Mainstream Health System Research Articles

The Barriers and Enablers of Primary Healthcare Service Transition From Government to Community Control in Yarrabah: A Grounded Theory Study.

Introduction: Consistent with the aspirations of First Nations Australians for community control of healthcare services, 123/196 (63%) of Australia's First Nations-specific primary health care services are community-controlled. Yet despite policy commitment over 30 years, the transition of government-run First Nations' primary healthcare services to First Nations community control has been slow. This paper identifies the barriers and enablers to transitioning the delivery of primary healthcare services from Queensland Health to Gurriny Yealamucka community-controlled health service in Yarrabah.Methods: Grounded theory methods were used to select 14 Gurriny and Queensland Health (QH) personnel involved in the transition for interview and to analyse these interview transcripts and 88 Gurriny organisational documents.Results: Barriers and enablers to transition were identified at three levels: those internal factors within Gurriny, external factors directly related to the government handover, and broader structural and policy factors outside the control of either Gurriny or QH. Barriers at the Gurriny organisational level were an internal lack of experience and capacity, and varying levels of community confidence; enablers were leadership stability and capacity, community mandate, relationships with partner organisations, and ability to provide service continuity. Barriers in Gurriny's relationship with QH were a lack of certainty, transparency and prioritisation of the transition process; systemic racism; difficulties obtaining and maintaining the necessary workforce; limited resources including insufficient, unstable and inappropriate funding support; and problems with information sharing; enablers were performance frameworks to keep transition progress on track. Barriers in broad policy environment were an unsupportive Queensland government policy environment; government bureaucracy; and delays, conflicts and divisions; enablers were high-level government support and commitment.Conclusions: The evaluation of Yarrabah's transition process suggests that future such transitions will require planning and commitment to a long-term, multi-faceted and complex process, encompassing the required level of authorisation and resourcing. This case example of a transition from government to community control of PHC highlighted the ongoing power issues that are faced every day by community-controlled organisations that co-exist with mainstream health systems within a colonial power structure.

Integrating Traditional Medicine and Healing into the Ghanaian Mainstream Health System: Voices From Within.

In this study, I employed interpretive ethnographic qualitative design to explore perceptions of and proposals from traditional healers, biomedical practitioners, and health care consumers regarding integrating traditional medicine and healing in Ghana. Data were gathered through focus groups, in-depth individual interviews, and qualitative questionnaires and analyzed thematically. The results revealed positive attitudes toward integrating traditional medicine in Ghana and a discursive discourse of power relations. The power imbalance between biomedical and traditional practitioners regarding what integrative models to adopt is sanctioned by formal education and institutional structure. As a result, multiple approaches for integration were made, including patient co-referrals, collaborations between biomedical and traditional medical practitioners, and creating a unit for traditional medicine and healers at the outpatients’ department for patients to choose either biomedicine or traditional medicine. Incorporating aspects of traditional healing in the training of biomedical practitioners and creating a space for knowledge sharing were also proposed. These integrative models reflected the distinctive interests of healers and biomedical practitioners. Considering these findings, I recommended policy options for consideration toward achieving an integrative health care system in Ghana.

Case Study of Ruqyah Therapy On Muslim Patient with Eczema

A case study on a female Malay living in the UK with serious eczema was presented. Her parents believed that it was a condition called santau, a common cultural belief in South East Asian countries. Santau is believed as the insertion of poisonous materials into the victim’s body with the help of jinn. Santau is normally differentiated from other medical skin conditions by the rapid deterioration of the condition and rapid improvement after successful treatment. Her skin condition was intolerable after a trip to Malaysia. Unable to be admitted to hospital because of the pressure on hospital beds during the Covid-19 pandemic, she resorted to intensive multiple-day ruqyah therapy, a therapy based on the incantation of verses from the Quran. Remarkable improvement was observed after three days. Apart from delivering therapeutic outcome, ruqyah therapy as a Traditional and Complementary Medicine has its role in relieving the pressure on the mainstream health system especially in time of pandemic.

