Funded Community Health Research Articles

Project PLACE: Enhancing community and academic partnerships to describe and address health disparities.

Achieving cancer health equity is a national imperative. Cancer is the second leading cause of death in the United States and in North Carolina (NC), where the disease disproportionately impacts traditionally underrepresented race and ethnic groups, those who live in rural communities, the impoverished, and medically disenfranchised and/or health-disparate populations at high-risk for cancer. These populations have worse cancer outcomes and are less likely to be participants in clinical research and trials. It is critical for cancer centers and other academic health centers to understand the factors that contribute to poor cancer outcomes, the extent to which they impact the cancer burden, and develop effective interventions to address them. Key to this process is engaging diverse stakeholders in the development and execution of community and population health assessments, and the subsequent programs and interventions designed to address the need across the catchment area. This chapter describes the processes and lessons learned of the Duke Cancer Institute's (DCI) long standing community partnerships that led to Project PLACE (Population Level Approaches to Cancer Elimination), a National Cancer Institute (NCI)-funded community health assessment reaching 2315 respondents in 7 months, resulting in a community partnered research agenda to advance cancer equity within the DCI catchment area. We illustrate the application of a community partnered health assessment and offer examples of strategic opportunities, successes, lessons learned, and implications for practice.

Understanding the limitations of "quasi-mandatory" approaches to enrolment in community-based health insurance: Empirical evidence from Tanzania.

In recent decades, a growing number of low-income countries (LICs) have experimented with voluntary community-based health insurance (CBHI), as an instrument to extend social health protection to the rural poor and the informal sector. While modest successes have been achieved, important challenges remain with regard to the recruitment and retention of members, and the regular collection of membership fees. In this context, there is a growing consensus among policymakers that there is a need to experiment with mandatory approaches towards CBHI. In some localities in Tanzania, local actors in charge of community health funds (CHFs) are now relying on what is best described as quasi-mandatory enrolment strategies, such as increasing user fees for non-members, automatically enrolling beneficiaries of cash transfer programmes and enrolling the exempted groups (people who are entitled to free healthcare). We find that, while these quasi-mandatory enrolment strategies may temporarily increase enrolment rates, dropout and the non-payment of contributions remain important problems. These problems are at least partly related to supply side issues, notably to inadequate benefit packages. Overall, these findings indicate the limitations of any strategy to increase enrolment into CBHI, which is not coupled to clear improvements in the supply and quality of healthcare.

Looking at the bigger picture: how the wider health financing context affects the implementation of the Tanzanian Community Health Funds.

In Tanzania, the health financing system is extremely fragmented with strategies in place to supplement funds provided from the central level. One of these strategies is the Community Health Fund (CHF), a voluntary health insurance scheme for the informal rural sector. As its implementation has been challenging, we investigated different CHF implementation practices and how these practices and the wider health financing context affect CHF implementation and potentially enrolment. Two councils were purposively selected for this study. Routine data relevant for understanding CHF implementation in the wider health financing context were collected at council and public health facility level. Additionally, an economic costing approach was used to estimate CHF administration cost and analyse its financing sources. Our results showed the importance of considering different CHF implementation practices and the wider health financing context when looking at CHF performance. Exemption policies and healthcare-seeking behaviour influenced negatively the maximum potential enrolment rate of the voluntary CHF scheme. Higher revenues from user fees, user fee policies and fund pooling mechanisms might have furthermore set incentives for care providers to prioritize user fees over CHF revenues. Costing results clearly pointed out the lack of financial sustainability of the CHF. The financial analysis however also showed that thanks to significant contributions from other health financing mechanisms to CHF administration, the CHF could be left with more than 70% of its revenues for financing services. To make the CHF work, major improvements in CHF implementation practices would be needed, but given the wider health financing context and healthcare-seeking behaviours, it is questionable whether such improvements are feasible, scalable and value for money. Thus, our results call for a reconsideration of approaches taken to address the challenges in health financing and demonstrate that the CHF cannot be looked at as a stand-alone system.

Uptake of community health fund: why is Mtwara District lagging behind?

Uptake of community health fund: why is Mtwara District lagging behind?

