Funded Community Health Research Articles

Factors Associated with the Implementation of an Improved Community Health Fund in the Ubungo Municipality Area, Dar es Salaam Region, Tanzania.

Community-based health insurance schemes help households to afford healthcare services. This paper describes healthcare facilities and community factors that are associated with the Improved Community Health Fund (iCHF) scheme in the Ubungo district of Tanzania. A cross-sectional descriptive study was conducted using online questionnaires that were completed by healthcare providers and community members in public-owned healthcare facilities in the Ubungo Municipal Council district of Dar es Salaam, Tanzania, between October and November 2021. The data were analyzed using descriptive statistics and the chi-squared test of association. We found a statistically significant relationship between income level and satisfaction with the iCHF scheme. For community-related factors, income level was statistically significant in the level of involvement in iCHF implementation among local leaders. Further, income level was statistically significant in relation to community behavior/culture toward the iCHF. Occupation was statistically significant in iCHF implementation, iCHF premiums, and iCHF membership size. A statistically significant relationship was also found between income, iCHF membership size, and iCHF premiums. Moreover, people would be willing to pay the required premiums if the quality of the healthcare services under the iCHF scheme improves. Therefore, the government should allocate resources to reduce the challenges that are facing iCHF implementation, such as the preference for a user fee scheme over the iCHF, the issues that are faced by enrollment officers, and inadequate iCHF premiums and membership size.

The quest for accountability of Health Facility Governing Committees implementing Direct Health Facility Financing in Tanzania: A supply-side experience.

User committees, such as Health Facility Governing Committees, are popular platforms for representing communities and civil society in holding service providers accountable. Fiscal decentralization via various arrangements such as Direct Health Facility Financing is thought to strengthen Health Facility Governing Committees in improving accountability in carrying out the devolved tasks and mandates. The purpose of this study was to analyze the status of accountability of Health Facility Governing Committees in Tanzania under the Direct Health Facility Financing setting as perceived by the supply side. In 32 different health institutions, a cross-sectional design was used to collect both qualitative and quantitative data at one point in time. Data was collected through a closed-ended questionnaire, an in-depth interview, and a Focus Group Discussion. Descriptive statistics, multiple logistic regression, and theme analysis were used to analyze the data. According to the findings, Health Facility Governing Committees’ accountability is 78%. Committees have a high level of accountability in terms of encouraging the community to join community health funds (91.71%), receiving medicines and medical commodities (88.57%), and providing timely health services (84.29%). The health facility governance committee’s responsibility was shown to be substantially connected with the health planning component (p = 0.0048) and the financial management aspect (p = 0.0045). This study found that the fiscal decentralization setting permits Committees to be accountable for carrying out their obligations, resulting in improved health service delivery in developing nations.

The functionality of health facility governing committees and their associated factors in selected primary health facilities implementing direct health facility financing in Tanzania: A mixed-method study.

BackgroundIn Lower and Middle‐Income Countries (LMICs), decentralization has dominated the agenda for reforming the organization of service delivery (LMICs). The fiscal decentralization challenge is a hard one for decentralization. As they strive to make decisions and use health facility funding, primary healthcare facilities encounter the obstacles of fiscal decentralization. LMICs are currently implementing fiscal decentralization reforms to empower health facilities and their Health Facility Governing Committees (HFGCs) to improve service delivery. Given the scarcity of systematic evidence on the impact of fiscal decentralization, this study examined the functionality of HFGCs and their associated factors in primary healthcare facilities in Tanzania that were implementing fiscal decentralization through Direct Health Facility Financing (DHFF).MethodsTo collect both qualitative and quantitative data, a cross‐sectional approach was used. The research was carried out in 32 primary healthcare facilities in Tanzania that were implementing the DHFF. A multistage sample approach was utilized to pick 280 respondents, using both probability and nonprobability sampling procedures. A structured questionnaire, in‐depth interviews, and focus group discussions were used to gather data. The functionality of HFGCs was determined using descriptive analysis, and associated factors for the functioning of HFGCs were determined using binary logistic regression. Thematic analysis was used to do qualitative research.ResultHFGC functionality under DHFF has been found to be good by 78.57%. Specifically, HFGCs have been found to have good functionality in mobilizing communities to join Community Health Funds 87.14%, participating in the procurement process 85%, discussing community health challenges 81.43% and planning and budgeting 80%. The functionality of HFGCs has been found to be associated with the planning and budgeting aspects p value of 0.0011, procurement aspects p value 0.0331, availability of information reports p value 0.0007 and Contesting for HFGC position p value 0.0187.ConclusionThe study found that fiscal decentralization via DHFF increases the functionality of HFGCs significantly. As a result, the report proposes that more effort be placed into making financial resources available to health facilities.

