Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, de... more Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one’s rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination a...
Country contributions: Many thanks to the heads of the UNFPA and WHO country offices, their staff... more Country contributions: Many thanks to the heads of the UNFPA and WHO country offices, their staff, and the people that coordinated, completed, and verified responses to the State of the World’s Midwifery country survey. In particular, thanks to the country focal points:
Background: Urbanization challenges the assumptions that have traditionally influenced maternal a... more Background: Urbanization challenges the assumptions that have traditionally influenced maternal and newborn health (MNH) programs. This landscaping outlines the ways in which current mental models for MNH programs have fallen short for urban slum populations, and identifies implications for the global community. We employed a three-pronged approach, including a literature review, key informant interviews with global- and national-level experts, and a case study in Bangladesh. Main Body: Our findings highlight that the current mental model for MNH is inadequate to address the needs of the urban poor. Implementation challenges have arisen from using traditional methods that are not well adapted to traits typically inherent of slum settings. A re-thinking of implementation strategies will also need to consider a paucity of available routine data, lack of formal coordination between stakeholders and providers, and challenging municipal government structures. Innovative approaches, inclu...
Non-communicable diseases (NCDs) are the greatest contributor to morbidity and mortality in low-a... more Non-communicable diseases (NCDs) are the greatest contributor to morbidity and mortality in low-and middle-income countries (LMICs). However, NCD care is limited in LMICs, particularly among the disadvantaged and rural. We explored the role of insurance in mitigating socioeconomic and urban-rural disparities in NCD treatment across 48 LMICs included in the 2002-2004 World Health Survey (WHS). We analyzed data about ever having received treatment for diagnosed highburden NCDs (any diagnosis, angina, asthma, depression, arthritis, schizophrenia, or diabetes) or having sold or borrowed to pay for healthcare. We fit multivariable regression models of each outcome by the interaction between insurance coverage and household wealth (richest 20% vs. poorest 50%) and urban-icity, respectively. We found that insurance was associated with higher treatment likelihood for NCDs in LMICs, and helped mitigate socioeconomic and regional disparities in treatment likelihood. These influences were particularly strong among women. Insurance also predicted lower likelihood of borrowing or selling to pay for health services among the poorest women. Taken together, insurance coverage may serve as an important policy tool in promoting NCD treatment and in reducing inequities in NCD treatment by household wealth, urbanicity, and sex in LMICs.
Despite a large body of anecdotal evidence, there are no reliable estimates of the prevalence of ... more Despite a large body of anecdotal evidence, there are no reliable estimates of the prevalence of disrespectful and abusive treatment during labour and delivery in health facilities. We measured the frequency of abusive and disrespectful treatment during delivery in eight Northeastern Tanzanian health facilities using a structured survey. We interviewed women on discharge from facility, and re-interviewed a subset in the community 5-10 weeks later. Reporting of any disrespectful treatment ranged from 19% on discharge to 28% on community follow-up, with ignoring, shouting and negative comments among the most frequently reported events. This work confirms that disrespectful treatment is relatively common in this low-income setting and signals a crisis in a health system that is attempting to encourage women to deliver in health facilities to reduce maternal mortality.
Objective: To explore the equity of utilization of inpatient health care at rural Tanzanian healt... more Objective: To explore the equity of utilization of inpatient health care at rural Tanzanian health centers through the use of a short wealth questionnaire. Methods: Patients admitted to four rural health centers in the Kigoma Region of Tanzania from May 2008 to May 2009 were surveyed about their illness, asset ownership and demographics. Principal component analysis was used to compare the wealth of the inpatients to the wealth of the region's general population, using data from a previous population-based survey. Results: Among inpatients, 15.3% were characterized as the most poor, 19.6% were characterized as very poor, 16.5% were characterized as poor, 18.9% were characterized as less poor, and 29.7% were characterized as the least poor. The wealth distribution of all inpatients (p < 0.0001), obstetric inpatients (p < 0.0001), other inpatients (p < 0.0001), and fee-exempt inpatients (p < 0.001) were significantly different than the wealth distribution in the community population, with poorer patients underrepresented among inpatients. The wealth distribution of pediatric inpatients (p = 0.2242) did not significantly differ from the population at large. Conclusion: The findings indicated that while current Tanzanian health financing policies may have improved access to health care for children under five, additional policies are needed to further close the equity gap, especially for obstetric inpatients.