Living with chronic pain: Evaluating patient experiences with a medical group visit focused on mindfulness and non-pharmacological strategies

ObjectivesLittle is known about the acceptance of non-pharmacological group strategies delivered to low income racially diverse patients with chronic pain and depression. This paper examines how the Integrative Medical Group Visit (IMGV) addresses many of the deficits identified with usual care. Design and settingSix IMGVs cohorts were held at a safety net hospital and two federally funded community health centres. Data was gathered through focus groups. Transcripts were analysed using both a priori codes and inductive coding. InterventionThe intervention included ten sessions of Integrative Medical Group Visits with a primary care provider and a meditation instructor. The curriculum uses principles of Mindfulness Based Stress Reduction and evidence based integrative medicine. The visit is structured similarly to other group medical visits. Main outcome measuresData was gathered through four focus groups held after the cohorts were completed. ResultsParticipants (N=20) were largely low income minority adults with chronic pain and comorbid depression. Six themes emerged from the coding including: chronic pain is isolating; group treatment contributes to better coping with pain; loss of control and autonomy because of the unpredictability of pain as well as dependence on medication and frequent medical appointments; groups improve agency and control over one’s health condition; navigating the healthcare system and unsatisfactory treatment options; and changes after the IMGV due to non-pharmacological health management. ConclusionsThe IMGV is a promising format of delivering integrative care for chronic pain and depression which addresses many of the problems identified by patients in usual care.

Implementation of the redesigned Community Health Fund in the Dodoma region of Tanzania: A qualitative study of views from rural communities.

The need to understand how an intervention is received by the beneficiary community is well recognised and particularly neglected in the micro-health insurance (MHI) domain. This study explored the views and reactions of the beneficiary community of the redesigned Community Health Fund (CHF) implemented in the Dodoma region of Tanzania. We collected data from focus group discussions with 24 groups of villagers (CHF members and nonmembers) and in-depth interviews with 12 key informants (enrolment officers and health care workers). The transcribed material was analysed thematically. We found that participants highly appreciate the scheme, but to be resolved are the challenges posed by the implementation strategies adopted. The responses of the community were nested within a complex pathway relating to their interaction with the implementation strategies and their ongoing reflections regarding the benefits of the scheme. Community reactions ranged from accepting to rejecting the scheme, demanding the right to receive benefit packages once enrolled, and dropping out of the scheme when it failed to meet their expectations. Reported drivers of the responses included intensity of CHF communication activities, management of enrolment procedures, delivery of benefit packages, critical features of the scheme, and contextual factors (health system and socio-political context). This study highlights that scheme design and implementation strategies that address people's needs, voices, and values can improve uptake of MHI interventions. The study adds to the knowledge base on implementing MHI initiatives and could promote interests in assessing the response to interventions within the MHI domain and beyond.

Decentralisation of Health Systems and the Fate of Community Health Fund in Tanzania: Critical Review of High and Low Performing Districts

The deterioration of health services provision in Tanzania from 1980s to 1990s made decentralization of health service provision through the Health Sector Reform (HSR) a necessity. HSR aimed at bringing better utilization of scarce resources, improved quality of health services, increasing user access and cutting rising costs. It is through HSR that health insurance schemes were introduced. Community Health Fund (CHF) came as a result of such efforts. The efficiency and effectiveness of CHF rests on district councils which are responsible for ensuring better performance of CHF. Although the Government of Tanzania targeted 85% of the population to be members of CHF, enrollment has remained as low as 9.2% by 2014. The most sticking problem is the variation in enrollment in different districts. There are districts with higher performance in CHF enrollment like Iramba (54%) and Bariadi (40.9%). Whereas, there are districts with very low enrollments in CHF like Liwale (8%), and Rungwe (6.5%). This paper is an effort to shed some light on this phenomenon ofperformance variation of CHF enrolment in districts. It argues that poor performing districts are constrained by their own weaknesses such as poor management and leadership capacities of Council Health Management Team (CHMT) and lack of motivation among health facility staff and allied health workers. Also, poor sensitization and mobilization of people to join CHF, as well as poor quality healthcare to people has deterred performance of CHF in some districts. The papers’ conclusion apart from offering recommendation also adds to the broader ongoing debate of decentralization process mainly through health insurance.

At Federally Funded Health Centers, Medicaid Expansion Was Associated With Improved Quality Of Care.

In 2014 many uninsured, low-income nonelderly adults gained access to health insurance in states that expanded Medicaid eligibility under the Affordable Care Act. Federally funded community health centers were likely to be particularly affected by this expansion because many of their patients were uninsured and low income. We used a difference-in-differences approach to compare changes among 1,057 such centers in expansion versus nonexpansion states from 2011 to 2014, in terms of their patients' insurance coverage, the number of patients they served, and the quality of care they provided. Medicaid expansion was associated with large increases (12 percentage points) in Medicaid coverage and corresponding declines (11 percentage points) in uninsurance rates. The numbers of patients served increased in both expansion and nonexpansion states, and the magnitude of increase did not differ significantly between the groups of states. Medicaid expansion was associated with improved quality on four of eight measures examined: asthma treatment, Pap testing, body mass index assessment, and hypertension control. This analysis suggests that states' decisions about Medicaid expansion have important consequences for health center patients, with expansion improving treatment and outcomes of chronic disease and bolstering the use of recommended preventive services.