Social Injustice by Prescription?

Abstract Since independence, Tanzania has instituted healthcare reforms in the quest for improving availability, quality, and social equity in access to public medical services. The extent to which the most recent healthcare reforms have impacted the existing patterns of medicinal prescription writing is largely opaque in the literature. This paper relies on data from two hospitals in Dar es Salaam. It emerges that the practice of categorising healthcare seekers into groups depending upon their varied health status and their entitlement to benefits has resulted in differential prescription allocations that might be interpreted as inequitable. The majority of very low income patients finance their healthcare through out-of-pocket payments and support of the Community Health Fund; this group receives a greater ratio of services with zero prescriptions, less poly-pharmacy and fewer prescribed generic medications than the proportion received by well-to-do patients with healthcare insurance. However, the medical and non-medical determinants of this differential in prescription allocation remain unclear, and so too, the ethical implications of such patterns in Tanzania’s out-patient medical service system are inconclusive.

Financial impacts of the Medicaid expansion on community health centers.

To determine the impacts of the Medicaid expansion on revenues, costs, assets, and liabilities of federally funded community health centers. We combined data from the Uniform Data System, Internal Revenue Service nonprofit tax returns, and county-level characteristics from the Census Bureau. Our final dataset included 5841 center-year observations. We used difference-in-differences model to estimate the fiscal impacts of the Medicaid expansion on community health centers. We employed event study models, state-specific trend models, and placebo law tests as robustness checks. Not applicable. On the revenue side, we found a $2.08 million relative increase (p=0.002) in Medicaid revenues, offset by a $0.44 million decrease (p=0.015) in total grants among community health centers in expansion states compared with centers in non-expansion states. On the expenditure side, we found a large but not statistically significant $0.98 million relative increase (p=0.201) in total expenditures among centers in expansion states. Uncompensated care for health centers in expansion states decreased by $1.19 million (p < 0.001) relative to their counterparts in non-expansion states. Community health centers in expansion states benefited from the increased, stable revenue stream from Medicaid expansions. While Medicaid revenue increased as a result of the policy, we find no major evidence of substitution away from other revenue lines, with one notable exception (i.e., substitution away from state and local government grants). From a policy perspective, these results are encouraging as the Biden Administration starts to implement the safety-net enhancements from the American Rescue Plan Act of 2021 and as more non-expansion states are considering opting into Medicaid expansions. It is anticipated that these added revenue streams will help to sustain health centers in the delivery of health care services to the underserved population.

Barriers and facilitators to health insurance enrolment among people working in the informal sector in Morogoro, Tanzania

Background: Health insurance is a crucial pathway towards the achievement of universal health coverage. In Tanzania, health-financing reforms are underway to speed up universal health coverage in the informal sector. Despite improved Community Health Fund (iCHF) rollout, iCHF enrolment remains a challenge in the informal sector. This study aimed to explore the perspectives of local women food vendors (LWFV) and Bodaboda (motorcycle taxi) drivers on factors that challenge and facilitate their enrolment in iCHF. Methods: A qualitative study was conducted in Morogoro Municipality through in-depth interviews with LWFV (n=24) and Bodaboda drivers (n=26), and two focus group discussions with LWFV (n=8) and Bodaboda drivers (n=8). Theory of planned behaviour (TPB) constructs (attitude, subjective norms, and perceived control) provided a framework for the study and informed a thematic analysis focusing on the barriers and facilitators of iCHF enrolment. Results: The views of LWFV and Bodaboda drivers on factors that influence iCHF enrolment converged. Three main barriers emerged: lack of knowledge about the iCHF (attitude); negative views from friends and families (subjective norms); and inability to overcome challenges, such as the quality and range of health services available to iCHF members and iCHF not being accepted at non-government facilities (perceived control). A number of facilitators were identified, including opinions that enrolling to iCHF made good financial sense (attitude), encouragement from already-enrolled friends and relatives (subjective norms) and the belief that enrolment payment is affordable (perceived control). Conclusions: Results suggest that positive attitudes supported by perceived control and encouragement from significant others could potentially motivate LWFV and Bodaboda drivers to enroll in iCHF. However, more targeted information about the scheme is needed for individuals in the informal sector. There is also a need to ensure that quality health services are available, including coverage for non-communicable diseases (NCDs), and that non-government facilities accept iCHF.

Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders’ perspectives

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing...

Community Health Representative Workforce: Meeting the Moment in American Indian Health Equity.

In 2018, the Community Health Representative (CHR) workforce celebrated their 50th year and serve as the oldest and only federally funded Community Health Worker (CHW) workforce in the United States. CHRs are a highly trained, well-established standardized workforce serving the medical and social needs of American Indian communities. Nationally, the CHR workforce consists of ~1,700 CHRs, representing 264 Tribes. Of the 22 Tribes of Arizona, 19 Tribes operate a CHR Program and employ ~250 CHRs, equivalent to ~30% of the total CHW workforce in the state. Since 2015, Tribal CHR Programs of Arizona have come together for annual CHR Policy Summits to dialogue and plan for the unique issues and opportunities facing CHR workforce sustainability and advancement. Overtime, the Policy Summits have resulted in the Arizona CHR Workforce Movement, which advocates for inclusion of CHRs in state and national level dialogue regarding workforce standardization, certification, training, supervision, and financing. This community case study describes the impetus, collaborative process, and selected results of a 2019–2020 multi-phase CHR workforce assessment. Specifically, we highlight CHR core roles and competencies, contributions to the social determinant of health and well-being and the level to which CHRs are integrated within systems and teams. We offer recommendations for strengthening the workforce, increasing awareness of CHR roles and competencies, integrating CHRs within teams and systems, and mechanism for sustainability.

Dental hygiene and public health students' perception of an online interprofessional education applied learning activity.

To pilot an online interprofessional education (IPE) applied learning activity (ALA), to understand students' socialization and values towards IPE teams, and evaluate the IPE learning activity for future implementation. A pre-and post-test design was used to assess interprofessional socialization and values utilizing the (ISVS-9A/9B) surveys before and after the IPE ALA among dental hygiene (DH) and Master of Public Health (MPH) students (n=86). Three statements from the ISVS-9A/9B surveys were not included due to the nature of the activity. The IPE ALA was a case study related to a federally funded community health center seeking funding for a dental van within 14 local targeted communities (i.e., children, senior citizens, special needs). Student groups were randomly assigned to one targeted community and completed questions that required application of prevention, systems thinking and management and solutions of oral health issues. Students collaboratively developed an executive summary and presentation through an online learning platform. A total of 73 DH (n=38) and MPH (n=35) students (84.8% response rate) completed the ISVS 9-A (modified), and 57 students DH (n=33) and MPH (n=24) students (66.3% response rate) completed the ISVS-9B (modified) and IPE activity evaluation. A positive change (pre-post) was observed based on the students' responses (p<0.05) and 64% agreed that the skills obtained from the IPE ALA would help them in their careers. Overall, student learners' ISVS toward IPE improved after engaging in the online ALA. The use of online platforms is one low resource strategy to integrate IPE experiences into allied health and dental education.

