Assessing equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda: a cross-sectional survey

BMC Health Services Research, Volume 22, No. 1, Year 2022

Interpretation

Background: The vast majority of refugees are hosted in low and middle income countries (LMICs), which are already struggling to finance and achieve universal health coverage for their own populations. While there is mounting evidence of barriers to health care access facing refugees, there is more limited evidence on equity in access to and affordability of care across refugee and host populations. The objective of this study was to examine equity in terms of health needs, service utilisation, and health care payments both within and between South Sudanese refugees and hosts communities (Ugandan nationals), in two districts of Uganda. Methods: Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Twenty host villages and 20 refugee villages were randomly selected from each district, and 30 households were sampled from each village, with a target sample size of 2400 households. The survey measured condition incidence, health care seeking and health care expenditure outcomes related to acute and chronic illness and maternal care. Equity was assessed descriptively in relation to household consumption expenditure quintiles, and using concentration indices and Kakwani indices (for expenditure outcomes). We also measured the incidence of catastrophic health expenditure- payments for healthcare and impoverishment effects of expenditure across wealth quintiles. Results: There was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for refugees and hosts. Service coverage for acute, chronic and antenatal care was similar among hosts and refugee communities. However, lower levels of delivery care access for hosts remain. Although maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor, the costs of acute and chronic care can be substantial and regressive and are largely responsible for catastrophic expenditures, with service access benefiting wealthier groups. Conclusions: Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects. Further research examining cost drivers and potential financing arrangements to offset these will be important. Uganda is host to the third largest population of refugees globally, and the largest in sub-Saharan Africa, estimated at 1.5 million people [1]. Approximately 960,000 of these originate from South Sudan [28], displaced as a result of ongoing violence which broke out in December 2013 [29]. The vast majority of South Sudanese refugees live in seven settlements alongside host communities in the northwest of the country [30]. Uganda has a pluralistic health system, with government health facilities (which provide care without formal user fees) operating alongside private and not-for-profit organisations [27]. In 2018, the year of the latest available national health accounts, out of pocket payments constituted 41% of total health expenditure, while government expenditure represented just 16% [31]. Historically, refugees had access to dedicated primary healthcare facilities which were managed and funded by the United Nations High Commissioner for Refugees (UNHCR), with access to government hospital referral services. This resulted in perceived inequities between host and refugee communities in service access and tensions between these communities. However, from the early 2000s, refugee and host health services were integrated into a single health system under local government control. All health facilities in refugee settlements are now owned by the Ugandan government, and health services are run and funded by the government, with additional financial and material support provided by the UNHCR and other humanitarian actors towards health services within refugee districts [10, 32, 33]. The integration of refugee and host health services means that host populations can access the same health facilities as refugees for free [34, 35]. South Sudanese refugees in Uganda have substantial need for mental health and psychosocial support as a result of their experience of conflict and displacement [36]. There is also evidence that refugees in Uganda have greater health needs than those in host communities, with 51 percent of refugee households in Uganda defined as in need, compared to 17 percent of host households [37]. This study was conducted in two districts in Uganda: Arua, in the Northern region of the country, and Kiryandongo, in the Western region. Both districts are home to sizeable settlements of South Sudanese refugees: Rhino Camp (in Arua) has a population of 131,000, and the Kiryandongo refugee settlement has a population of 75,000 [28] . Rhino Camp is 70km from the main host town Arua, while the Kiryandongo settlement is just 5km from Bweyale town. Refugees in Rhino Camp tend to be more recent arrivals than those in Kiryandongo, who have generally been living in Uganda longer [28]. Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Every village was defined as either a host village if more than 50% of the population were Ugandan nationals, or a refugee village otherwise. A two-stage sampling approach was taken. Twenty host villages and 20 refugee villages were randomly selected from each district. Thirty households from each village were selected randomly through door-to-door household visits, and were eligible for inclusion if the household contained at least one woman of reproductive age (15-49 years). In host villages, only host households were eligible for inclusion in the survey, and in refugee villages only refugee households were eligible. In households with more than one woman of reproductive age, a pre-assigned table of random numbers was used to randomly select an interviewee, so no two women were interviewed from the same household [38]. A sample size calculation was undertaken based on estimating a prevalence of 50% for any given outcome, 30 respondents per cluster and intra-cluster correlation coefficient of 0.1 (design effect 3.9), and a 95% confidence interval and margin of error of 4%. This gave a target sample size of 1200 refugee and 1200 host women of reproductive age, or 80 villages. The survey was conducted through in-person interviews in English and Arabic, and data was entered on tablets using SurveyCTO platform. Interviews lasted approximately 45 minutes and were