Preparedness for and impact of COVID-19 on primary health care delivery in urban and rural Malawi: a mixed methods study

BMJ Open, Volume 12, No. 6, Year 2022

Interprétation

Objective Across Africa, the impact of COVID-19 continues to be acutely felt. This includes Malawi, where a key component of health service delivery to mitigate against COVID-19 are the primary healthcare facilities, strategically placed throughout districts to offer primary and maternal healthcare. These facilities have limited infrastructure and capacity but are the most accessible and play a crucial role in responding to the COVID-19 pandemic. This study assessed health facility preparedness for COVID-19 and the impact of the pandemic on health service delivery and frontline workers. Setting Primary and maternal healthcare in Blantyre District, Malawi. Participants We conducted regular visits to 31 healthcare facilities and a series of telephone-based qualitative interviews with frontline workers (n=81 with 38 participants) between August 2020 and May 2021. Results Despite significant financial and infrastructural constraints, health centres continued to remain open. The majority of frontline health workers received training and access to preventative COVID-19 materials. Nevertheless, we found disruptions to key services and a reduction in clients attending facilities. Key barriers to implementing COVID-19 prevention measures included periodic shortages of resources (soap, hand sanitiser, water, masks and staff). Frontline workers reported challenges in managing physical distancing and in handling suspected COVID-19 cases. We found discrepancies between reported behaviour and practice, particularly with consistent use of masks, despite being provided. Frontline workers felt COVID-19 had negatively impacted their lives. They experienced fatigue and stress due to heavy workloads, stigma in the community and worries about becoming infected with and transmitting COVID-19. Conclusion Resource (human and material) inadequacy shaped the health facility capacity for support and response to COVID-19, and frontline workers may require psychosocial support to manage the impacts of the COVID-19 pandemic. The Malawian health system is structured around three levels: tertiary (large referral hospitals situated in major urban centres), secondary (district hospital) and primary (health facilities, community and home-based services). Funding for the health sector is heavily dependent on international donors.22 Health services are provided by government, private and faith-based organisations; government services are the only ones provided without fees, and recent estimates suggest they provide approximately 60% of services accessed.23 24 Despite policies being well designed, key challenges faced in the health sector include chronic underfunding, shortage of staff and fragmentation of services.24 The District Health Office (DHO) is mandated to provide management and oversight of primary healthcare facilities.25 This study was situated in Blantyre District in the Southern region, which is serviced by 31 government and faith based primary healthcare facilities (n=14 urban; n=17 rural) (see online supplemental file 1 for further characteristics of the facilities). The district has a total population of 1.25 million including Blantyre city (64%), the second largest city in Malawi. The study ran from April 2020 to August 2021. This encompassed the first and second waves of the COVID-19 pandemic in Malawi and the national rollout of the preventative vaccine. bmjopen-2021-051125supp001.pdf To understand the impact of COVID-19 on primary healthcare provision, we used a mixed method approach. Combining qualitative and quantitative research methods allowed us to capture data from across the district and gain a deeper understanding of the findings through qualitative interviews. All data collection tools were developed in consultation with the Blantyre DHO and were reviewed regularly through feedback loops to help inform service delivery improvements. Field work was conducted in two phases: For this phase, we aligned qualitative and quantitative approaches to understand the impact of the first wave of the pandemic. Quantitative structured data collection tools were selected to enable real-time data to be captured through direct observations at each healthcare facility. Tools focused on the key components of the National COVID-19 Preparedness and Response Plan,26 reporting on preparedness proxies (eg, hand washing facilities (HWFs), soap and thermometers) and observed behaviour of frontline workers (inclusive of healthcare workers and auxiliary staff) and clients (eg, mask wearing and physical distancing) (see online supplemental file 2). Qualitative interviews were selected because they allowed frontline workers to express their lived realities and explore a range of themes flexibly.27 Conducting interviews at different time points allowed us to capture health workers changing perceptions and experiences across the dynamic period of the pandemic. To reduce the risk of COVID-19 transmission with prolonged contact with participants, we conducted qualitative interviews over the telephone. bmjopen-2021-051125supp002.pdf Following the second wave of the pandemic and the national roll out of the COVID-19 vaccine, we conducted a second phase of qualitative interviews. These interviews sought to understand the perception of, and response to, the vaccine within primary healthcare clinics. Quantitative assessments were only conducted during the first phase of the study (July–November 2020). Working in all 31 rural and urban health facilities in Blantyre District, we collected structured data at three-time points (August, September and October 2020). Experienced researchers administered a questionnaire with the clinician responsible for managing the health facility or their representative. All quantitative data were collected using a preprogrammed questionnaire on KoboCollect (https://www.kobotoolbox.org) (see online supplemental