The failure of community-based health insurance schemes in Tanzania: opening the black box of the implementation process

BackgroundGlobally, there is increased advocacy for community-based health insurance (CBHI) schemes. Like other low and middle-income countries (LMICs), Tanzania officially established the Community Health Fund (CHF) in 2001 for rural areas; and Tiba Kwa Kadi (TIKA) for urban population since 2009. This study investigated the implementation of TIKA scheme in urban districts of Tanzania.MethodsA descriptive qualitative case study was conducted in four urban districts in Tanzania in 2019. Data were collected using semi-structured interviews, focus group discussions and review of documents. A thematic approach was used to analyse the data.ResultsWhile TIKA scheme was important in increasing access to health services for the poor and other disadvantaged groups, it faced many challenges which hindered its performance. The challenges included frequent stock-out of drugs and medical supplies, which frustrated TIKA members and hence contributed to non-renewal of membership. In addition, the scheme was affected by poor collections and management of the revenue collected from TIKA members, limited benefit packages and low awareness of the community.ConclusionsSimilar to rural-based Community Health Fund, the TIKA scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging Community-Based Health Insurance schemes into a single national pool with decentralised arms to win national support while also maintaining local accountability.

Financial protection and coping strategies in rural Uganda: an impact evaluation of community-based zero-interest healthcare loans.

In low- and middle-income countries, catastrophic health expenditures and economic hardship constitute a common risk for households' welfare. Community health financing (CHF) represents a viable option to improve financial protection, but robust impact evaluations are needed to advance the debate concerning universal health coverage in informal settings. This study aims at assessing the impact of a CHF pilot programme and, specifically, of the initial phase involving zero-interest loans on health expenditures and coping strategies in a rural district of Uganda. The analysis relies on a panel household survey performed before and after the intervention and complemented by qualitative data obtained from structured focus group discussions. Exploiting an instrumental variable approach, we measured the causal effect of the intervention, and the main findings were then integrated with qualitative evidence on the heterogeneity of the programme's impact across different household categories. We found that the intervention of zero-interest healthcare loans is effective in improving financial protection and longer-term welfare. Community perceptions suggested that the population excluded from the scheme is disadvantaged when facing unpredictable health costs. Among the enrolled members, the poorest seem to receive a greater benefit from the intervention. Overall, our study provides support for the positive role of community-based mechanisms to progress towards universal coverage and offers policy-relevant insights to timely design comprehensive health financing reforms.

Decentralization in Tanzania: Perceptible Efficiency and Effectiveness in Management of Community Health Care, Free Basic Education and Public Private Partnership

Abstract Decentralization has been a means to enhance efficiency and effectiveness in the management of local government affairs. Tanzania has undergone a reform through decentralization by devolution (D by D) and shifted relative power to lower levels of government known as local government authorities. The purpose is to improve the management of local government affair including the management of community health, free basic education and the management of contracts through public-private partnership. The objective of this paper is to review and analyse on how D by D has enhanced efficiency and effectiveness in the management of local government affairs in Tanzania. Data were collected through reviewing different documents including published journal articles, unpublished Master and PhD thesis/dissertations, government reports and online materials. Efficiency and effectiveness in the management of local government affairs are enhanced by D by D as there are improvements in the management of the community health fund as the number of households enrolled is consecutively increasing in the past five years from 543,328 in 2012/2013 to 2,251,055 in 2017/2018giving a total of 13,506,330 beneficiaries out of the total population. In the management of free fee basic education, head masters, mistress and head teachers in Singida and Ruangwa districts are successful in overcoming the challenges of free fee basic education while there is improved community participation in the management of management of contracted services in Ulanga district council. This paper recommends for reviewing and analysing how D by D has enhanced management of waste collection, the use of Government electronic Payment Gateway (GePG) in revenue collection and the efficiency and effectiveness of Tanzania Rural and Urban Roads Agency (TARURA).

Factors influencing variation in implementation outcomes of the redesigned community health fund in the Dodoma region of Tanzania: a mixed-methods study

