WHO Health System Research Articles

Examining Macro-Level Barriers and Facilitators to Scaling Up Integrated Care from a Complexity Perspective: A Multi-Case Study of Cambodia, Slovenia, and Belgium.

The 'Scale-Up diaBetes and hYpertension care' (SCUBY) project provides evidence on scaling-up integrated care (IC) in Cambodia, Slovenia, and Belgium. This paper examines macro-level barriers and facilitators to scaling up IC in these settings. We used a multi-case study design, with each country being a case. Document review, focus groups, and stakeholder interviews were conducted. The WHO health system building blocks guided the thematic analysis. We then visualised and examined the interlinkages between barriers in each country. Common challenges to scaling up IC across the three health systems relate to: governance and leadership; health workforce; inadequate health financing system; and fragmented health information systems. In Cambodia, access to non-communicable disease (NCD) services and medicine are important issues. IC scale-up is facilitated by its strong governance and public health service model in Slovenia but health workforce shortages risk progress. In Belgium, the fragmented governance system and predominant fee-for-service provider payment are important barriers. A common response to health workforce and workload challenges was task shifting: to primary care nurses in Belgium, peer supporters in Slovenia, and community health workers in Cambodia. Examining differences and similarities between barriers in each health system stimulated reciprocal learning. Interactions between health system barriers in specific contexts require further attention to move complex health systems forward.

The WHO health system performance assessment applied to child healthcare in Luxembourg, 2011-2022

Abstract Background Health System Performance Assessments (HSPAs) evaluate health systems in terms of their objectives and their overall goals, such as access to quality services and health improvement. Beyond the overall health system assessment, HSPA can evaluate performance in providing care to specific populations. We assessed the response of the Luxembourg health system to children’s particular health needs, by populating the WHO HSPA framework for universal healthcare with child-specific indicators. Methods We searched international databases, guidelines, policy documents, and the scientific literature to identify child-specific indicators suitable for assessing the health system objectives as defined by the WHO HSPA framework. To select the most relevant indicators, we conducted expert appraisal regarding feasibility, validity and actionability. Those indicators were calculated based on available national data. To explore inequities within the system, we performed socioeconomic stratifications. Results Twenty-nine indicators were used to populate the framework, sourced from social security databases (n = 15), monitoring and surveillance (n = 11), and surveys (n = 2). For effectiveness assessment, we used 11 indicators and found that preventive services performed best for children under two years. Five indicators showed good accessibility to primary and secondary care. Another five indicators assessed safety indicating a recent increase in the relative use of broad-spectrum antimicrobials and an overuse of caesarean sections. Additional disaggregation of three indicators didn’t expose socioeconomic inequities in service delivery. Data gaps exist to assess children’s user-experience and financing of child health services. Conclusions The WHO HSPA framework proved valuable for evaluating the Luxembourg health system’s performance for children. We identified good performance in accessibility and effectiveness for young children, alongside data gaps to assess user-experience. Key messages • The application of national child-specific indicators to the WHO health system performance assessment, highlighted strengths in accessibility and effectiveness while also pointing to key data gaps. • We used the WHO health system performance assessment (HSPA) to evaluate the health system for children in Luxembourg. This exercise enhances the development of a tailored national HSPA framework.

2.L. Round table: Monitoring health reforms to inform policy innovation: the Health Systems and Policies Monitor