Do Management and Leadership Practices in the Context of Decentralisation Influence Performance of Community Health Fund? Evidence From Iramba and Iringa Districts in Tanzania.

Background: In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country’s level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. Methods: A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. Results: There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. Conclusion: This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.

Factors affecting adoption, implementation fidelity, and sustainability of the Redesigned Community Health Fund in Tanzania: a mixed methods protocol for process evaluation in the Dodoma region

BackgroundDespite the implementation of various initiatives to address low enrollment in voluntary micro health insurance (MHI) schemes in sub-Saharan Africa, the problem of low enrollment remains unresolved. The lack of process evaluations of such interventions makes it difficult to ascertain whether their poor results are because of design failures or implementation weaknesses.ObjectiveIn this paper, we describe a process evaluation protocol aimed at opening the ‘black box’ to evaluate the implementation processes of the Redesigned Community Health Fund (CHF) program in the Dodoma region of Tanzania.DesignThe study employs a cross-sectional mixed methods design and is being carried out 3 years after the launch of the Redesigned CHF program. The study is grounded in a conceptual framework which rests on the Diffusion of Innovation Theory and the Implementation Fidelity Framework. The study utilizes a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews, and document review), and aligns the evaluation to the Theory of Intervention developed by our team. Quantitative data will be used to measure program adoption, implementation fidelity, and their moderating factors. Qualitative data will be used to explore the responses of stakeholders to the intervention, contextual factors, and moderators of adoption, implementation fidelity, and sustainability.DiscussionThis protocol describes a systematic process evaluation in relation to the implementation of a reformed MHI. We trust that the theoretical approaches and methodologies described in our protocol may be useful to inform the design of future process evaluations focused on the assessment of complex interventions, such as MHI schemes.

Birth preparedness and complication readiness – a qualitative study among community members in rural Tanzania

BackgroundBirth preparedness and complication readiness (BP/CR) strategies are aimed at reducing delays in seeking, reaching, and receiving care. Counselling on birth preparedness is provided during antenatal care visits. However, it is not clear why birth preparedness messages do not translate to utilisation of facility delivery. This study explores the perceptions, experiences, and challenges the community faces on BP/CR.DesignA qualitative study design using Focused Group Discussions was conducted. Twelve focus group discussions were held with four separate groups: young men and women and older men and women in a rural community in Tanzania. Qualitative content analysis was used to analyse the data.ResultsThe community members expressed a perceived need to prepare for childbirth. They were aware of the importance to attend the antenatal clinics, relied on family support for practical and financial preparations such as saving money for costs related to delivery, moving closer to the nearest hospital, and also to use traditional herbs, in favour of a positive outcome. Community recognised that pregnancy and childbirth complications are preferably treated at hospital. Facility delivery was preferred; however, certain factors including stigma on unmarried women and transportation were identified as hindering birth preparedness and hence utilisation of skilled care. Challenges were related to the consequences of poverty, though the maternal health care should be free, they perceived difficulties due to informal user fees.ConclusionsThis study revealed community perceptions that were in favour of using skilled care in BP/CR. However, issues related to inability to prepare in advance hinder the realisation of the intention to use skilled care. It is important to innovate how the community reinforces BP/CR, such as using insurance schemes, using community health funds, and providing information on other birth preparedness messages via community health workers.

Be Wise

Stroke is a leading cause of death for women, and midlife, low-income women are unlikely to appreciate their risk for stroke. The Well-Integrated Screening and Evaluation for Women Across the Nation program, administered by the Centers for Disease Control and Prevention Division for Heart Disease and Stroke Prevention, was developed for this population. The program offers screenings, referrals, and evidence-based lifestyle interventions targeting poor nutrition and physical inactivity. The goal of "Be Wise," the evidence-based lifestyle intervention developed for the Illinois Well-Integrated Screening and Evaluation for Women Across the Nation program, is for midlife women to develop healthier diet and physical-activity-related behaviors and, as a result, reduce their risk for heart disease and stroke. The goal of this project was to implement "Be Wise" at a federally funded community health center serving a primarily Hispanic population. The project's director, a stroke program coordinator and clinical nurse specialist, for the area's advanced primary stroke center collaborated with the community health center's medical staff and registered dietitian in delivering the program.