Sustaining Tradition and Fulfilling Agreements on Traditional Medicine Since the Alma Ata Conference

Introduction: The implementation of traditional medicine strategies and their integration into the mainstream health systems by African governments has been a difficult process since its recommendation at the Alma Ata Conference of 1978. Objective: This paper seeks to review how traditional medicine has survivedand what various African countries have done to implement traditional healthcare strategies and their integration into the national health systems as recommended by the Alma Alta conference of 1978. Methodology: We purposively selected developed, middle income and African countries for the purpose of this review.We reviewed traditional medicine policies and programs in elevenpurposively selected countries from different political and economic blocks. We conducted a review of published works on traditional medicine implementation with more focus on the African continent. We have used the historical and thematic perspectives to obtain, organize and report data from published documents. Results: There is the public use of traditional medicine in every African country at very high proportions. African governments celebrate African Traditional Medicine Days. But very few African countries have fully implemented Alma Ata recommended traditional medicine strategies and integrated traditional medicine into their national health systems to the latter. Strong adherence to tradition has kept traditional medicine in African alive. However, the coronavirus pandemic (COVID-19) has revealed strong adherence of Africans and their governments to African Traditional Medicine. But the developed world sticks to standard conventional medical practices. This reverence is an acknowledgment of the truism that rather than integrating African medicine into conventional medicine, proponents of African medicine would want to operate parallel to conventional medicine or integrate it into the African medical system. Conclusion: African medicine exists in Africa as a culturally bound practice, therefore, providing solutions to health problems in situations where conventional medicine may not. It exists on its own without a real and strong legal framework to guide its practice because of its conflicting parallel validation methods to conventional medicine.

Operability, Usefulness, and Task-Technology Fit of an mHealth App for Delivering Primary Health Care Services by Community Health Workers in Underserved Areas of Pakistan and Afghanistan: Qualitative Study.

BackgroundThe recent proliferation of digital health technology in low- and middle-income countries has made it possible for community health workers (CHWs) to use mobile health (mHealth) to perform tasks such as data collection and training. Although most studies focus on the prospect of digital apps to motivate and connect CHW, only a few have captured end-user experiences with mobile-based apps. We examined the experience of frontline health workers with a move towards digitalized real-time data to record maternal and childcare services in remote areas of Afghanistan and Pakistan.ObjectiveOur study aimed to explore CHW perceptions on the operability of the mHealth app in a community setting, usefulness of the app in the delivery of assigned maternal and childcare functions, and the task-technology fit with monitoring information systems.MethodsThe Hayat app, designed to digitalize and facilitate electronic record keeping, was evaluated to be embedded into mainstream health systems. The app had 2 components: smartphone app for data entry and web dashboard for visualization of the maternal, newborn, and child health reports. Using a qualitative exploratory study design, we conducted a total of 8 focus group discussions with purposively selected lady health workers (LHWs) and CHWs in 3 districts of Pakistan and 3 hamlets of Afghanistan, respectively. Focus group discussions were conducted in the local language, audio recorded, and converted into expanded notes for thematic analysis.ResultsAlthough a majority of LHWs used the app with ease, some initially faced difficulties in operating it and requested a longer duration of training. Contrary to LHWs, the CHWs were able to use the app without difficulty, as they were using it only to register clients. Overall, use of the mHealth app in both countries resulted in a positive impact on health education sessions, easier communication with parents or clients, tracking of routine immunization defaulters and follow-ups, improved data validity, easily accessible vaccination schedules, and faster registration. In addition to building up their image in the community and personal development, the improved reporting and monitoring mechanisms also set the stage for the LHWs to get recognized for their hard work. CHWs in Afghanistan also reported the app provided immediate access to information when requested by their supervisor. Although the Hayat app eliminates the need to carry multiple registers and helps in recalling client information at the touch of a button, technical issues around connectivity and data inputting tabs were highlighted by the participants.ConclusionsThe digitization of records not only provided CHWs support in their daily routine but also strengthened monitoring mechanisms and improved motivation. We recommend conducting end user experience studies before embedding apps into mainstream health systems as high acceptability does not always result in high uptake of digital technology.