Abstract Background The European Observatory on Health Systems and Policies’ (Observatory) Health Systems and Policy Monitor (HSPM) network convenes an international group of around 50 national health systems researchers from over 40 institutions across 31 high-income countries, including all EU countries, Canada, Israel, the UK and the US. In advance of the HSPM annual meeting, experts share the current year’s “top-three” health reforms in their countries via a standardized survey, soliciting details on content and general implementation processes. Reforms are iteratively organized into to 2 of 11 clusters, derived from the WHO health system building blocks. Experts then discuss background, status and content of national reforms in the year’s main clusters and initiate cross-country collaborations. A repository of over 650 reforms since 2018 has been created and is available online, showcasing reform patterns in HSPM countries. The collected data have informed studies on reform trends in HSPM countries from 2018-2019 and between 2020-2022, with work ongoing. Data are also consulted by researchers and policymakers wishing to learn about and from reforms in other countries. This workshop specifically aims to: • Inform participants about the methodologies used by the HSPM network to track reforms • Highlight common trends in major health reforms across countries since 2018 • Discuss national health reforms and the value of understanding and tracking these across countries • Identify research gaps in reform monitoring relevant to policy makers • Discuss how the health system research community can generate more relevant and actionable evidence Added-value The comparative analysis of reform trends provides insights into how systems operate and the types of reforms more likely to be implemented. The sharing of these insights also serves as a source of inspiration, allowing countries to learn from each other’s successes and failures and adopt proven best practices. This is relevant for policymakers and researchers striving to support health systems strengthening. Therefore, the workshop will support knowledge exchange between researchers and policymakers by (1) informing researchers and policymakers about similar ongoing reforms in other countries and (2) identifying areas where researchers can contribute to country reform agendas, and (3) stimulating interest in cross-country collaborative research on similar and topical reforms in different countries. Format This is a roundtable workshop chaired and moderated by the Observatory. An overview of reform trends and patterns since 2018 will set the scene, followed by an interactive discussion with policymakers and HSPM network members to (1) delve into trend dynamics and implications for health policy and research and (2) identify major (missing) research areas relevant to policymakers. In addition, we will leverage the geographic scope and expertise of the audience to reflect on the value of monitoring reforms. Key messages • Cross-country exchange of information on reform trends and implementation patterns can inspire future reforms and help policymakers identify promising policy approaches abroad. • Knowledge exchange between researchers and policymakers helps to determine evidence gaps and to generate relevant and actionable evidence that can drive policy innovation. Speakers/Panelists Reinhard Busse Berlin University of Technology, Berlin, Germany Ines Fronteira National School of Public Health - NOVA University of Lisbon, Lisbon, Portugal Iwona Kowalska-Bobko Jagiellonian University Medical College, Institute of Public Health, Cracow, Poland Isabel de La Mata DG SANTE, European Commission, Luxembourg, Luxembourg Vesna-Kestrin Petric Ministry of Health, Ljubljana, Slovenia

Factors influencing vaccination up-take among nomadic population in four regions of Ghana: a qualitative study

BackgroundVaccination has contributed to the reduction in vaccine preventable diseases. Despite, improved global coverage, vaccination among nomadic populations is still low especially in Africa. This study explored factors influencing vaccination uptake among pastoralist nomads in Ghana.MethodsWe conducted key informant interviews (KII) in 11 districts across four regions of Ghana, using grounded theory qualitative research approach. One hundred and eighty-two KII were conducted among pastoralist nomads, community opinion leaders, community health volunteers, security services personnel, local government personnel and health workers. Guided by the WHO health systems building blocks, data was coded using Nvivo 12 and analysed thematically. Results were presented as narratives with excerpts to support the findings.ResultsCommunity leaders support vaccination among pastoralist nomads as part of their leadership and governance responsibilities. Language barrier between health workers and pastoralist nomads affects service delivery. Also, healthcare providers fear being attacked by pastoralist nomads hence are hesitant to visit their settlements for vaccination. With regards to health workforce, healthcare providers’ perceived use of derogatory words and discrimination against pastoralist nomads influence their vaccination uptake. On medical product, the lack of knowledge about diseases, severity and perceived negative effects about vaccines influence vaccination uptake. Inadequate funds and logistics at the district health directorates affects outreach to nomads during vaccinations. Leveraging existing partnership between the health services and community leaders, information centers, volunteers and butchers to send health information to pastoralist nomads influence vaccination uptake.ConclusionCommunity leaders support vaccination among pastoralist nomads. Nomadic pastoralist miss vaccination dues to language barrier, feel discriminated against, and lack information about diseases and vaccinations. Strengthening Ghana Health Service collaboration with leaders of pastoralist nomads could build trust, create awareness and overcome language barrier between healthcare providers and pastoralist nomads.

