the people (eg, initial expectations) sides. While we hope to trigger further thinking on the conceptualisation of health system responsiveness, the proposed framework can guide assessments of, and interventions to strengthen, health systems responsiveness. more...

Introduction: Responsiveness to service users’ views is a widely-recognised objective of health systems. A key component of responsive health systems is effective interaction between users and service providers. Despite a growing literature on patient feedback from high-income settings, less is known about effectiveness of such systems in low and middle income countries. Methodology and analysis: This paper disseminates the protocol for an 18-month ‘RESPOND’ project that aims to evaluate the system of collecting and responding to user feedback in Bangladesh. This mixed-method study uses a Realist Evaluation approach to examine user feedback systems at two Upazila Health Complexes in Comilla district of Bangladesh, and comprises three steps: i) initial theory development; ii) theory validation; and iii) theory refinement and development of lessons learned. The project also utilises: i) Process evaluation to understand causal mechanisms and contexts of implementation; ii) Statistical analysis of patient feedback to clarify the nature of issues reported; iii) Social science methods to illuminate feedback processes and user and provider experiences; and iv) Health policy and systems research to clarify issues related to integration of feedback systems with quality assurance and human resource management. During data analysis, qualitative and quantitative findings will be integrated throughout to help achieve study objectives. Analysis of qualitative and quantitative data will be done using a convergent mixed methods model, involving continuous triangulation of multiple datasets to facilitate greater understanding of the context of user feedback systems including the links with relevant policies, practices and programmes. Ethics and dissemination: Ethics approvals were obtained from the University of Leeds and the Bangladesh Medical Research Council. All data collected for this study will be anonymised and identifying characteristics of respondents will not appear in a final manuscript or reports. The study findings will be presented at scientific conferences and published in peer-reviewed journals. more...

Background: Community Health Workers (CHWs) are an essential component of resilient and responsive health systems, within which they are a bridge between the community and formal health service to increase access to services. Although evidence shows that CHW programmes are effective in improving maternal and child health (MCH), greater clarity is required to understand what makes CHW programmes work, for whom and under what circumstances. This presentation draws lessons from using logic mapping as a tool to de-construct a multi-intervention CHW programme in Nigeria, which aimed to increase access to quality maternity services and improve MCH outcomes. The presentation should be of interest to policymakers and researchers interested in innovative approaches for evaluating and/or strengthening health systems. Methods: A logic map (LM) is a graphic way of organizing and displaying information about a strategy, programme or policy. A coherent LM is a thread of evidence-based logic that integrates programme planning, implementation, evaluation and programme reporting. We used logic mapping as part of a realist evaluation framework, to assess whether the CHW programme in Nigeria worked, for whom and under what circumstances. The evaluation methodology involved 3 steps: initial programme theory development, theory validation and theory refinement. We share reflections on using logic mapping for the first evaluation step. To achieve this, we used logic mapping to graphically de-construct stakeholder’s (i.e. policymakers, implementers and researchers) thinking of how the programme should work, by illustrating interrelations between actors, context, implementation process, outputs and outcomes. Data for developing the LM was collected using documents review, email discussions and a technical workshop (for researchers and implementers), to untangle relationships between programme elements, and develop initial working theories. Results: Logic mapping enabled stakeholders to collaboratively describe and link desired outputs and impacts to actual activities, to confirm that activities contribute towards achieving measurable final outcomes. Discussion/conclusions: Logic mapping provided stakeholders with a shared language for, and an approach to strengthen learning at local levels, to build health system responsiveness. However, we experienced two challenges with using LMs. First, the LM depicted linear/simplified relationships between inputs, activities and outputs, or between outputs and outcomes whereas in reality, interrelationships between and among inputs, activities and outputs, or between outputs and outcomes are more complex. Second, it was difficult to represent all relationships among programme elements in a single two-dimensional LM. Consequently, a series of (or nested) LMs were required to depict various components within the multi-intervention programme. more...

Introduction: Health Policy and Systems Research and Analysis (HPSR&A) is an applied science that deals with complexity as it tries to provide lessons, tools and methods to understand and improve health systems and health policy. It is defined by the kinds of questions asked rather than a particular methodology. Objective: Our objective was to assess capacity and capacity strengthening needs for HPSR&A conduct and teaching in the University of Ghana School of Public Health (UG-SPH). We conceptualized dynamically inter-related levels of capacity as contextual, institutional and individual. Methods: The study had a cross sectional, mixed methods design. Data collection involved desk review, ,an in-depth interview, focus group discussions (FGD) and an interviewer administered questionnaire with closed and open ended items. Netmap was used as a tool in the FGD. Findings: At all levels, HPSR&A capacity exists in Ghana but is somewhat fragile. The fragility reflects in part contextual challenges related to national income and priorities as well as the fact that globally HPSR&A remains an emerging field. At the contextual level, Institutions involved in some way or other in HPSR&A were part of larger organizations with broader mandates. Only a handful of SPH staff indicated that they specifically do teaching and /or research related to HPSR&A. Conclusion & Recommendations: There is a need to raise awareness of the field of HPSR&A and its potential contributions to health sector development; build upon already existing contextual, institutional and individual capacity; and also attract and develop the next generation of researchers and teachers. more...

Background Mental illnesses are increasingly recognised as a leading cause of disability worldwide, yet many countries lack a mental health policy or have an outdated, inappropriate policy. This paper explores the development of appropriate mental health policies and their effective implementation. It reports comparative findings on the processes for developing and implementing mental health policies in Ghana, South Africa, Uganda and Zambia as part of the Mental Health and Poverty Project. Methods The study countries and respondents were purposively selected to represent different levels of mental health policy and system development to allow comparative analysis of the factors underlying the different forms of mental health policy development and implementation. Data were collected using semi-structured interviews and document analysis. Data analysis was guided by conceptual framework that was developed for this purpose. A framework approach to analysis was used, incorporating themes that emerged from the data and from the conceptual framework. Results Mental health policies in Ghana, South Africa, Uganda and Zambia are weak, in draft form or non-existent. Mental health remained low on the policy agenda due to stigma and a lack of information, as well as low prioritisation by donors, low political priority and grassroots demand. Progress with mental health policy development varied and respondents noted a lack of consultation and insufficient evidence to inform policy development. Furthermore, policies were poorly implemented, due to factors including insufficient dissemination and operationalisation of policies and a lack of resources. Conclusions Mental health policy processes in all four countries were inadequate, leading to either weak or non-existent policies, with an impact on mental health services. Recommendations are provided to strengthen mental health policy processes in these and other African countries. more...