conducted by a team of 25 trained enumerators in July-August 2019. Data were collected on individual and household characteristics, healthcare need, care seeking and costs of care as outlined below. We examined equity across illness incidence as a measure of health need, health care seeking and health care expenditure outcomes. We included three measures of healthcare need, for acute sickness, chronic sickness and maternal care. Households were defined as having experienced acute sickness if anyone in the household had a short-term illness in the two weeks preceding the survey, and chronic sickness if anyone in the household had a long-lasting illness in the preceding month. Acute sickness was defined as an illness or injury that occurs suddenly with a rapid onset, and tends to resolve quickly on their own or with medical treatment, or is so severe and fast acting that a patient does not survive. Chronic sickness was defined as an illness which has a slow progression that builds over time, and tends to be a long lasting problem requiring multiple visits to a health facility. Women were defined as having need for maternal care if they reported having delivered a baby in Uganda in the preceding year. Care seeking for households with acute or chronic sickness was defined as the sick household member having attended a public health centre, hospital or private clinic (excluding traditional healers, herbalists and community health workers) during the recall period (two weeks for acute sickness and one month for chronic sickness) . The two measures of cares seeking for maternal care were four or more antenatal care (ANC) visits, and facility-based delivery. Women were defined as having had four or more ANC visits if they reported seeking ANC at least four times during their pregnancy, regardless of timing or facility type. They were defined as having a facility-based delivery if the baby was delivered at a health centre, hospital or private clinic. Annual healthcare expenditures were estimated for acute and chronic care. Annual acute and chronic care costs were defined as the total expenditure on medicines, tests and consultation fees for any acute or chronic sickness in the household in the preceding two weeks (for acute care) or one month (chronic care), multiplied by 26 (acute care) or 12 (chronic care) to estimate annual expenditures. Maternal care costs were defined as the total expenditure on all reported components of ANC received before a delivery in Uganda in the last year and all costs of the delivery (including fees, and medicines). We estimated equity in relation to household wealth, measured as reported monthly household consumption expenditure, and adjusted per adult equivalent. Consumption expenditure was considered a more reliable measure of ability to pay than income, which is often under-reported in developing countries [39]. We generated two measures of financial protection to monitor progress towards UHC, catastrophic health expenditure and impoverishment by health expenditure. Catastrophic expenditure was defined for categories of care (acute, chronic, and maternal) and all care at two thresholds, 10% and 25% of household expenditure. Households were defined as poor if their daily consumption expenditure per adult equivalent was below the international poverty line of 1.9USD per day (2011 PPP prices). The number of adult equivalents in the household was calculated using the formula adult equivalents = (children × 0.33 + adults)0.9. As household size was reported categorically, households reporting 5 or 6 members were given a nominal size of 5.5, and households reporting 9+ members a nominal size of 9. As we did not have numbers of children and adults in the household separately, the number of household members who were adults was estimated indirectly from other questions about the respondent’s circumstances. We did this by summing the respondent herself, and any adults the respondent reported living with either as husbands, non-husband heads of household, or other women of reproductive age, as the number of adults. All other members of the household were assumed to be children. Households were defined as being impoverished by health expenditure if their adult equivalent consumption expenditure exceeded $1.90 per day, but subtracting their total annualised health expenditure from their total annualised expenditure pushed them below the international poverty line. We generated quintiles of household consumption expenditure by ranking households based on expenditure per adult equivalent and dividing them into five equally sized groups from richest to poorest. We first described the characteristics of the overall sample, as well as separately for refugees and hosts, using descriptive statistics. We compared these to the same statistics drawn from the 2016 Demographic and Health Survey for the national Ugandan population [40]. We analysed equity in relation to condition incidence, service utilisation and expenditures across household wealth quintiles, measured by their reported monthly household consumption expenditure per adult equivalent. We estimated concentration indices to assess whether the distribution of outcomes was pro-rich (positive index value) or pro-poor (negative index value) [39] using the conindex command in Stata. The Gini index was used to estimate wealth inequality, and the Kakwani index, defined as the Gini index subtracted from the concentration index (CI), was used to estimate the progressivity of health expenditures [41]. The Gini index can vary between 0 and 1, with 0 indicating perfect wealth equality (the population having exactly the same wealth) and 1 maximum inequality. The Kakwani index can vary between -1 and 1, with negative values indicating the poor contribute a higher share of their income, or a regressive financing system, 0 indicating perfectly proportional expenditure and positive values indicating progressive contributions, whereby the richest pay a higher proportion of their income. Dominance tests were carried out to ascertain whether the concentration indices were significantly pro-rich or pro-poor, and whether the Kakwani index was significantly progressive or regressive. We finally estimated the incidence of catastrophic and impoverishing health expenditure outcomes across the whole sample, and comparing refugee and host communities.