Health policy and systems research priority-setting exercise in Ethiopia: a collaborative approach

IntroductionHealth policy and systems research (HPSR) is a multi-disciplinary approach of generating health system and policy-level evidence. Setting HPSR agendas is considered as an efficient strategy to map and identify policy and cost-effective research topics, but its practice in developing countries is limited. This paper aimed to conduct a collaborative health policy and system research priority-setting exercise in Ethiopia.MethodThe WHO’s plan, implement, publish, and evaluate (PIPE) framework and the Delphi technique were used to conduct the priority-setting exercise. The PIPE model was used to lead the priority-setting process from planning to evaluation, while the Delphi technique was used to run the rating and ranking exercise with the aim of reaching a consensus. Two rounds of expert panel workshops supplemented with an online survey were used for the HPSR agenda setting, rating and ranking purposes. Groups were formed using the WHO health system building blocks as a base framework to identify and prioritize the HPSR topics.ResultUnder 8 themes, 32 sub-themes and 182 HPSR topics were identified. The identified research themes include leadership management and governance, health policy, health information system, healthcare financing, human resource for health, medical products and supply, service delivery and cross-cutting issues.ConclusionsPriority HPSR topics focussing on national health priority issues were identified. The identified topics were shared with policymakers and academic and research institutions. Evidence generation on the identified priority topics will guide future research endeavours and improve evidence-informed decision-making practice, health system performance and national health goals and targets.

To What Extent Are Informal Healthcare Providers in Slums Linked to the Formal Health System in Providing Services in Sub-Sahara Africa? A 12-Year Scoping Review.

The contributions of informal providers to the urban health system and their linkage to the formal health system require more evidence. This paper highlights the collaborations that exist between informal providers and the formal health system and examines how these collaborations have contributed to strengthening urban health systems in sub-Sahara Africa. The study is based on a scoping review of literature that was published from 2011 to 2023 with a focus on slums in sub-Sahara Africa. Electronic search for articles was performed in Google, Google Scholar, PubMed, African Journal Online (AJOL), Directory of Open Access Journals (DOAJ), ScienceDirect, Web of Science, Hinari, ResearchGate, and yippy.com. Data extraction was done using the WHO health systems building blocks. The review identified 26 publications that referred to collaborations between informal providers and formal health systems in healthcare delivery. The collaboration is manifested through formal health providers registering and standardizing the practice of informal health providers. They also participate in training informal providers and providing free medical commodities for them. Additionally, there were numerous instances of client referrals, either from informal to formal providers or from formal to informal providers. However, the review also indicates that these collaborations are unformalized, unsystematic, and largely undocumented. This undermines the potential contributions of informal providers to the urban health system.

Implementation factors of non-communicable disease policies and programmes for children and youth in low-income and middle-income countries: a systematic review

IntroductionDespite declared life-course principles in non-communicable disease (NCD) prevention and management, worldwide focus has been on older rather than younger populations. However, the burden from childhood NCDs has mounted; particularly...

Die Bevölkerungsperspektive in der Bewertung der Leistungsfähigkeit des deutschen Gesundheitssystems: Ergebnisse einer Querschnittsbefragung GKV-Versicherter

IntroductionSince the World Health Report in 2000, Health System Performance Assessment (HSPA) has been established as a tool for the evaluation and evidence-informed governance of health systems. So far, the population perspective has not been integrated into HSPA in a systematic manner, although people's experiences and expectations are of great importance to improve health systems and especially to strengthen patient-centered care. Therefore, this study aims to conduct an HSPA of Germany's health system from the population's perspective covering all eight goals of WHO’s Health Systems Framework, and to identify strengths and needs for improvement. MethodsIn 2018, 32,000 people insured with the German sickness fund ‘AOK Nordost’ were invited by mail to participate in the survey. The questionnaire contained a total of 43 items covering the eight goals of WHO's Health Systems Framework (e.g., access, quality, safety) plus socioeconomics and other characteristics of the insured persons. The data on the health system goals were analyzed descriptively and by subgroups (age, sex, income, chronic conditions, health literacy). ResultsThe sample (n=1,481; response rate 4.6%) was 54.8% female and had a mean age of 59.1 years (±18.5). Altogether, the participants saw several needs for improvement within the German health system. For instance, 60.0% found quality differences between hospitals to be big, and between 3.9% and 8.5% reported mistakes related to their treatment or prescription medication in the previous two years. A big need for reform was especially seen regarding out-of-pocket payments (51.5%) and the coordination of ambulatory care physicians among each other (44.2%) and with hospitals (41.9%). In addition, big subgroup differences were seen, especially for income and health literacy. Of the participants in the lower income group, 37.2% reported a (very) strong financial burden due to out-of-pocket payments (vs. 20.7%). People with limited health literacy (52.1%) assessed the access to care generally as not being good, and they perceived greater quality differences and needs for reform, compared to their counterparts. For instance, 36.6% had experienced discrimination in the previous year (vs. 19.9%). DiscussionThe survey results provide a comprehensive picture of Germany's health system from the population perspective. In some areas, previous findings were confirmed (e.g., a lack of coordination between providers). Other results expand existing knowledge (e.g., the role of health literacy in health care provision) or raise new questions (e.g., the difference between the subjectively assessed burden from out-of-pocket payments and the objective measures currently used). The great differences between subgroups are a call to action on the level of both politics and practice to better consider the individual's needs in order to make health better for everyone. Further research could provide deeper insights in this regard. ConclusionStrengthening the population perspective in HSPA allows for a better understanding and evaluation of health systems and, in particular, helps to identify areas for improvement in patient-centered care.