Barriers and enablers for Indigenous public health practitioners

Abstract Indigenous Maori Public Health Practitioners who work in mainstream public health systems experience significant barriers to workplace success and the barriers to positive public health impact in our communities. This is a Kaupapa Maori qualitative study that highlights the barriers and enablers to Maori Senior Public Health practitioners within Mainstream New Zealand Public Health Units. Given there are nearly 400 million Indigenous people worldwide, this is an opportunity to share recommendations from this research study with the global public health community about how to re-orient public health organisations and approaches to effectively address workforce development as well as improve engagement and impact in Indigenous communities. Key messages Indigenous knowledge is undervalued in Mainstream Public Health Systems. Indigenous inequities cannot be truly addressed unless providers re-orient themselves by authentically understanding Indigenous ways of working.

Multistakeholder Experiences of Providing, Receiving, and Setting Priorities for Lung Cancer Care in KwaZulu-Natal Province, South Africa

PURPOSE The purpose of the study was to explore the key stakeholders’—health care professionals, patients, and family caregivers—experiences of providing, receiving, and setting priorities for lung cancer care in KwaZulu-Natal, South Africa, with a view to propose potentially effective interventions for improved care. METHODS This was a qualitative study conducted in 5 communities and 3 hospitals offering oncology services in KwaZulu-Natal Province. Data were generated using in-depth interviews and the nominal group technique. Nineteen patients with lung cancer, 20 family caregivers (FCs) and 18 health care professionals (HCPs) were interviewed, with an additional subsample of 7 HCPs participating in the nominal group technique. Results were analyzed using thematic analysis. RESULTS Similar to patients with lung cancer and FCs, HCPs were concerned about the limited access to oncology services and poor lung cancer diagnostic facilities, as these also ranked high in HCPs’ priority settings. Limited access was attributed to a lack of lung cancer awareness and low lung cancer suspicion index among different stakeholders, a shortage of health care specialists, poor diagnostic equipment and general resource constraints, unavailability of diagnostic services at the lowest levels of health care (for example, primary health care), geographic location of specialized services, and poor multidisciplinary collaboration. Patients’ perceptions of the quality of care in public health facilities also affected their treatment-seeking behavior. Challenges experienced at the health care worker-patient level also affected the FCs. For example, FCs were psychosocially and economically affected by the caring responsibilities, which, in turn, was an important determinant of a patient’s care pathways. CONCLUSION As a result of this study, new approaches to lung cancer care are being explored, including increased community awareness, the introduction of well-equipped community mobile screening services, patient navigation to track patients, and building cadres for providing and integrating palliative care services into the mainstream health systems.

"There is anointing everywhere": An interpretative phenomenological analysis of the role of religion in the recovery of Black African service users in England.

WHAT IS KNOWN ON THE SUBJECT?: Religion plays important role in recovery from mental illness. Religion can have both positive and negative effects on recovery. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: It is conceivable for Black African service users (BASUs) to engage with the mainstream mental health services at the onset of their symptoms. BASUs see mental illness and recovery through the lens of religion. They mostly use Pentecostalism and traditional African healing systems to aid their recovery. The mainstream mental health system and the traditional African healing system exist in harmony for BASUs who are open to simultaneously access both services. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: There is a need to recognize that most Black Africans have unique ways of practising their Christianity. Thus, broad changes are needed in the services to support religious coping tailored to the individual persons in their recovery journey. There is a need for service providers and healthcare professionals to integrate Pentecostalism and traditional African healing systems into the recovery processes. It should equally be recognized that such changes could trigger confusion, dilemmas and paradoxes. Service providers and healthcare professionals must build partnership and collaborative working with cultural practitioners and the clergy from the Black African communities to facilitate recovery and address any misunderstandings. ABSTRACT: Introduction Religion is an important impetus for recovery. However, there has been little work examining the role of religion in recovery for Black African service users (BASUs) in England. Aim The aim of this study was to explore how religion influences recovery from mental illness for BASUs in England. Method Twelve Black African service users were purposively selected and interviewed using face-to-face semi-structured interviews. Data were analysed using interpretative phenomenological analysis (IPA). Results The study generates fascinating insights that BASUs views about mental illness and recovery are influenced by Pentecostalism and traditional African healing systems. Discussion The participants' perceptions of their mental illness experiences and recovery which are characterized by the pragmatism of Pentecostalism and cultural beliefs are consistent with what is reported in the literature. Implications for practice The findings of the study show that broad changes are needed to accommodate the religious coping of BASUs in their recovery journey.