AI Digest

Study Justification:

This study aimed to assess the equity of access and affordability of care among South Sudanese refugees and host communities in two districts in Uganda. The justification for this study is based on the need to understand the barriers to healthcare access facing refugees and to examine the equity in access to and affordability of care between refugee and host populations. This is important because the majority of refugees are hosted in low and middle-income countries that are already struggling to achieve universal health coverage for their own populations.

Highlights:

1. The study found that there was higher health need for acute and chronic conditions in wealthier groups, while maternal care need was greater among poorer groups for both refugees and host communities.
2. Service coverage for acute, chronic, and antenatal care was similar among host and refugee communities. However, lower levels of delivery care access for hosts remain.
3. Maternal care services are now largely affordable in Uganda among the studied communities, and service access is generally pro-poor. However, the costs of acute and chronic care can be substantial and regressive, leading to catastrophic expenditures that disproportionately affect wealthier groups.

Recommendations:

1. Efforts are needed to enhance access among the poorest for acute and chronic care and reduce associated out-of-pocket payments and their impoverishing effects.
2. Further research is needed to examine the cost drivers of healthcare and potential financing arrangements to offset these costs.

Key Role Players:

1. Government of Uganda: Responsible for managing and funding health facilities in refugee settlements and providing healthcare services to both refugees and host communities.
2. United Nations High Commissioner for Refugees (UNHCR): Provides financial and material support to the government for health services within refugee districts.
3. Humanitarian actors: Provide additional support to the government for health services within refugee districts.

Cost Items for Planning Recommendations:

1. Enhanced access to acute and chronic care for the poorest: This would include costs for expanding healthcare facilities, training healthcare providers, and providing subsidies or waivers for healthcare services.
2. Reducing out-of-pocket payments: This would involve costs for implementing health insurance schemes or other financing mechanisms to reduce the financial burden on individuals seeking healthcare.
3. Research on cost drivers and financing arrangements: This would include costs for conducting further research, data collection, analysis, and dissemination of findings.
Please note that the cost items provided are general categories and not actual cost estimates. The actual costs would depend on the specific context and implementation strategies.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is robust, with a large sample size and a two-stage sampling approach. The authors used various measures to assess equity in access to and affordability of care, including concentration indices and Kakwani indices. The results provide valuable insights into the health needs, service utilization, and healthcare payments among South Sudanese refugees and host communities in Uganda. However, to improve the evidence, the authors could consider including more details on the methodology, such as the specific data collection methods and statistical analysis techniques used. Additionally, providing information on the limitations of the study would further enhance the strength of the evidence.