Health system responsiveness to the mental health needs of Syrian refugees: mixed-methods rapid appraisals in eight host countries in Europe and the Middle East.

Syrian refugees have a high burden of mental health symptoms and face challenges in accessing mental health and psychosocial support (MHPSS). This study assesses health system responsiveness (HSR) to the MHPSS needs of Syrian refugees, comparing countries in Europe and the Middle East to inform recommendations for strengthening MHPSS systems. A mixed-methods rapid appraisal methodology guided by an adapted WHO Health System Framework was used to assess HSR in eight countries (Egypt, Germany, Jordan, Lebanon, Netherlands, Sweden, Switzerland, and Türkiye). Quantitative and qualitative analysis of primary and secondary data was used. Data collection and analysis were performed iteratively by multiple researchers. Country reports were used for comparative analysis and synthesis. We found numerous constraints in HSR: i) Too few appropriate mental health providers and services; ii) Travel-related barriers impeding access to services, widening rural-urban inequalities in the distribution of mental health workers; iii) Cultural, language, and knowledge-related barriers to timely care likely caused by insufficient numbers of culturally sensitive providers, costs of professional interpreters, somatic presentations of distress by Syrian refugees, limited mental health awareness, and stigma associated to mental illness; iv) High out-of-pocket costs for psychological treatment and transportation to services reducing affordability, particularly in middle-income countries; v) Long waiting times for specialist mental health services; vi) Information gaps on the mental health needs of refugees and responsiveness of MHPSS systems in all countries. Six recommendations are provided to address these issues. All eight host countries struggle to provide responsive MHPSS to Syrian refugees. Strengthening the mental health workforce (in terms of quantity, quality, diversity, and distribution) is urgently needed to enable Syrian refugees to receive culturally appropriate and timely care and improve mental health outcomes. Increased financial investment in mental health and improved health information systems are crucial.

Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries

Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44). This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).

Development of indicators to measure health system capacity for quality abortion care in 10 countries: a rapid assessment of a measurement framework and indicators

IntroductionA significant gap exists in the availability of indicators and tools to monitor health system capacity for quality abortion care at input and process levels. In this paper, we describe...

3D Printing Approach in Maxillofacial Surgery in Iran: An Evaluation Using the Non-Adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) Framework

The integration of 3D printing technology in maxillofacial surgery in Iran represents a significant advancement in medical practice, offering unprecedented precision and efficiency in surgical procedures. Employing the Non-Adoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework and the WHO Health Systems Framework, this study analyzes the complex impact and challenges of 3D printing adoption within the Iranian healthcare sector. Maxillofacial surgery has seen transformative progress with 3D printing’s ability to produce accurate surgical models and customized implants. The results indicate a notable improvement in surgical precision and patient recovery times, alongside combatting identified barriers including technological access, cost, and skill acquisition. This conclusion underscores the critical need for targeted educational programs, policy support, and infrastructure development to overcome these obstacles. This paper highlights 3D printing’s potential to revolutionize maxillofacial surgery in Iran, provided that comprehensive strategies are implemented to address the current limitations and fully leverage this innovative technology’s benefits.