Operability, Acceptability, and Usefulness of a Mobile App to Track Routine Immunization Performance in Rural Pakistan: Interview Study Among Vaccinators and Key Informants.

BackgroundThere has been a recent spate of mobile health (mHealth) app use for immunizations and other public health concerns in low- and middle-income countries. However, recent evidence has largely focused on app development or before-and-after effects on awareness or service coverage. There is little evidence on the factors that facilitate adoption of mHealth programs, which is critical to effectively embed digital technology into mainstream health systems.ObjectiveThis study aimed to provide the qualitative experiences of frontline health staff and district managers while engaging with real-time digital technology to improve the coverage of routine childhood immunization in an underserved rural district in Pakistan.MethodsAn Android-based app was iteratively developed and used for a 2-year period in 11 union councils of the Tando Muhammad Khan district, an underserved rural district with poor immunization coverage in Pakistan. We used iterative methods to examine the (1) acceptability and operability of the app, (2) validity of the collected data, and (3) use of the collected data. In addition, we collected the barriers and enablers for uptake of the mHealth app. Each of these topics was further explored related to changes in work as well as the enabling factors for and barriers to app use. In-depth interviews were conducted with the 26 vaccinators posted in the 11 union councils and 7 purposively selected key informants (government district managers) involved with the Expanded Program for Immunization. Findings were triangulated in line with the three broad research areas.ResultsDigital immunization tracking was considered acceptable by vaccinators and district managers. Real-time immunization data were used to monitor vaccination volume, track children with incomplete vaccinations, develop outreach visit plans, correct existing microplans, and disburse a fuel allowance for outreach sessions. The validity of the app data was perceived to be superior to that of data from manual records. Ease of operability, satisfaction with data, personal recognition, links to field support, and a sense of empowerment served as powerful enablers. Taking twice the time to complete both manual and digital entries and outdated phones over time were considered constraints. An unintended knock-on effect was improved coordination and strengthening of Expanded Program for Immunization review platforms across district stakeholders through digitalized data.ConclusionsEmbedding digital technology into mainstream health systems relies on use by both end users and district stakeholders. Ease of operability, satisfaction with data reliability, personal recognition, links to field support, and empowerment are powerful enablers, whereas improved coordination as a result of easy, transparent data access can be an important by-product of digitalization. Findings are relevant not only for wide-scale implementation of immunization tracking apps in Pakistan but also for informing the use of digital technology for results-based delivery by frontline health workers.

Listening and Learning: A Case for Indigenous Conceptualizations of the Learning Health System

Mainstream health systems fail to support Indigenous peoples’ health and must be reorganized with guidance from Indigenous knowledges and ways of knowing if they are to gain relevance and address t...

Health, faith and therapeutic landscapes: Places of worship as Black, Asian and Minority Ethnic (BAME) public health settings in the United Kingdom

Within the United Kingdom, there is evidence that faith-based affiliations, ideas, actors and organisations play a role in public health (PH) that has been neither properly recognised nor integrated into mainstream health systems (November, 2014). Discourses on faith and improving health outcomes have been particularly focused on 'seldom heard' groups, including 'Black, Asian and Minority Ethnic' (BAME) communities (November, 2014; Jain, 2014; Burton et al., 2017; Muhammad, 2018). In this paper we first present findings from a qualitative scoping study carried out in the UK cities of Leeds and Bradford, between 2014 and 2015, which examined Places of Worship (PWs) as BAME PH settings. We carried out 19 semi-structured interviews with purposively selected respondents, and three focus groups. Second, we develop a theory that originates from one in the sub-discipline of 'health geography' concerned with 'therapeutic landscapes', applying it to our research findings on PWs as BAME PH settings. The paper argues for the recentring of religion and faith settings back into the therapeutic landscapes literature, reflecting evidence that faith-based affiliations, ideas, actors and organisations are relevant to the pursuit of health and wellbeing. We also contend that a therapeutic landscapes framework provides a way of making the health relevance of PWs visible to both health practitioners and to members of PWs. We argue that PWs act as therapeutic places (i.e. specific transformative sacred sites) as well as therapeutic spaces (i.e. settings that provide adjuncts to formal PH promotion services), and are often part of therapeutic networks included in 'kinship groups and networks of care provided by family, friends, therapists and other agents of support' (Smyth, 2005: 490). This approach allows us to see how influences on health behaviour are not just confined to biomedical settings, but that the 'healing process works itself out in places (or situations, locales, settings and milieus)' (Gesler, 1992: 743).