Background The Millennium Development Goals call for a 75% reduction in maternal mortality betwee... more Background The Millennium Development Goals call for a 75% reduction in maternal mortality between 1990 and 2015. Skilled birth attendance and emergency obstetric care, including Caesarean section, are two of the most important interventions to reduce maternal mortality. Although international pressure is rising to increase donor assistance for essential health services in developing countries, we know less about whether government or the private sector is more effective at financing these essential services in developing countries. Methods We conducted a cross-national analysis to determine the association between government versus private financing of health services and utilization of antenatal care, skilled birth attendants and Caesarean section in 42 low-income and lower-middle-income countries. We controlled for possible confounding effects of total per capita health spending and female literacy. Findings In multivariable analysis, adjusting for confounders, government health expenditure as a percentage of total health expenditure is significantly associated with utilization of skilled birth attendants (P ¼ 0.05) and Caesarean section (P ¼ 0.01) but not antenatal care. Total health expenditure is also significantly associated with utilization of skilled birth attendants (P < 0.01) and Caesarean section (P < 0.01). Discussion Greater government participation in health financing and higher levels of health spending are associated with increased utilization of two maternal health services: skilled birth attendants and Caesarean section. While government financing is associated with better access to some essential maternal health services, greater absolute levels of health spending will be required if developing countries are to achieve the Millennium Development Goal on maternal mortality.
This article discusses ways in which the analytical tools of public health can be used in conjunc... more This article discusses ways in which the analytical tools of public health can be used in conjunction with emerging theories of human rights to craft effective advocacy strategies, focusing particularly on women's reproductive health and reproductive rights. Public health research, although often presented as an objective scientific inquiry, is actually a value-laden and therefore, highly political endeavor that should be used by advocates to elucidate the connections between women's health and the wider social, economic, and political conditions in which they live. Such research can then inform theory and practice in the dynamic field of women's human rights. This article suggests an approach to health and human rights collaboration that views women as committed, indispensable members of the collectivities in which they live, and that seeks to identify and implement social structures and cultural configurations that promote and support women's dignity and autonomy and thus, their health and well-being, in that social context.
a b s t r a c t a r t i c l e i n f o Objectives: To show how GIS can be used by health planners ... more a b s t r a c t a r t i c l e i n f o Objectives: To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services. Methods: A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities. Results: Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capabilit...
In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite e... more In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite efforts to reduce barriers to utilization. Disrespect and abuse during childbirth has not been explored as a contributor to delivery satisfaction or as a deterrent to institutional delivery. We assessed the association between reported disrespectful treatment during childbirth and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. Interviews using a structured questionnaire were conducted in Tanga Region, Tanzania with women on discharge from delivery at two hospitals. Disrespect and abuse was measured by asking women about specific disrespectful events during childbirth. Multivariable logistic regression models were used to assess the association between disrespect/abuse and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. 1388 women participated in the survey (67 % response rate). Disrespect/abuse during childbirth was associated with lower satisfaction with delivery (OR 0.26, 95 % CI 0.19-0.36) and reduced likelihood of rating perceived quality of care as excellent/very good (OR 0.55, 95 % CI 0.35-0.85). Of women who planned to have more children (N = 766), those who experienced disrespect/abuse were half as likely to plan to deliver again at the same facility (OR 0.51, 95 % CI 0.32-0.82). Our study highlights disrespectful and abusive treatment during childbirth as an important factor in reducing women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s confidence in health facilities. Improving interpersonal care must be an integral part of quality improvement in maternal health.
Historically, global efforts to accelerate progress toward achieving health and well-being for wo... more Historically, global efforts to accelerate progress toward achieving health and well-being for women and children have appeared separate, despite the inextricable links among maternal, perinatal, and newborn health outcomes. n Accelerating progress demands that the maternal and newborn health (MNH) community more rapidly and effectively share learning, new evidence, and program experiences. n A new global initiative, AlignMNH, will establish a country-driven, multidirectional knowledge hub and series of convenings to promote purposeful knowledge sharing and problem solving and align on priorities for action. These efforts are intended to facilitate increased application of evidence and regular review of progress ultimately contributing to improved MNH and prevention of stillbirths.