The impact of devolution on local health systems: Evidence from Greater Manchester, England

Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. We evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach.We estimated the impact of devolution until February 2020 on 98 measures of health system performance, using the generalised synthetic control method and adjusting for multiple hypothesis testing. We selected measures from existing monitoring frameworks to populate the WHO Health System Performance Assessment framework. The included measures captured information on health system functions, intermediatory objectives, final goals, and social determinants of health. We identified which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents.Life expectancy (0.233 years, S.E. 0.012) and healthy life expectancy (0.603 years, S.E. 0.391) increased more in GM than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with social determinants of health, including a reduction in alcohol-related admissions (−110.1 admission per 100,000, S.E. 9.07). In contrast, the impact on outpatient, mental health, maternity, and dental services was mixed.Devolution was associated with improved population health, driven by improvements in health services and wider social determinants of health. These changes occurred despite limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-making across health, social care, and wider public services in the region.

Learning from the End of the Public-Private Partnership for Lesotho's National Referral Hospital Network.

Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP. We assessed successes and challenges to performance of the QMMH-IN PPP. We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis. Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility. The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

‘It’s about time’: policymakers’ and health practitioners’ perspectives on implementing fertility care in the Gambian health system

BackgroundInfertility is a major health issue worldwide, yet very few examples of interventions addressing infertility in the Global South have been documented to date. In The Gambia, West Africa, infertility is recognised as a burden and the health authorities have included it in several health policies and the new National Reproductive Health Strategy however, a detailed operationalisation plan for fertility care has not yet been established. Here, we aim to understand and document the factors that influence the implementation of fertility care in The Gambia.MethodsWe conducted 46 semi-structured interviews with policymakers, implementers, and health practitioners in both the public and private sectors from July to November 2021. The interviews were transcribed, anonymised and analysed with NVivo Pro version 1.6.1. The analysis was initially inductive, with themes arising from the coding categorised according to the WHO health systems building blocks framework.ResultsThis study identified several barriers to a successful implementation of fertility care in The Gambia, including (i) a lack of routinely collected infertility data; (ii) an absence of financial protection mechanisms for patients, and/or a specific budget for infertility; (iii) limited cooperation between the public and private sectors in the provision of fertility care; and (iv) gaps in fertility care training among health practitioners. Conversely, enablers included: (i) strong national infertility leadership; and (ii) the integration of infertility care within public reproductive health services.ConclusionThe Gambian health system is not yet in the position to support a comprehensive fertility care package in its public health facilities. Several aspects of the implementation of fertility care must be considered in operationalising the health strategy including the systematic collection of infertility data, fertility awareness, and the provision of specialised fertility care training. Furthermore, a stronger partnership between the public and private sectors must be developed. Given the increasing availability of assisted reproductive technologies in the sub-Saharan Africa region, and the tendency to locate these technologies in the private sector, further research is needed to understand and identify the processes underlying the implementation of fertility care and to foster better integration with the existing health system.

What makes health systems resilient? An analytical framework drawing on European learnings from the COVID-19 pandemic based on a multitiered approach

IntroductionThe COVID-19 pandemic posed an unprecedented challenge, which caught many health systems widely unprepared. The aim of this research was to develop a comprehensive analytical framework on health system resilience...

Exploring how non-clinical factors in childbirth care shape users’ experiences in public health facilities in rural Chiapas, Mexico: a qualitative study using the WHO health systems responsiveness framework