IntroductionMicro-health insurance (MHI) has been identified as a possible interim solution to foster progress towards Universal Health Coverage (UHC) in low- and middle- income countries (LMICs). Still, MHI schemes suffer from chronically low penetration rates, especially in sub-Saharan Africa. Initiatives to promote and sustain enrolment have yielded limited effect, yet little effort has been channelled towards understanding how such initiatives are implemented. We aimed to fill this gap in knowledge by examining heterogeneity in implementation outcomes and their moderating factors within the context of the Redesigned Community Health Fund in the Dodoma region in Tanzania.MethodsWe adopted a mixed-methods design to examine implementation outcomes, defined as adoption and fidelity of implementation (FOI) as well as their moderating factors. A survey questionnaire collected individual level data and a document review checklist and in-depth interview guide collected district level data. We relied on descriptive statistics, a chi square test and thematic analysis to analyse our data.ResultsA review of district level data revealed high adoption (78%) and FOI (77%) supported also by qualitative interviews. In contrast, survey participants reported relatively low adoption (55%) and FOI (58%). Heterogeneity in adoption and FOI was observed across the districts and was attributed to organisational weakness or strengths, communication and facilitation strategies, resource availability (fiscal capacity, human resources and materials), reward systems, the number of stakeholders, leadership engagement, and implementer’s skills.At an individual level, heterogeneity in adoption and FOI of scheme components was explained by the survey participant’s level of education, occupation, years of stay in the district and duration of working in the scheme. For example, the adoption of job description was statistically associated with occupation (p = 0.001) and wworking in the scheme for more than 20 months had marginal significant association with FOI (p = 0.04).ConclusionThe study demonstrates that assessing the implementation processes helps to detect implementation weaknesses and therefore address such weaknesses as the interventions are implemented or rolled out to other settings. Attention to contextual and individual implementer elements should be paid in advance to adjust implementation strategies and ensure greater adoption and fidelity of implementation.

"At Least I Didn't Get Raped": A Qualitative Exploration of IPV and Reproductive Coercion among Adolescent Girls Seeking Family Planning in Mexico.

Adolescent girls who report intimate partner violence (IPV) are at an increased risk of experiencing reproductive coercion (RC); both these forms of gender-based violence (GBV) are associated with unintended pregnancy. Yet little is known about these experiences among adolescent girls in Mexico. Qualitative data were collected as part of formative research for the adaptation of an evidence-based intervention to address RC and IPV in community health centers in Tijuana, Mexico. From September, 2017 to January, 2018, adolescent girls aged 16 to 20 years old (n = 20) seeking voluntary family planning (FP) services were identified and recruited from two publicly funded community health centers. We conducted semi-structured, in-depth interviews and analyzed the transcripts using inductive and deductive techniques. Participants in this sample commonly described experiencing IPV and RC (including pregnancy coercion and contraceptive sabotage), which many girls reported resulted in unintended pregnancy. Further, participants' narratives and general lack of knowledge on how to cope with IPV or RC illuminated the acceptability of offering GBV prevention intervention within FP clinics serving this population. Findings highlight an urgent need to prevent IPV and RC, and reduce risk for unintended pregnancy among adolescent girls in this region and the potential of FP clinics to serve as a safe space for intervention delivery. Findings contribute to the limited qualitative evidence from Mexico, describing adolescent girl's experiences of IPV and RC, strategies for preventing pregnancy in the context of RC, and opportunities for support from FP providers.

Contributions of Community Health Fund to Social Health Security in Kalambo District Rukwa, Tanzania

Community Health Fund (CHF) was established in 1996 as a District Council based pre-payment health insurance scheme in Tanzania with the aim of improving health of communities working in the informal sectors. However, since its formulation, it has been performing unsatisfactorily, and hence majority of Households (HHs) are not members while other members are withdrawing from the scheme. This necessitated the need for assessing the contribution of CHF on social health security among members. Specifically, this paper examined the challenges faced by households regarding CHF membership and analysed the contributions of CHF on its member. The study area was Kalambo District Council. A cross-sectional research design was used, whereas a simple random sampling technique through lottery method was employed to select the sample size of 354 respondents. Qualitative data were collected using Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs), while quantitative data were collected using a questionnaire. Quantitative data were coded and analysed using IBM-SPSS. Qualitative data were analysed through content analysis. The results show that CHF contributed to social health security among its members in the study area, through provision of health services to its members once they fall sick. On other hand, CHF had few members as only 24.3% of HHs had membership to CHF. One of the barriers for CHF was lack of awareness among communities about the existence of CHF, while other cited lack of money for contributing to CHF. Thus, the study concludes that CHF has not contributed significantly to the health security among targeted members. The study recommends that, CHF officials should widely sensitize communities through seminars and meetings about CHF and its benefits to them. Furthermore, CHF stakeholders should coordinate communities in the area to establish financial institutions such as Village Community Banks (VICOBA) where they can save and borrow money for registration cards.