Integrating traditional medical knowledge into mainstream healthcare in Limpopo Province

In most African states, the majority of the population depend on indigenous healing knowledge for their healthcare. This knowledge is in danger of being obliterated due to a number of factors such as it being not documented, low life expectancy where people die before transferring it to the next generation and the governments failing to incorporate it into the mainstream health system that is often overloaded. This qualitative study adopted a hermeneutic phenomenology to investigate the development of a framework to integrate knowledge of traditional healing into the mainstream healthcare system in the Limpopo province. Data were collected through interviews with traditional healers chosen through snowball sampling technique augmented by observations and analysis of legislation, notes, records and other forms of documents held by healers. Data were analysed and interpreted thematically according to the objectives of the study. The study established that indigenous medical knowledge is marginalised, and healers are not getting support from the government despite the important role they play in the national health systems. Traditional healing is not properly regulated creating a loophole for anyone to practise as a healer. A framework that points the link factors that attempt to create an understanding of how knowledge of traditional healing can be managed and integrated into the mainstream healing is proposed. It is concluded that failure to recognise traditional healing and integrate it in the mainstream health system will continue to hamstring the health system with resources in South Africa.

Turning mirrors into windows: Knowledge transfer among indigenous healers in Limpopo province of South Africa

Background: Knowledge transfer is an unavoidable process when it comes to indigenous knowledge especially in Africa, the continent known for its oral tradition. Such knowledge is in danger of being obliterated as a result of a number of factors, including lack of interest from younger generations and low life expectancy whereby knowledgeable people die before transferring it to the next generation as it is mostly not documented. Objectives: This qualitative study utilised hermeneutic phenomenology guided by the organisational knowledge conversion theory to investigate the transfer of indigenous knowledge by traditional healers in the Limpopo province of South Africa. Method: The study utilised a snowball sampling technique to determine the population. Data collected through interviews with traditional healers were augmented with observations done on two healers who were in the middle of their training when this study was conducted, as well as an analysis of records held by some healers. Results: The findings suggestthat knowledge of traditional healing is believed to be transferred to the chosen ones through dreams and visions. However, this knowledge seems to be transferred through mentorship and apprenticeship, as well as interactions with other healers. Conclusion: It is concluded that transferring knowledge of traditional healing goes beyond just transference; it is embedded as a belief system in many African communities. An in-depth study on the development of a framework to integrate indigenous knowledge of traditional healers into mainstream health system is recommended.

Transforming First Nations’ health governance in British Columbia

Purpose The purpose of this paper is to present a study of the transformation of First Nations’ health governance, describing the development of partnerships between First Nations and provincial and federal governments for co-creating solutions to address First Nations’ health inequities in British Columbia (BC). The paper frames this transformation in the context of a Canada-wide reconciliation initiative stimulated by the Truth and Reconciliation Commission. Design/methodology/approach This qualitative case study was a joint initiative between Simon Fraser University and the BC First Nations Health Authority (FNHA), involving interviews with senior leaders within the BC health system, FNHA and First Nations communities. In addition, a policy roundtable was held in February 2015 which gathered 60 participants for further dialogue on the process. Findings Key themes included: partnership and relationships, governance and reciprocal accountability, First Nations perspectives on health and wellness, and quality and cultural safety. Findings indicate that significant transformational changes have happened in the relationship between First Nations and the mainstream health system. The creation of the FNHA has led to more representation for First Nations people at all levels of governance and health service planning, which will ultimately lead to more culturally safe health services that incorporate a First Nations perspective of wellness. Social implications The transformation of First Nations health governance in BC can serve as an example in other indigenous health settings both within Canada and internationally. Originality/value This paper describes a transformative health governance process in First Nations communities that is an historical first in Canada.

Situational analysis and future directions of AYUSH: An assessment through 5-year plans of India.