IntroductionMany Mexicans face barriers to receive delivery care from qualified professionals, especially indigenous and poor sectors of the population, which represent most of the population in the state of Chiapas. When access to institutional delivery care is an option, experiences with childbirth care are often poor. This underscores the need for evidence to improve the quality of services from the user’s perspective. The present study was conceived with the objective of understanding how non-clinical aspects of care shape women’s birthing experiences in public health institutions in Chiapas.MethodsWe conducted an exploratory qualitative study. Data collection consisted in 20 semi-structured interviews to women who had delivered in a public health facility in Chiapas during the last six months prior to the interview. For the design of the interview guide we used the WHO health system responsiveness framework, which focus on the performance of the health system in terms of the extent to which it delivers services according to the “universally legitimate expectations of individuals” and focuses on the non-financial and non-clinical qualities of care. The resulting data were analyzed using thematic analysis methodology.ResultsWe identified a total of 16 themes from the data, framed in eight categories which followed the eight domains of the WHO health systems responsiveness framework: Choice of the provider and the facility, prompt attention, quality of basic amenities, access to social support, respectful treatment, privacy, involvement in decisions, and communication. We shed light on the barriers women face in receiving prompt care, aspects of health facilities that impact women’s comfort, the relevance of being provided with adequate food and drink during institutional delivery, how accompaniment contributes positively to the birthing experience, the aspects of childbirth that women find important to decide on, and how providers’ interpersonal behaviors affect the birthing experience.ConclusionsWe have identified non-clinical aspects of childbirth care that are important to the user experience and that are not being satisfactorily addressed by public health institutions in Chiapas. This evidence constitutes a necessary first step towards the design of strategies to improve the responsiveness of the Chiapas health system in childbirth care.

Politics and implications on the health systems preparedness to COVID-19 pandemic response: The Malawian experience.

The spread of the COVID-19 disease to Africa has raised concerns around the resultant effects on the fragile and non-resilient health systems. Malawi reported its first COVID-19 cases in early April 2020 at the time of the country's political turmoil, as the courts ruled for a re-run of presidential elections in July 2020 due to irregularities observed in the May 2019 elections. Therefore, assessing the implications of politics on the COVID-19 health systems preparedness is critical to design health systems strengthening efforts during the pandemic. We applied the WHO health systems framework to assess the implications of politics on the COVID-19 on the Malawi health systems preparedness. There was the population's lack of trust in government hampering government efforts, which posed as a huge concern for Malawi to navigate through the pandemic including the health systems preparedness for the pandemic. This, coupled with mass demonstrations by the public disagreeing with the Lockdown and health service providers put across their COVID-19 related demands. The political environment and the trust people have in the government determines a country's response to a pandemic. In a pandemic situation like COVID-19, the government's ability to coordinate the various key stakeholders while instilling trust in people remain critical in strengthening health systems to contain and mitigate the pandemic. However, the Malawi political turmoil highlighted in this paper derailed the process and efforts to contain the and timely prepare the health systems to manage the pandemic whilst maintaining its core functions of delivering essential health services. Therefore, governments should consider the effects of political challenges in supporting a country's health system to prepare for pandemics.

A qualitative study examining the health system's response to COVID-19 in Sierra Leone.

The paper examines the health system's response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013-16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients' experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients' livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.

Task shifting healthcare services in the post-COVID world: A scoping review.

Task shifting (TS) is the redistribution of healthcare services from specialised to less-qualified providers. Need for TS was intensified during COVID-19. We explore what impact TS had on service delivery during the pandemic and examine how the pandemic affected TS strategies globally. We searched five databases in October 2022, namely Medline, CINAHL Plus, Elsevier, Global Health and Google Scholar. 35 citations were selected following the PRISMA-ScR guidelines. We analysed data thematically and utilised the WHO health systems framework and emergent themes to frame findings. We uncovered instances of TS in countries across all income levels. 63% (n = 22) of the articles discussed the impact of TS on healthcare services. These encompassed services related to mental healthcare, HIV, sexual and reproductive health, nutrition and rheumatoid diseases. The remaining 37% (n = 13) focused on how the pandemic altered strategies for TS, particularly in services related to mental healthcare, HIV, hypertension, diabetes and emergency care. We also found that studies differed in how they reported TS, with majority using terms "task shifting", followed by "task sharing", "task shifting and sharing" and "task delegation". Our analysis demonstrates that TS had a substantial impact across healthcare systems. Modifying roles through training and collaboration strengthened workforce and enhanced diagnostic services. Strategic leadership played a crucial role in the process. More research on the financial aspects of TS during pandemics is required. Stakeholders generally accepted TS, but transferring staff between healthcare programs caused unintended disruptions. The pandemic reshaped TS, moving training, patient care and consultations to digital platforms. Virtual interventions showed promise, but digital access remained a challenge. Healthcare organisations adapted by modifying procedures, pathways and staff precautions. We recommend refining strategies for TS, and expanding on it to address workforce shortages, improve access, and enhance services, not only during crises but also beyond.