Abstract

Uganda is host to the third largest population of refugees globally, and the largest in sub-Saharan Africa, estimated at 1.5 million people [1]. Approximately 960,000 of these originate from South Sudan [28], displaced as a result of ongoing violence which broke out in December 2013 [29]. The vast majority of South Sudanese refugees live in seven settlements alongside host communities in the northwest of the country [30]. Uganda has a pluralistic health system, with government health facilities (which provide care without formal user fees) operating alongside private and not-for-profit organisations [27]. In 2018, the year of the latest available national health accounts, out of pocket payments constituted 41% of total health expenditure, while government expenditure represented just 16% [31]. Historically, refugees had access to dedicated primary healthcare facilities which were managed and funded by the United Nations High Commissioner for Refugees (UNHCR), with access to government hospital referral services. This resulted in perceived inequities between host and refugee communities in service access and tensions between these communities. However, from the early 2000s, refugee and host health services were integrated into a single health system under local government control. All health facilities in refugee settlements are now owned by the Ugandan government, and health services are run and funded by the government, with additional financial and material support provided by the UNHCR and other humanitarian actors towards health services within refugee districts [10, 32, 33]. The integration of refugee and host health services means that host populations can access the same health facilities as refugees for free [34, 35]. South Sudanese refugees in Uganda have substantial need for mental health and psychosocial support as a result of their experience of conflict and displacement [36]. There is also evidence that refugees in Uganda have greater health needs than those in host communities, with 51 percent of refugee households in Uganda defined as in need, compared to 17 percent of host households [37]. This study was conducted in two districts in Uganda: Arua, in the Northern region of the country, and Kiryandongo, in the Western region. Both districts are home to sizeable settlements of South Sudanese refugees: Rhino Camp (in Arua) has a population of 131,000, and the Kiryandongo refugee settlement has a population of 75,000 [28] . Rhino Camp is 70km from the main host town Arua, while the Kiryandongo settlement is just 5km from Bweyale town. Refugees in Rhino Camp tend to be more recent arrivals than those in Kiryandongo, who have generally been living in Uganda longer [28]. Participants were recruited from host and refugee villages from Arua and Kiryandongo districts. Every village was defined as either a host village if more than 50% of the population were Ugandan nationals, or a refugee village otherwise. A two-stage sampling approach was taken. Twenty host villages and 20 refugee villages were randomly selected from each district. Thirty households from each village were selected randomly through door-to-door household visits, and were eligible for inclusion if the household contained at least one woman of reproductive age (15-49 years). In host villages, only host households were eligible for inclusion in the survey, and in refugee villages only refugee households were eligible. In households with more than one woman of reproductive age, a pre-assigned table of random numbers was used to randomly select an interviewee, so no two women were interviewed from the same household [38]. A sample size calculation was undertaken based on estimating a prevalence of 50% for any given outcome, 30 respondents per cluster and intra-cluster correlation coefficient of 0.1 (design effect 3.9), and a 95% confidence interval and margin of error of 4%. This gave a target sample size of 1200 refugee and 1200 host women of reproductive age, or 80 villages. The survey was conducted through in-person interviews in English and Arabic, and data was entered on tablets using SurveyCTO platform. Interviews lasted approximately 45 minutes and were conducted by a team of 25 trained enumerators in July-August 2019. Data were collected on individual and household characteristics, healthcare need, care seeking and costs of care as outlined below. We examined equity across illness incidence as a measure of health need, health care seeking and health care expenditure outcomes. We included three measures of healthcare need, for acute sickness, chronic sickness and maternal care. Households were defined as having experienced acute sickness if anyone in the household had a short-term illness in the two weeks preceding the survey, and chronic sickness if anyone in the household had a long-lasting illness in the preceding month. Acute sickness was defined as an illness or injury that occurs suddenly with a rapid onset, and tends to resolve quickly on their own or with medical treatment, or is so severe and fast acting that a patient does not survive. Chronic sickness was defined as an illness which has a slow progression that builds over time, and tends to be a long lasting problem requiring multiple visits to a health facility. Women were defined as having need for maternal care if they reported having delivered a baby in Uganda in the preceding year. Care seeking for households with acute or chronic sickness was defined as the sick household member having attended a public health centre, hospital or private clinic (excluding traditional healers, herbalists and community health workers) during the recall period (two weeks for acute sickness and one month for chronic sickness) . The two measures of cares seeking for maternal care were four or more antenatal care (ANC) visits, and facility-based delivery. Women were defined as having had four or more ANC visits if they reported seeking ANC at least four times during their pregnancy, regardless of timing or facility type. They were defined as having a facility-based delivery if the baby was delivered at a health centre, hospital or private clinic. Annual healthcare expenditures were estimated for acute and chronic care. Annual acute and chronic care costs were defined as the total expenditure on medicines, tests and consultation fees for any acute or chronic sickness in the household in the preceding two weeks (for acute care) or one month (chronic care), multiplied by 26 (acute care) or 12 (chronic care) to estimate annual expenditures. Maternal care costs were defined as the total expenditure on all reported components of ANC received before a delivery in Uganda in the last year and all costs of the delivery (including fees, and medicines). We estimated equity in relation to household wealth, measured as reported monthly household consumption expenditure, and adjusted per adult equivalent. Consumption expenditure was considered a more reliable measure of ability to pay than income, which is often under-reported in developing countries [39]. We generated two measures of financial protection to monitor progress towards UHC, catastrophic health expenditure and impoverishment by health expenditure. Catastrophic expenditure was defined for categories of care (acute, chronic, and maternal) and all care at two thresholds, 10% and 25% of household expenditure. Households were defined as poor if their daily consumption expenditure per adult equivalent was below the international poverty line of 1.9USD per day (2011 PPP prices). The number of adult equivalents in the household was calculated using the formula adult equivalents = (children × 0.33 + adults)0.9. As household size was reported categorically, households reporting 5 or 6 members were given a nominal size of 5.5, and households reporting 9+ members a nominal size of 9. As we did not have numbers of children and adults in the household separately, the number of household members who were adults was estimated indirectly from other questions about the respondent’s circumstances. We did this by summing the respondent herself, and any adults the respondent reported living with either as husbands, non-husband heads of household, or other women of reproductive age, as the number of adults. All other members of the household were assumed to be children. Households were defined as being impoverished by health expenditure if their adult equivalent consumption expenditure exceeded $1.90 per day, but subtracting their total annualised health expenditure from their total annualised expenditure pushed them below the international poverty line. We generated quintiles of household consumption expenditure by ranking households based on expenditure per adult equivalent and dividing them into five equally sized groups from richest to poorest. We first described the characteristics of the overall sample, as well as separately for refugees and hosts, using descriptive statistics. We compared these to the same statistics drawn from the 2016 Demographic and Health Survey for the national Ugandan population [40]. We analysed equity in relation to condition incidence, service utilisation and expenditures across household wealth quintiles, measured by their reported monthly household consumption expenditure per adult equivalent. We estimated concentration indices to assess whether the distribution of outcomes was pro-rich (positive index value) or pro-poor (negative index value) [39] using the conindex command in Stata. The Gini index was used to estimate wealth inequality, and the Kakwani index, defined as the Gini index subtracted from the concentration index (CI), was used to estimate the progressivity of health expenditures [41]. The Gini index can vary between 0 and 1, with 0 indicating perfect wealth equality (the population having exactly the same wealth) and 1 maximum inequality. The Kakwani index can vary between -1 and 1, with negative values indicating the poor contribute a higher share of their income, or a regressive financing system, 0 indicating perfectly proportional expenditure and positive values indicating progressive contributions, whereby the richest pay a higher proportion of their income. Dominance tests were carried out to ascertain whether the concentration indices were significantly pro-rich or pro-poor, and whether the Kakwani index was significantly progressive or regressive. We finally estimated the incidence of catastrophic and impoverishing health expenditure outcomes across the whole sample, and comparing refugee and host communities.

