BackgroundResearch on practical and effective governance of the health workforce is limited. This paper examines health system strengthening as it occurs in the intersection between the health workforce and governance by presenting a framework to examine health workforce issues related to eight governance principles: strategic vision, accountability, transparency, information, efficiency, equity/fairness, responsiveness and citizen voice and participation.MethodsThis study builds off of a literature review that informed the development of a framework that describes linkages and assigns indicators between governance and the health workforce. A qualitative analysis of Health System Assessment (HSA) data, a rapid indicator-based methodology that determines the key strengths and weaknesses of a health system using a set of internationally recognized indicators, was completed to determine how 20 low- and middle-income countries are operationalizing health governance to improve health workforce performance.Results/discussionThe 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalizing the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses emerging in the HSAs include difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers.ConclusionsThe breadth of challenges facing the health workforce requires strengthening health governance as well as human resource systems in order to effect change in the health system. Further research into the effectiveness of specific interventions that enhance the link between the health workforce and governance are warranted to determine approaches to strengthening the health system.
Participatory design (PD) is an emerging alternative to existing methods of user-centered design (UCD), and may be a more appropriate approach for designing patient-facing products in the health care sector than conventional UCD. Type 2 Diabetes Mellitus (T2D) is a serious chronic illness that requires life-long treatment and life-long self-management of food intake, physical activity, and self-testing to avoid complications. T2D disproportionately affects low-income minority communities. Using PD, we have developed an app to help T2D patients. Called the Diabetes Networking Tool (DNT), the app is intended to help patients better self-manage by empowering their network of family and friends to better contribute and support the patient’s self-management needs. PD was used to involve a low-income African American community into the process of identifying the specific problems and issues DNT needed to address. We then used multiple complementary analytical methods to condense and abstract the community inputs to yield a functional and user interface design for DNT.
IntroductionConditional cash transfers (CCTs) have become an important policy tool for increasing demand for key maternal and child health services in low/middle-income countries. Yet, these programs have had variable success in increasing service use. Understanding beneficiary preferences for design features of CCTs can increase program effectiveness.MethodsWe conducted a Discrete choice experiment in two districts of Uttar Pradesh, India in 2018 with 405 mothers with young children (<3 years). Respondents were asked to choose between hypothetical CCT programme profiles described in terms of five attribute levels (cash, antenatal care visits, growth-monitoring and immunisation visits, visit duration and health benefit received) and responses were analysed using mixed logit regression.ResultsMothers most valued the cash transfer amount, followed by the health benefit received from services. Mothers did not have a strong preference for conditionalities related to the number of health centre visits or for time spent seeking care; however, service delivery points were in close proximity to households. Mothers were willing to accept lower cash rewards for better perceived health benefits—they were willing to accept 2854 Indian rupees ($41) less for a programme that produced good health, which is about half the amount currently offered by India’s Maternal Benefits Program. Mothers who had low utilisation of health services, and those from poor households, valued the cash transfer and the health benefit significantly more than others.ConclusionBoth cash transfers and the perceived health benefit from services are highly valued, particularly by infrequent service users. In CCTs, this highlights the importance of communicating value of services to beneficiaries by informing about health benefits of services and providing quality care. Conditionalities requiring frequent health centre visits or time taken for seeking care may not have large negative effects on CCT participation in contexts of good service coverage.
Objectives
Conditional Cash Transfers (CCTs) are important national strategies to improve maternal and child health and nutrition. India recently began implementing a Maternity Benefit Program (MBP) to encourage health care use during pregnancy and early childhood; under discussion is to include child nutrition services within a CCT program. This paper aims to understand the preferences of mothers with young children for design features (cash transfer amount and conditionalities) of CCT programs.
Methods
We conducted a Discrete Choice Experiment in Uttar Pradesh, India where 405 mothers with children below three years of age were interviewed. Respondents were presented 18 hypothetical CCT program profiles defined by five attributes – cash transfer amount, number of ante-natal care visits, number of visits for child immunization/growth monitoring, time taken to complete a visit, and health benefit received (proxy for service quality). Conditional logit regression was used to analyze respondent choices.
Results
Mothers valued the amount of cash transfer, quality of services, and quicker health center visits. They did not have a strong preference for the number of visits required. Higher cash amounts are associated with greater probability of participation. For any given amount of cash amount, better service quality (produced better health) elicited greater participation. Mothers put high valuation on service quality; they were willing-to-pay (give up) INR 2858 ($41) for a program that produced good health. Without any cash transfer, only improving service quality from average to good would increase participation by 27%. A cash transfer amount of INR 6000 ($86, currently offered by MBP) combined with fair (good) quality services would increase participation by 78% (85%). Preference for CCT programs differed across sub-groups defined by prior users of government health services and socioeconomic status. Poor households valued a given cash transfer amount more than better-off households, while better-off households valued good health outcomes more than poorer households.
Conclusions
Aligning maternal and child health CCT programs with user preferences can increase program participation. This study provides guidance on incorporating user preferences in the CCT program design.
Funding Sources
Department of International Health, Johns Hopkins University.
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