Social Capital and Willingness to Pay for Community Based Health Insurance: Empirical Evidence from Rural Tanzania

This study examines the effect of social capital on willingness to pay (WTP) for health services provided through community based health insurance schemes (Community Health Fund) in Tanzania. The study covered 274 household heads. We use probit regression analysis to model the relationship between the predictors and our outcome variable. Our results have shown that with the exception of religion, all other social capital variables have a positive and significant impact on the WTP for the Community Health Fund (CHF). Specifically, membership in social organisations and networks, trust among community members and trust of community members on scheme management are positively and significantly related to WTP. On the other hand, the age, education level, household size and number of children and participation in health insurance are not predicting WTP for CHF. Taken together, these results suggest that enhancing access to health care services in the rural areas and the sustainability of CHF would require building appropriate forms of social capital at individual and community levels. Specifically, CHF may increase enrolment through the existing social organisations and associations. Similarly, CHFs may well increase their membership if the avenues for trust building are created and nurtured.

Risk distribution across multiple health insurance funds in rural Tanzania.

IntroductionMultiple insurance funds serving different population groups may compromise equity due to differential revenue raising capacity and an unequal distribution of high risk members among the funds. This occurs when the funds exist without mechanisms in place to promote income and risk cross-subsidisation across the funds. This paper analyses whether the risk distribution varies across the Community Health Fund (CHF) and National Health Insurance Fund (NHIF) in two districts in Tanzania. Specifically we aim to 1) identify risk factors associated with increased utilisation of health services and 2) compare the distribution of identified risk factors among the CHF, NHIF and non-member households.MethodsData was collected from a survey of 695 households. A multivariate logisitic regression model was used to identify risk factors for increased health care utilisation. Chi-square tests were performed to test whether the distribution of identified risk factors varied across the CHF, NHIF and non-member households.ResultsThere was a higher concentration of identified risk factors among CHF households compared to those of the NHIF. Non-member households have a similar wealth status to CHF households, but a lower concentration of identified risk factors.ConclusionMechanisms for broader risk spreading and cross-subsidisation across the funds are necessary for the promotion of equity. These include risk equalisation to adjust for differential risk distribution and revenue raising capacity of the funds. Expansion of CHF coverage is equally important, by addressing non-financial barriers to CHF enrolment to encourage wealthy non-members to join, as well as subsidised membership for the poorest.

Health care seeking behaviour and utilisation in a multiple health insurance system: does insurance affiliation matter?

BackgroundMany countries striving to achieve universal health insurance coverage have done so by means of multiple health insurance funds covering different population groups. However, existence of multiple health insurance funds may also cause variation in access to health care, due to the differential revenue raising capacities and benefit packages offered by the various funds resulting in inequity and inefficiency within the health system. This paper examines how the existence of multiple health insurance funds affects health care seeking behaviour and utilisation among members of the Community Health Fund, the National Health Insurance Fund and non-members in two districts in Tanzania.MethodsUsing household survey data collected in 2011 with a sample of 3290 individuals, the study uses a multinomial logit model to examine the influence of predisposing, enabling and need characteristics on the probability of seeking care and choice of provider.ResultsGenerally, health insurance is found to increase the probability of seeking care and reduce delays. However, the probability, timing of seeking care and choice of provider varies across the CHF and NHIF members.ConclusionsReducing fragmentation is necessary to provide opportunities for redistribution and to promote equity in utilisation of health services. Improvement in the delivery of services is crucial for achievement of improved access and financial protection and for increased enrolment into the CHF, which is essential for broadening redistribution and cross-subsidisation to promote equity.

The administrative costs of community-based health insurance: a case study of the community health fund in Tanzania

Community-based health insurance expansion has been proposed as a financing solution for the sizable informal sector in low-income settings. However, there is limited evidence of the administrative costs of such schemes. We assessed annual facility and district-level costs of running the Community Health Fund (CHF), a voluntary health insurance scheme for the informal sector in a rural and an urban district from the same region in Tanzania. Information on resource use, CHF membership and revenue was obtained from district managers and health workers from two facilities in each district. The administrative cost per CHF member household and the cost to revenue ratio were estimated. Revenue collection was the most costly activity at facility level (78% of total costs), followed by stewardship and management (13%) and pooling of funds (10%). Stewardship and management was the main activity at district level. The administration cost per CHF member household ranged from USD 3.33 to USD 12.12 per year. The cost to revenue ratio ranged from 50% to 364%. The cost of administering the CHF was high relative to revenue generated. Similar studies from other settings should be encouraged.