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as text messaging and mobile apps, to provide pregnant women and new mothers with important health information, reminders for prenatal and postnatal care appointments, and access to teleconsultations with healthcare providers.

2. Community Health Workers: Training and deploying community health workers (CHWs) who can provide essential maternal health services, including antenatal care, postnatal care, and health education, in remote or underserved areas. CHWs can also serve as a bridge between the community and formal healthcare facilities.

3. Telemedicine: Establishing telemedicine platforms that enable pregnant women in remote areas to consult with healthcare professionals through video conferencing or phone calls. This can help address the lack of healthcare providers in certain regions and reduce the need for long-distance travel.

4. Maternal Health Vouchers: Introducing voucher programs that provide pregnant women with financial assistance to cover the costs of maternal health services, including antenatal care, delivery, and postnatal care. These vouchers can be distributed to vulnerable populations, such as refugees, to ensure equitable access to care.

5. Transportation Support: Developing transportation initiatives, such as providing free or subsidized transportation services, to help pregnant women reach healthcare facilities for prenatal and postnatal care, as well as emergency obstetric care. This can address the challenges of geographical barriers and limited transportation options.

6. Maternal Health Education: Implementing comprehensive maternal health education programs that target both pregnant women and their families. These programs can raise awareness about the importance of antenatal care, safe delivery practices, and postnatal care, ultimately improving maternal and neonatal health outcomes.