AYUSH is an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homeopathy. These are the six indigenous systems of medicine practiced in India. A department called Department of Indian System of medicine was created in March 1995 and renamed to AYUSH in November 2003 with a focus to provide increased attention for the development of these systems. Very recently, in 2014, a separate ministry was created under the union Government of India, which is headed by a minister of state. Planning regarding these systems of medicine was a part of 5-year planning process since 1951. Since then many developments have happened in this sector albeit the system was struggling with a great degree of uncertainty at the time of 1st5-year plan. A progressive path of development could be observed since the first to the 12th5-year plan. It was up to the 7thplan the growth was little sluggish and from 8thplan onward the growth took its pace and several innovative development processes could be observed thereafter. The system is gradually progressing ahead with a vision to be a globally accepted system, as envisaged in 11th5-year plan. Currently, AYUSH system is a part of mainstream health system implemented under National Rural Health Mission (NRHM). NRHM came into play in 2005 but implemented at ground level in 2006 and introduced the scheme of “Mainstreaming of AYUSH and revitalization of local health traditions” to strengthen public health services. This scheme is currently in operation in its second phase, since 1stApril 2012, with the 12th5-year plan. The scheme was primarily brought in to operation with three important objectives; choice of treatment system to the patients, strengthen facility functionally and strengthen the implementation of national health programmes, however, in some places it seems to be a forced medical pluralism owing to a top-down approach by the union government without considerable involvement of the concerned community. In this study, the 5-year planning documents have been reviewed, from the 1stplan to 12thplan, to enable reflection and throw some light into the future directions of AYUSH system.

Room for improvement: complementary therapy users and the Australian health system.

People with chronic conditions who are often in contact with the health-care system are well placed to reflect on how services meet their needs. Some research characterizes people who use complementary and alternative medicines (CAMs) as a distinct group who opt out of the mainstream health system. However, many CAM users are people with chronic or terminal health conditions who concurrently use mainstream health-care services. The difference in perspectives between people with chronic conditions who do or do not use CAM has received little attention by researchers. To explore the views of CAM users with chronic conditions and identify their perspectives on the health system. In-depth interviews and a self-administered questionnaire were used to collect data on care-seeking, self-management and CAM use among people with type 2 diabetes and/or cardiovascular disease living in Victoria, Australia. One in four CAM practitioner users was partly motivated to use CAM as a result of their dissatisfaction with the mainstream health system. In general, their dissatisfaction mirrored the concerns of the general population. This included the perceived lack of a humanistic or person-centred approach, which was central to problems relating to individuals' clinical encounters as well as to health system design. Participants' concerns suggest room for improvement in the Australian health system to better reflect patients' needs. A systems approach is needed to reorient health-care practitioners to modify the organization of care because of the incentives embedded in the structure of the health-care system.

Traditional Anishinabe Healing in a Clinical Setting: The Development of an Aboriginal Interdisciplinary Approach to Community-based Aboriginal Mental Health Care

Traditional medicine has been practiced by Aboriginal people for thousands of years at the community level. It is still practiced today outside of the mainstream health system by many Aboriginal people. However, providing this type of care in a clinical, health centre setting and in co-operation with western treatment methods is new, and requires a merging of traditional Aboriginal and western medical world views in order to develop protocols for service delivery that ensure the integrity of both systems. The groundwork required to ensure the safety of clients, providers, and organizations within the new integrated system is still largely undocumented. To address this gap, we studied factors that support the successful integration of traditional Aboriginal healing and western mental health care approaches, and document the experiences of clients and providers. To accomplish this we contextualize 10 years of experience of traditional healing services development with in-depth interviews and focus groups with 17 community service providers and 23 clients. We found that the development of traditional healing protocols, inter-professional education for providers and community members and a focus on client access to traditional Anishinabe health services provide the basis for the integration of western and traditional healing practices in the model under study. Our findings show integrated care resulted in positive experiences for clients and providers. We conclude that traditional healing approaches can be successfully integrated with clinical mental health services. Further research is necessary to improve our understanding of client experiences with this integrated approach and the impact on wholistic health and well-being.

Tuberculosis in children: getting started on the road to zero.