Strategi Meningkatkan Kesejahteraan Masyarakat Berbasis Masjid

The purpose of this study was to determine and analyze how the strategy of the mosque in improving the welfare of the community in Gedangan District, Sidoarjo Regency? and how to increase the welfare of the community at the Baitul Mukminin Mosque, Gedangan District, Sidoarjo Regency? This type of research is descriptive qualitative, this research is classified as field research or field research. The data collection techniques used interviews, observation and documentation. Meanwhile, the data analysis technique uses the Miland Huberman model based on data reduction analysis, display data and conclusion drawing. The results of this study concluded that (1) the strategy carried out by the Baitul Mukminin Mosque to improve the welfare of the community was to form the Dhuafa Crisis Center '(CCD). There are several programs being developed, namely: (a) BAMBU (Entrepreneurial Capital Assistance); (b) PASTA (Love Dhuafa Staple Food Package '); (c) SANTAN (Education Support for Orphans); (d) DAHSYAT (Community Health Fund); (e) SEDAP (Responsive Alms); (f) MAXIFA (Lunch with Dhuafa`); (g) SAJIAN (Teacher's Benefits of Koran); and (h) Humanitarian Post. (2) From the programs run by the Crisis Center Dhuafa ', it can be seen that there is an increase in welfare that is felt by the community. The form of increased welfare is an increase in income, reduced consumption expenditure, ease of accessing health services, ease of continuing education, ease of getting a place. living and living facilities. The Dhuafa Crisis Center '(CCD) is expected to be able to maintain and develop the program optimally both in terms of raising funds and distributing it so that more and more people will be prosperous.

Exploring Factors Influencing Dropping-out of CommunityBased Health Insurance Schemes in Mpwapwa District, Tanzania

Community-Based Health Insurance schemes are meant to expand the coverage of healthcare provision to, especially, the majority poor in the rural areas of the Developing World. Despite high sensitization and mobilization campaigns, enrolment, re-enrolment and utilization of such schemes have been unexpectedly low. This is also the case with the Redesigned Community Health Fund (rCHF) in Tanzania. We took a qualitative approach to explore the reasons for the drop-outs of the rCHF in Mpwapwa District in central Tanzania. We reviewed various rCHF-related documents and used Key Informant Interviews and Focused Group Discussions to collect data from randomly selected drop-out cases. The findings suggest the availability of drugs, premium costs, quality of healthcare facilities as key reasons influencing households to enrol, re-enrol or drop-out of the rCHF. In this paper we argue that rCHF should integrate more participatory approaches to understand local concerns and re-design the scheme to address the challenges.&#x0D; Keywords: Drop-outs; Community Based Health Insurance; rCHF&#x0D; Community-Based Health Insurance schemes are meant to expand the coverage of healthcare provision to, especially, the majority poor in the rural areas of the Developing World. Despite high sensitization and mobilization campaigns, enrolment, re-enrolment and utilization of such schemes have been unexpectedly low. This is also the case with the Redesigned Community Health Fund (rCHF) in Tanzania. We took a qualitative approach to explore the reasons for the drop-outs of the rCHF in Mpwapwa District in central Tanzania. We reviewed various rCHF-related documents and used Key Informant Interviews and Focused Group Discussions to collect data from randomly selected drop-out cases. The findings suggest the availability of drugs, premium costs, quality of healthcare facilities as key reasons influencing households to enrol, re-enrol or drop-out of the rCHF. In this paper we argue that rCHF should integrate more participatory approaches to understand local concerns and re-design the scheme to address the challenges.