Background Legal empowerment and social accountability are two strategies that are increasingly u... more Background Legal empowerment and social accountability are two strategies that are increasingly used to address gaps in healthcare in low- and middle-income countries, including failure to provide services that should be available and poor clinical and interpersonal quality of care. This paper is an explanatory case study of a legal empowerment effort that employs community paralegals and trains Village Health Committees (VHCs) in Mozambique. The research objective was to explore how community paralegals solved cases, the impact paralegals had on health services, and how their work affected the relationship between the community and the health sector at the local level. Methods The case study had two components: (1) a retrospective review of 24 cases of patient/community grievances about the health system, and (2) qualitative investigation of the program and program context. The case reviews were accomplished by conducting structured in-depth interviews (IDIs) with those directly in...
This paper is a critical interpretive synthesis of community health workers (CHWs) and accountabi... more This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as ‘CHWs and equity.’CHWs are intended to comprise a ‘bridge’ between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with ot...
Human rights has been a vital tool in the global movement to reduce maternal mortality and to exp... more Human rights has been a vital tool in the global movement to reduce maternal mortality and to expose the disrespect and abuse that women experience during childbirth in facilities around the world. Yet to truly transform the relationship between women and providers, human rights-based approaches (HRBAs) will need to go beyond articulation, dissemination and even legal enforcement of formal norms of respectful maternity care. HRBAs must also develop a deeper, more nuanced understanding of how power operates in health systems under particular social, cultural and political conditions, if they are to effectively challenge settled patterns of behaviour and health systems structures that marginalise and abuse. In this paper, we report results from a mixed methods study in two hospitals in the Tanga region of Tanzania, comparing the prevalence of disrespect and abuse during childbirth as measured through observation by trained nurses stationed in maternity wards to prevalence as measured by the self-report upon discharge of the same women who had been observed. The huge disparity between these two measures (baseline: 69.83% observation vs. 9.91% self-report; endline: 32.91% observation vs. 7.59% self-report) suggests that disrespect and abuse is both internalised and normalised by users and providers alike. Building on qualitative research conducted in the study sites, we explore the mechanisms by which hidden and invisible power enforces internalisation and normalisation, and describe the implications for the development of HRBAs in maternal health.
International journal for equity in health, Jan 25, 2018
Community health workers (CHWs) are frequently put forward as a remedy for lack of health system ... more Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a 'think in', held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger "accountability ecosystem." This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs' social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several...
Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, de... more Labouring women may be subjected to physical and verbal abuse that reflects dynamics of power, described as Mistreatment of Women (MoW). This Critical Interpretive Synthesis on power and MoW consolidates current research and advances theory and practice through inter-disciplinary literature exploration. The review was undertaken in 3 phases. Phase 1 consisted of topic scoping; phase 2 entailed exploration of key power-related drivers emerging from the topic scoping; and phase 3 entailed data synthesis and analysis, with a particular focus on interventions. We identified 63 papers for inclusion in Phase 1. These papers utilized a variety of methods and approaches and represented a wide range of geographic regions. The power-related drivers of mistreatment in these articles span multiple levels of the social ecological model, including intrapersonal (e.g. lack of knowledge about one’s rights), interpersonal (e.g. patient-provider hierarchy), community (e.g. widespread discrimination a...
Country contributions: Many thanks to the heads of the UNFPA and WHO country offices, their staff... more Country contributions: Many thanks to the heads of the UNFPA and WHO country offices, their staff, and the people that coordinated, completed, and verified responses to the State of the World’s Midwifery country survey. In particular, thanks to the country focal points:
Background: Urbanization challenges the assumptions that have traditionally influenced maternal a... more Background: Urbanization challenges the assumptions that have traditionally influenced maternal and newborn health (MNH) programs. This landscaping outlines the ways in which current mental models for MNH programs have fallen short for urban slum populations, and identifies implications for the global community. We employed a three-pronged approach, including a literature review, key informant interviews with global- and national-level experts, and a case study in Bangladesh. Main Body: Our findings highlight that the current mental model for MNH is inadequate to address the needs of the urban poor. Implementation challenges have arisen from using traditional methods that are not well adapted to traits typically inherent of slum settings. A re-thinking of implementation strategies will also need to consider a paucity of available routine data, lack of formal coordination between stakeholders and providers, and challenging municipal government structures. Innovative approaches, inclu...