In 2011, of the 8.7 million new tuberculosis cases in the world, approximately 0.5 million occurred in children, representing at least 6% of the global burden.1 But do we truly know the child tuberculosis burden? Is a global tuberculosis death rate of 71 000 children per year1 accurate when these data do not include the tuberculosis-related deaths that are classified as due to human immunodeficiency virus (HIV) infection, pneumonia or malnutrition? Childhood tuberculosis is receiving much needed attention of late as we gear up to reaching Millennium Development Goal Number 5 (to reduce child mortality) and the new ambitious World Health Organization (WHO) post-2015 targets for tuberculosis prevention, treatment and care. In this issue of the Journal, Dendup et al. present child tuberculosis data from Bhutan, representing 14% of the total burden.2 Bhutan is a small South-East Asian country with a free national health care system and no private practitioners. This is an example of child tuberculosis care integration into the mainstream health system, leading to better health care provider awareness and hundred per cent case notification. These findings are similar to national data reported from Malawi, where all children access the same health care system and registration with the National Tuberculosis Programme (NTP) is required to receive treatment.3 Another study in this issue, by Ade, compares child tuberculosis data from a general hospital with data from basic health units in Cotonou, Benin, a small West African country.4 This study highlights issues such as underreporting of children with tuberculosis from the hospital, lack of age-disaggregated data, poor access to HIV testing in the hospital for children with tuberculosis, and lack of training in child tuberculosis for health workers, leading to missed opportunities in case detection. Similar issues are echoed in other studies, such as underreporting of childhood tuberculosis in East Java,5 enhanced child TB case detection following private practitioner involvement in Karachi 6 and following health worker training in Bangladesh.7 The WHO post-2015 tuberculosis strategy highlights the information gap that child tuberculosis needs to fill and the difficulty in setting targets in the absence of baseline data. Despite existing NTP policies, national child tuberculosis guidelines and efforts to decentralise care, a policy-practice gap exists in most high-burden countries. Child contact management and active case finding are policies that are rarely implemented. Recent efforts to include child tuberculosis in NTP reviews and to provide technical assistance and training in child tuberculosis, with a push towards its integration with existing child care services, are a step in the right direction. Efforts to engage the community, civil society and the private sector with a strong focus on a family-centred approach and prevention will cast a wider net for early detection of child tuberculosis. Filling research gaps in child tuberculosis, along with the development of a point-of-care diagnostic test, child-friendly drugs and vaccines, urgently demands attention. The Bhutan study is an example of how, with additional training in diagnosis and management, good child tuberculosis care is possible under programmatic conditions in high burden settings.

It hinges on the door: Time, spaces and identity in Australian Aboriginal Health services

This paper explores how the structuring of places and time influence Aboriginal and Torres Strait Islander patient and carer experiences of health services. Face-to-face in-depth interviews were conducted with urban Aboriginal and Torres Strait Islander people with diabetes, chronic heart failure or chronic obstructive pulmonary disease as well as family carers (N = 19). Content analysis was undertaken. Participants report that each element of the time spent in Aboriginal Medical Services is seen as more valuable and worthwhile than in mainstream health services, from social and health sharing experiences in the waiting room to health care in clinical places; and that users feel they can rely on sufficient time and respectful care in their clinical consultation. Purposeful design of both physical and temporal aspects of health services is called for. We suggest re-introducing opportunities for spatiotemporal design in health care that have been limited by the segmented ‘person as illness’ design features of Australia’s current mainstream health system.

Indigenous Health Organizations in Australia: Connections and Capacity

The health of Aboriginal people is significantly worse than that of the rest of the Australian population. Aboriginal community-controlled health organizations live with uncertainty in terms of funding, and the amount of money spent on indigenous people through mainstream health services is less than that spent on the non-indigenous population, especially when the different needs of these two groups are taken into account. The Aboriginal population is small and widely dispersed, causing problems for policy and funding. This article provides an analysis of the network of health organizations in Victoria, with a specific focus on indigenous health, and analyzes the connections between mainstream and indigenous-specific health services. The research approach involved semi-structured interviews with informants from a range of health organizations within the state. This research illustrates the importance of Aboriginal community-controlled health organizations to the indigenous community. There is evidence that connections between the indigenous and mainstream health systems need to be further developed and strengthened to provide the indigenous population with a high-quality, culturally sensitive, and comprehensive health service.