Community attitude towards Community Health Fund on Health Security in Kalambo District, Rukwa Region, Tanzania

Community Health Fund (CHF) is one among health insurance schemes found in Tanzania. It was established in 1996 with the aim of improving the health of people who work in informal sectors. However, since its formulation, it has not performed well; the majority of HHs are not members, and some members are withdrawing from the scheme. The overall objective was to assess the attitude of community members towards the importance of CHF for health security. Specifically, the paper assesses the attitude towards CHF interventions among members and non-members of CHF and compares the attitude between members and non-members of CHF on health security. Cross sectional research design was used in this study. Simple random sampling technique using the lottery method was employed to select 354 respondents. Data were collected using a household questionnaire survey, Focus Group Discussions guide, Key Informant Interviews checklist and documents’ reviews. Descriptive statistics, inferential statistics and content analysis were used to analyze the data. The findings show that CHF has inclusive benefits to its members as it covers costs of health treatment rather than paying money every time they attend medical treatments. Furthermore, the attitude towards CHF among members and non-members was accounted for 9.3% and 51.9 negative, 2.3% and 4.1 neutral and 88.4 and 44.0 positive. This indicates that the majority of people in the study area had a positive attitude towards CHF services. Thus, the study concludes that a great proportion of members of CHF in Kalambo District have positive attitude towards CHF intervention while the majority of non-members have negative attitude towards CHF intervention because they were not aware of it due to lack of knowledge. It is recommended that the government should mainstream CHF intervention to all communities so that non-members can join the scheme and hence get better health services. Also, the study recommends that the CHF service providers should put more emphasis on sensitising communities against negative attitudes from non-members of CHF.

How do decision-makers use evidence in community health policy and financing decisions? A qualitative study and conceptual framework in four African countries.

Various investments could help countries deliver on the universal health coverage (UHC) goals set by the global community; community health is a pillar of many national strategies towards UHC. Yet despite resource mobilization towards this end, little is known about the potential costs and value of these investments, as well as how evidence on the same would be used in related decisions. This qualitative study was conducted to understand the use of evidence in policy and financing decisions for large-scale community health programmes in low- and middle-income countries. Through key informant interviews with 43 respondents in countries with community health embedded in national UHC strategies (Ethiopia, Kenya, Malawi, Mozambique) and at global institutions, we investigated evidence use in community health financing and policy decision-making, as well as evidentiary needs related to community health data for decision-making. We found that evidence use is limited at all levels, in part due to a perceived lack of high-quality, relevant evidence. This perception stems from two main areas: first, desire for local evidence that reflects the context, and second, much existing economic evidence does not deal with what decision-makers value when it comes to community health systems—i.e. coverage and (to a lesser extent) quality. Beyond the evidence gap, there is limited capacity to assess and use the evidence. Elected officials also face political challenges to disinvestment as well as structural obstacles to evidence use, including the outsized influence of donor priorities. Evaluation data must to speak to decision-maker interests and constraints more directly, alongside financiers of community health providing explicit guidance and support on the role of evidence use in decision-making, empowering national decision-makers. Improved data quality, increased relevance of evidence and capacity for evidence use can drive improved efficiency of financing and evidence-based policymaking.

The evolution of community-based primary health care, Slovenia.

ProblemSlovenia’s model of primary health care relied on reactive, episodic care and was ill-equipped to address the country’s burden of disease dominated by noncommunicable diseases.ApproachThe government has developed a multidisciplinary, community-based, prevention-oriented service delivery model for primary health care. A compulsory family medicine residency programme was introduced in 2000, and from 2004 screening and control of chronic diseases were established in family medicine practices. Health promotion centres were established, providing group interventions to support healthy lifestyles. After 2011, registered nurses were introduced to conduct screening for chronic diseases, provide counselling and manage patients with stable noncommunicable diseases.Local settingIn 1992, the government transformed Slovenia’s health financing scheme to a social insurance system based on mandatory payroll taxes. The system enabled private provision of health services, although primary care was mostly provided by publicly funded community health centres. A strong gatekeeping role was introduced.Relevant changesDespite spending less on health than the European Union (EU) average, by 2013 Slovenia’s life expectancy was higher than the average for EU countries. The increase was due in part to rapidly declining infant and under-five mortality and a faster decline in premature mortality due to chronic diseases.Lessons learntSlovenia’s approach was enabled by strong public health and governance structures, along with accountability mechanisms that monitored outcomes and took corrective action when necessary. New programmes were piloted, creating a strong evidence base that facilitated obtaining sustainable financing, while national roll-out was supported by regional branches of the National Institute of Public Health.