7. Strengthening Health Systems: Investing in the overall strengthening of health systems, including infrastructure, healthcare workforce, and supply chain management, to ensure that maternal health services are available, accessible, and of high quality.

It is important to note that the specific context and needs of the South Sudanese refugees and host communities in Uganda should be taken into consideration when designing and implementing these innovations.

AI Innovations Description

Based on the provided description, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Primary Healthcare Services: Focus on strengthening primary healthcare services in both refugee and host communities. This can be done by increasing the number of healthcare facilities, ensuring availability of essential medicines and equipment, and training healthcare providers to deliver quality maternal care.

2. Promoting Antenatal Care (ANC) Services: Implement strategies to increase the utilization of ANC services, particularly among poorer groups. This can include community outreach programs, awareness campaigns, and incentives for pregnant women to attend ANC visits.

3. Improving Delivery Care Access: Address the lower levels of delivery care access among host communities. This can be achieved by improving transportation infrastructure, providing financial support for delivery costs, and ensuring the availability of skilled birth attendants in remote areas.

4. Reducing Financial Barriers: Take measures to reduce the financial burden of healthcare expenses, especially for acute and chronic care. This can involve implementing health insurance schemes, providing subsidies for healthcare services, and exploring innovative financing mechanisms to offset the costs of care.

5. Enhancing Equity in Access: Continuously monitor and evaluate the equity in access to maternal health services between refugee and host communities. This can be done through regular data collection and analysis, and adjusting interventions based on the identified disparities.

6. Collaboration and Partnerships: Foster collaboration and partnerships between government agencies, non-governmental organizations, and international stakeholders to ensure coordinated efforts in improving access to maternal health. This can involve sharing resources, expertise, and best practices to maximize impact.

By implementing these recommendations, it is expected that access to maternal health services will be improved, particularly among vulnerable populations, leading to better maternal and child health outcomes in both refugee and host communities.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen primary healthcare services: Enhance the capacity and resources of primary healthcare facilities in both refugee and host communities to provide comprehensive maternal health services. This includes ensuring the availability of skilled healthcare providers, essential medicines, and necessary equipment.

2. Increase awareness and education: Implement targeted awareness campaigns to educate women and their families about the importance of maternal health, including antenatal care, safe delivery practices, and postnatal care. This can be done through community health workers, mobile clinics, and community engagement activities.

3. Improve transportation and referral systems: Address transportation barriers by establishing reliable and affordable transportation options for pregnant women to access healthcare facilities. Additionally, develop effective referral systems to ensure timely access to higher-level healthcare facilities for complicated pregnancies or emergencies.

4. Enhance financial protection: Implement strategies to reduce out-of-pocket expenses for maternal healthcare, particularly for the most vulnerable populations. This can include expanding health insurance coverage, providing subsidies or waivers for maternal health services, and strengthening social protection programs.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of pregnant women receiving antenatal care, the percentage of facility-based deliveries, and the reduction in maternal mortality rates.

2. Data collection: Collect baseline data on the selected indicators from both refugee and host communities. This can be done through surveys, interviews, and existing health records.

3. Model development: Develop a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This model should consider factors such as population size, healthcare infrastructure, transportation availability, and financial resources.

4. Scenario analysis: Run different scenarios within the simulation model to assess the potential impact of each recommendation individually and in combination. This can help determine the most effective strategies to improve access to maternal health.

5. Data validation: Validate the simulation results by comparing them with real-world data and existing studies on maternal health access. This will ensure the accuracy and reliability of the simulation model.

6. Policy recommendations: Based on the simulation results, generate policy recommendations that prioritize the most effective strategies for improving access to maternal health. These recommendations should consider the specific context of the refugee and host communities in Uganda.

7. Monitoring and evaluation: Continuously monitor and evaluate the implementation of the recommended strategies to assess their actual impact on improving access to maternal health. This will help identify any necessary adjustments or additional interventions needed to achieve the desired outcomes.

Author

Dima Health

Identifiers:

DOI: 10.1186/s12913-022-08547-5

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Mental Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury, Workforce

Study Countries:

Multi-Countries, South Sudan, Sudan, Uganda

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female