file 3). The questions included data on patient management, physical distancing, WASH provision and practices, the presence and use of PPE and patient attendance at routine health services. The team photographed clinic registers (without any identifying patient data) for OPD, EPI, TB, FP, HIV and cancer screening services; these data were collected from January 2019 to September 2020 to allow for comparison of patient numbers pre-COVID-19. bmjopen-2021-051125supp003.pdf Following analysis of each round of data collection, ‘score cards’ were generated for each health facility. The score cards summarised how the healthcare facilities were implementing COVID-19 preventative measures, including training of frontline staff and WASH materials. This included the location and presence of HWFs (including soap and water), stock and use of PPE including face masks and thermometers, waste management and case management of suspected COVID-19 cases. These scorecards were then provided to the DHO team through monthly feedback loops to provide guidance on which healthcare facilities had managed to adapt their practices and which facilities required further support. Qualitative assessments were undertaken across both phases of the study. Following the generation of the scorecards from initial quantitative data collection, eight healthcare facilities were purposively sampled to be included in the qualitative component. In the sample, we included both rural (n=4) and urban facilities (n=4). In these healthcare facilities, we conducted a total of 81 interviews with 38 participants, all frontline workers. In table 1, we provide a breakdown of the participants included in each round of the interviews and the number conducted at each time point. Semistructured qualitative interviews were conducted over the telephone and guided by a discussion guide (see online supplemental file 4). These interviews happened at five-time points (July–August, September, October–November 2020 and April–May and August 2021) to allow us to capture the dynamic nature of the pandemic and the rollout of the vaccine programme. Summary of qualitative sampling bmjopen-2021-051125supp004.pdf For each round of the interviews, we used a purposive sampling approach that aimed to sample a wide range of frontline workers including those employed in support and operations at the health facilities. In July/August, we included auxiliary staff (guards, ground staff, patient attendants and cleaners) recruiting up to four participants in each healthcare facility. In September 2020, due to time and resource constraints, we repeated interviews with two participants per healthcare facility; this sample included both a health worker and an auxiliary worker. Between October and November 2020, we conducted a third set of interviews with the healthcare facility in-charges, those who manage the clinic (or their representative), these interviews focused more on broader changes to care provision. Between April and August 2021, we undertook a second phase of interviews with in-charges (or their representative). Key themes included experiences delivering care during the COVID-19 pandemic. Participants were asked during the interviews to reflect on the pandemic including preparedness of clinics and training on COVID-19, changes in the provision of care as well as perceived changes in patient behaviour. Finally, the impact of working during the pandemic on frontline workers’ well-being and lives. The second phase of interviews explored the rollout of the COVID-19 vaccination programme and its impacts on patient attendance. We took a pragmatic approach to sampling, constrained by conducting fieldwork during the pandemic and financial limitations and did not seek to achieve data saturation. However, we did generate a significant of data through the 81 interviews from a range of participants that was triangulated with quantitative data and structured observations. Quantitative discrete data related to COVID-19 preparedness within the facility was downloaded from KoboCollect (https://www.kobotoolbox.org) as a.csv file, cleaned and analysed using Microsoft Excel V.16 (Microsoft Corporation, Redmond, Washington, USA). Continuous data related to the department and attendance from health records were abstracted from photographs to Microsoft Excel V.16 for comparative analysis between 2019 and 2020 attendance across specific services. All data were analysed for Blantyre as a whole and as a comparison between urban and rural facilities. For the qualitative data, we used thematic content analysis28 (see online supplemental file 5 for coding strategy). All transcripts were transcribed and imported into NVivo V.12 (QSR, International) to facilitate data management and analysis. Initial themes were identified, and key gaps were included in subsequent rounds of data collection. The study team (drawing together the quantitative and qualitative researchers) held weekly debriefing sessions to allow for discussion of findings from each week’s data collection. Any new avenues of inquiry were incorporated into the data collection. Halfway through the study, we presented initial findings to the DHO to gain feedback and participant checking. bmjopen-2021-051125supp005.pdf For the qualitative interviews, the participant information sheet and consent form were shared on WhatsApp before the interview to allow participants to review the information. Before the research began, the information was reviewed again, and oral consent was taken from the participants. No data WERE collected from the clinic, including clinic registers contained patient’s personal information. This study was developed in partnership with the Blantyre DHO, specifically the team leading the COVID-19 preparedness and response for primary healthcare within Blantyre District. Halfway through the project, we presented our initial findings to the District Health COVID-19 Task Force during their weekly meetings for direct feedback, incorporating their suggestions into the qualitative data collection.