<I>Cuidate</I>: Implementation of a Culturally Based Sexual Risk Reduction Program for Hispanic Adolescents

Birth rates for adolescents have been declining in the United States since 1991 for all races. However, the rate for Hispanic teens still remains significantly higher than those for White teens. The Centers for Disease Control and Prevention (CDC) recommends that community-based organizations implement evidence-based programs to address the risky sexual behaviors of adolescents. Cuidate is an evidence-based sexual risk reduction program designed specifically for Hispanic adolescents ages 13-18 years. The program uses Hispanic cultural beliefs to influence the use of abstinence and condoms as culturally accepted practices. The purpose of this article is to describe the implementation of Cuidate at a federally funded community health center to reduce the sexual risk behaviors of the adolescent Hispanic population it serves.

A gendered users′ perspective on decentralized primary health services in rural Tanzania

Since the 1990s, Tanzania has been implementing health sector reforms including decentralization of primary healthcare services to districts and users. The impact of the reforms on the access, quality and appropriateness of primary healthcare services from the viewpoint of users is, however, not clearly documented. This article draws on a gendered users' perspective to address the question of whether the delivery of gender-sensitive primary health services has improved after the reforms. The article is based on empirical data collected through a household survey, interviews, focus group discussions, case studies and analysis of secondary data in two rural districts in Tanzania. The analysis shows that the reforms have generated mixed effects: they have contributed to improving the availability of health facilities in some villages but have also reinforced inter-village inequalities. Men and women hold similar views on the perceived changes and appropriateness to women on a number of services. Gender inequalities are, however, reflected in the significantly low membership of female-headed households in the community health fund and their inability to pay the user fees and in the fact that women's reproductive and maternal health needs are as yet insufficiently addressed. Although over half of users are satisfied with the services, more women than men are dissatisfied. The reforms appear to have put much emphasis on building health infrastructure and less on quality issues as perceived by users.

Implementation of Community Health Fund in Tanzania: why do some districts perform better than others?

In early 1990s, Tanzania, like other African countries, introduced user fees in public health systems. Although user fees were considered important in promoting health, they appear to reduce people's access to health services. To counteract the detrimental effects of the user fees, various types of health insurances were introduced, including the Community Health Fund (CHF). Drawing from the review of minutes, health facility visits and key informant interviews, this study explored why implementation of the CHF in Tanzania has been more successful in some districts than in others. The findings indicate that in Lindi district, the enrolment rate for the CHF was very low. This was attributed to high premium rates, frequent drug stock-out, lack of trust by the community members to the health providers, low incentives and local politics. In contrast, in Iramba district, the performance was better. Availability of drugs in the health facilities, effective supervision, commitment of the top district-level officials and incentives to the health facility committees were the main factors that facilitated good performance of the fund in Iramba district. The focus of the implementation needs to be placed on the active engagement of the local-level leaders and politicians who are responsible for the implementation of the policy. Equally important is the availability of quality health services in the health facilities.

Feasibility of introducing compulsory community health fund in low resource countries: views from the communities in Liwale district of Tanzania

BackgroundIn 1995, Tanzania introduced the voluntary Community Health Fund (CHF) with the aim of ensuring universal health coverage by increasing financial investment in the health sector. The uptake of the CHF is low, with an enrolment of only 6% compared to the national target of 75%. Mandatory models of community health financing have been suggested to increase enrolment and financial capacity. This study explores communities’ views on the introduction of a mandatory model, the Compulsory Community Health Fund (CCHF) in the Liwale district of Tanzania.MethodsA cross-sectional study which involved 387 participants in a structured face to face survey and 33 in qualitative interviews (26 in focus group discussions (FGD) and 7 in in-depth interviews (IDI). Structured survey data were analyzed using SPSS version 16 to produce descriptive statistics. Qualitative data were analyzed using content analysis.Results387 people completed a survey (58% males), mean age 38 years. Most participants (347, 89.7%) were poor subsistence farmers and 229 (59.2%) had never subscribed to any form of health insurance scheme. The idea of a CCHF was accepted by 221 (57%) survey participants. Reasons for accepting the CCHF included: reduced out of pocket expenditure, improved quality of health care and the removal of stigma for those who receive waivers at health care delivery points. The major reason for not accepting the CCHF was the poor quality of health care services currently offered. Participants suggested that enrolment to the CCHF be done after harvesting when the population were more likely to have disposable income, and that the quality care of care and benefits package be improved.ConclusionsThe CHF is acceptable to the most of study participants and feasible in rural Tanzania as an alternative mechanism to finance health care for the rural poor. Community members are willing to join the scheme provided they are well informed, involved in the design and implementation, and assured quality health care. Strong political will and a supportive environment are key ingredients for the success of the CCHF.