Non-communicable diseases (NCDs) are the greatest contributor to morbidity and mortality in low-a... more Non-communicable diseases (NCDs) are the greatest contributor to morbidity and mortality in low-and middle-income countries (LMICs). However, NCD care is limited in LMICs, particularly among the disadvantaged and rural. We explored the role of insurance in mitigating socioeconomic and urban-rural disparities in NCD treatment across 48 LMICs included in the 2002-2004 World Health Survey (WHS). We analyzed data about ever having received treatment for diagnosed highburden NCDs (any diagnosis, angina, asthma, depression, arthritis, schizophrenia, or diabetes) or having sold or borrowed to pay for healthcare. We fit multivariable regression models of each outcome by the interaction between insurance coverage and household wealth (richest 20% vs. poorest 50%) and urban-icity, respectively. We found that insurance was associated with higher treatment likelihood for NCDs in LMICs, and helped mitigate socioeconomic and regional disparities in treatment likelihood. These influences were particularly strong among women. Insurance also predicted lower likelihood of borrowing or selling to pay for health services among the poorest women. Taken together, insurance coverage may serve as an important policy tool in promoting NCD treatment and in reducing inequities in NCD treatment by household wealth, urbanicity, and sex in LMICs.
Despite a large body of anecdotal evidence, there are no reliable estimates of the prevalence of ... more Despite a large body of anecdotal evidence, there are no reliable estimates of the prevalence of disrespectful and abusive treatment during labour and delivery in health facilities. We measured the frequency of abusive and disrespectful treatment during delivery in eight Northeastern Tanzanian health facilities using a structured survey. We interviewed women on discharge from facility, and re-interviewed a subset in the community 5-10 weeks later. Reporting of any disrespectful treatment ranged from 19% on discharge to 28% on community follow-up, with ignoring, shouting and negative comments among the most frequently reported events. This work confirms that disrespectful treatment is relatively common in this low-income setting and signals a crisis in a health system that is attempting to encourage women to deliver in health facilities to reduce maternal mortality.
Objective: To explore the equity of utilization of inpatient health care at rural Tanzanian healt... more Objective: To explore the equity of utilization of inpatient health care at rural Tanzanian health centers through the use of a short wealth questionnaire. Methods: Patients admitted to four rural health centers in the Kigoma Region of Tanzania from May 2008 to May 2009 were surveyed about their illness, asset ownership and demographics. Principal component analysis was used to compare the wealth of the inpatients to the wealth of the region's general population, using data from a previous population-based survey. Results: Among inpatients, 15.3% were characterized as the most poor, 19.6% were characterized as very poor, 16.5% were characterized as poor, 18.9% were characterized as less poor, and 29.7% were characterized as the least poor. The wealth distribution of all inpatients (p < 0.0001), obstetric inpatients (p < 0.0001), other inpatients (p < 0.0001), and fee-exempt inpatients (p < 0.001) were significantly different than the wealth distribution in the community population, with poorer patients underrepresented among inpatients. The wealth distribution of pediatric inpatients (p = 0.2242) did not significantly differ from the population at large. Conclusion: The findings indicated that while current Tanzanian health financing policies may have improved access to health care for children under five, additional policies are needed to further close the equity gap, especially for obstetric inpatients.
Background The Millennium Development Goals call for a 75% reduction in maternal mortality betwee... more Background The Millennium Development Goals call for a 75% reduction in maternal mortality between 1990 and 2015. Skilled birth attendance and emergency obstetric care, including Caesarean section, are two of the most important interventions to reduce maternal mortality. Although international pressure is rising to increase donor assistance for essential health services in developing countries, we know less about whether government or the private sector is more effective at financing these essential services in developing countries. Methods We conducted a cross-national analysis to determine the association between government versus private financing of health services and utilization of antenatal care, skilled birth attendants and Caesarean section in 42 low-income and lower-middle-income countries. We controlled for possible confounding effects of total per capita health spending and female literacy. Findings In multivariable analysis, adjusting for confounders, government health expenditure as a percentage of total health expenditure is significantly associated with utilization of skilled birth attendants (P ¼ 0.05) and Caesarean section (P ¼ 0.01) but not antenatal care. Total health expenditure is also significantly associated with utilization of skilled birth attendants (P < 0.01) and Caesarean section (P < 0.01). Discussion Greater government participation in health financing and higher levels of health spending are associated with increased utilization of two maternal health services: skilled birth attendants and Caesarean section. While government financing is associated with better access to some essential maternal health services, greater absolute levels of health spending will be required if developing countries are to achieve the Millennium Development Goal on maternal mortality.
This article discusses ways in which the analytical tools of public health can be used in conjunc... more This article discusses ways in which the analytical tools of public health can be used in conjunction with emerging theories of human rights to craft effective advocacy strategies, focusing particularly on women's reproductive health and reproductive rights. Public health research, although often presented as an objective scientific inquiry, is actually a value-laden and therefore, highly political endeavor that should be used by advocates to elucidate the connections between women's health and the wider social, economic, and political conditions in which they live. Such research can then inform theory and practice in the dynamic field of women's human rights. This article suggests an approach to health and human rights collaboration that views women as committed, indispensable members of the collectivities in which they live, and that seeks to identify and implement social structures and cultural configurations that promote and support women's dignity and autonomy and thus, their health and well-being, in that social context.
a b s t r a c t a r t i c l e i n f o Objectives: To show how GIS can be used by health planners ... more a b s t r a c t a r t i c l e i n f o Objectives: To show how GIS can be used by health planners to make informed decisions about interventions to increase access to emergency services. Methods: A combination of data sources, including the 2008 national Ethiopian baseline assessment for emergency obstetric and newborn care that covered 797 geo-coded health facilities, LandScan population data, and road network data, were used to model referral networks and catchment areas across 2 regions of Ethiopia. STATA and ArcGIS software extensions were used to model different scenarios for strengthening the referral system, defined by the structural inputs of transportation and communication, and upgrading facilities, to compare the increase in access to referral facilities. Results: Approximately 70% of the population of Tigray and Amhara regions is served by facilities that are within a 2-hour transfer time to a hospital with obstetric surgery. By adding vehicles and communication capabilit...
In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite e... more In Tanzania, maternal mortality is high and coverage with health facility delivery low, despite efforts to reduce barriers to utilization. Disrespect and abuse during childbirth has not been explored as a contributor to delivery satisfaction or as a deterrent to institutional delivery. We assessed the association between reported disrespectful treatment during childbirth and delivery satisfaction, perceived quality of care, and intention to deliver at the same facility in the future. Interviews using a structured questionnaire were conducted in Tanga Region, Tanzania with women on discharge from delivery at two hospitals. Disrespect and abuse was measured by asking women about specific disrespectful events during childbirth. Multivariable logistic regression models were used to assess the association between disrespect/abuse and (1) satisfaction with delivery, (2) perceived quality of care for delivery, and (3) intent to use the same facility for a future delivery, controlling for confounders. 1388 women participated in the survey (67 % response rate). Disrespect/abuse during childbirth was associated with lower satisfaction with delivery (OR 0.26, 95 % CI 0.19-0.36) and reduced likelihood of rating perceived quality of care as excellent/very good (OR 0.55, 95 % CI 0.35-0.85). Of women who planned to have more children (N = 766), those who experienced disrespect/abuse were half as likely to plan to deliver again at the same facility (OR 0.51, 95 % CI 0.32-0.82). Our study highlights disrespectful and abusive treatment during childbirth as an important factor in reducing women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s confidence in health facilities. Improving interpersonal care must be an integral part of quality improvement in maternal health.
Historically, global efforts to accelerate progress toward achieving health and well-being for wo... more Historically, global efforts to accelerate progress toward achieving health and well-being for women and children have appeared separate, despite the inextricable links among maternal, perinatal, and newborn health outcomes. n Accelerating progress demands that the maternal and newborn health (MNH) community more rapidly and effectively share learning, new evidence, and program experiences. n A new global initiative, AlignMNH, will establish a country-driven, multidirectional knowledge hub and series of convenings to promote purposeful knowledge sharing and problem solving and align on priorities for action. These efforts are intended to facilitate increased application of evidence and regular review of progress ultimately contributing to improved MNH and prevention of stillbirths.
Background Legal empowerment and social accountability are two strategies that are increasingly u... more Background Legal empowerment and social accountability are two strategies that are increasingly used to address gaps in healthcare in low- and middle-income countries, including failure to provide services that should be available and poor clinical and interpersonal quality of care. This paper is an explanatory case study of a legal empowerment effort that employs community paralegals and trains Village Health Committees (VHCs) in Mozambique. The research objective was to explore how community paralegals solved cases, the impact paralegals had on health services, and how their work affected the relationship between the community and the health sector at the local level. Methods The case study had two components: (1) a retrospective review of 24 cases of patient/community grievances about the health system, and (2) qualitative investigation of the program and program context. The case reviews were accomplished by conducting structured in-depth interviews (IDIs) with those directly in...
This paper is a critical interpretive synthesis of community health workers (CHWs) and accountabi... more This paper is a critical interpretive synthesis of community health workers (CHWs) and accountability in low-income and middle-income countries. The guiding questions were: What factors promote or undermine CHWs as accountability agents? (and) Can these factors be intentionally fostered or suppressed to impel health system accountability? We conducted an iterative search that included articles addressing the core issue of CHWs and accountability, and articles addressing ancillary issues that emerged in the initial search, such as ‘CHWs and equity.’CHWs are intended to comprise a ‘bridge’ between community members and the formal health system. This bridge function is described in three key ways: service extender, cultural broker, social change agent. We identified several factors that shape the bridging function CHWs play, and thus, their role in fomenting health system accountability to communities, including the local political context, extent and nature of CHW interactions with ot...
Human rights has been a vital tool in the global movement to reduce maternal mortality and to exp... more Human rights has been a vital tool in the global movement to reduce maternal mortality and to expose the disrespect and abuse that women experience during childbirth in facilities around the world. Yet to truly transform the relationship between women and providers, human rights-based approaches (HRBAs) will need to go beyond articulation, dissemination and even legal enforcement of formal norms of respectful maternity care. HRBAs must also develop a deeper, more nuanced understanding of how power operates in health systems under particular social, cultural and political conditions, if they are to effectively challenge settled patterns of behaviour and health systems structures that marginalise and abuse. In this paper, we report results from a mixed methods study in two hospitals in the Tanga region of Tanzania, comparing the prevalence of disrespect and abuse during childbirth as measured through observation by trained nurses stationed in maternity wards to prevalence as measured by the self-report upon discharge of the same women who had been observed. The huge disparity between these two measures (baseline: 69.83% observation vs. 9.91% self-report; endline: 32.91% observation vs. 7.59% self-report) suggests that disrespect and abuse is both internalised and normalised by users and providers alike. Building on qualitative research conducted in the study sites, we explore the mechanisms by which hidden and invisible power enforces internalisation and normalisation, and describe the implications for the development of HRBAs in maternal health.
International journal for equity in health, Jan 25, 2018
Community health workers (CHWs) are frequently put forward as a remedy for lack of health system ... more Community health workers (CHWs) are frequently put forward as a remedy for lack of health system capacity, including challenges associated with health service coverage and with low community engagement in the health system, and expected to enhance or embody health system accountability. During a 'think in', held in June of 2017, a diverse group of practitioners and researchers discussed the topic of CHWs and their possible roles in a larger "accountability ecosystem." This jointly authored commentary resulted from our deliberations. While CHWs are often conceptualized as cogs in a mechanistic health delivery system, at the end of the day, CHWs are people embedded in families, communities, and the health system. CHWs' social position and professional role influence how they are treated and trusted by the health sector and by community members, as well as when, where, and how they can exercise agency and promote accountability. To that end, we put forward several...
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Papers by Lynn Freedman