Résumé de l’IA

Study Justification:

– The study aimed to assess the preparedness of primary healthcare facilities in Malawi for COVID-19 and the impact of the pandemic on health service delivery and frontline workers.
– This study was important because primary healthcare facilities play a crucial role in responding to the COVID-19 pandemic, especially in areas with limited infrastructure and capacity.
– Understanding the challenges and barriers faced by these facilities and frontline workers can help inform strategies to improve preparedness and response to future pandemics.

Study Highlights:

– Despite significant financial and infrastructural constraints, primary healthcare facilities in Malawi remained open during the COVID-19 pandemic.
– The majority of frontline health workers received training and access to preventative COVID-19 materials.
– However, disruptions to key services and a reduction in clients attending facilities were observed.
– Barriers to implementing COVID-19 prevention measures included periodic shortages of resources and challenges in managing physical distancing and suspected COVID-19 cases.
– Frontline workers reported experiencing fatigue, stress, stigma, and concerns about becoming infected with and transmitting COVID-19.
– Resource inadequacy shaped the capacity of health facilities to respond to COVID-19, and frontline workers may require psychosocial support to manage the impacts of the pandemic.

Recommendations:

– Increase funding and resources for primary healthcare facilities to improve their capacity to respond to pandemics like COVID-19.
– Ensure consistent availability of essential resources such as soap, hand sanitizer, water, masks, and staff.
– Provide ongoing training and support to frontline health workers to effectively implement COVID-19 prevention measures.
– Address challenges in managing physical distancing and suspected COVID-19 cases in healthcare facilities.
– Implement strategies to address fatigue, stress, stigma, and concerns among frontline workers, including providing psychosocial support.

Key Role Players:

– Malawian government
– International donors
– District Health Office (DHO)
– Primary healthcare facility managers
– Frontline health workers
– Community leaders and organizations

Cost Items for Planning Recommendations:

– Funding for infrastructure improvements in primary healthcare facilities
– Procurement of essential resources such as soap, hand sanitizer, water, masks, and staff
– Training programs for frontline health workers
– Psychosocial support services for frontline workers
– Communication and awareness campaigns for the community

Force de la preuve

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is based on a mixed methods study that includes regular visits to healthcare facilities and qualitative interviews with frontline workers. The study provides insights into the preparedness for COVID-19 and the impact on health service delivery. The findings highlight challenges in implementing prevention measures, disruptions to key services, and negative impacts on frontline workers. The study also identifies resource inadequacy and the need for psychosocial support. To improve the evidence, the abstract could include more specific details about the methodology, such as the sampling strategy and data analysis techniques. Additionally, providing a summary of the main findings and their implications would enhance the clarity and usefulness of the abstract.

Abstrait

The Malawian health system is structured around three levels: tertiary (large referral hospitals situated in major urban centres), secondary (district hospital) and primary (health facilities, community and home-based services). Funding for the health sector is heavily dependent on international donors.22 Health services are provided by government, private and faith-based organisations; government services are the only ones provided without fees, and recent estimates suggest they provide approximately 60% of services accessed.23 24 Despite policies being well designed, key challenges faced in the health sector include chronic underfunding, shortage of staff and fragmentation of services.24 The District Health Office (DHO) is mandated to provide management and oversight of primary healthcare facilities.25 This study was situated in Blantyre District in the Southern region, which is serviced by 31 government and faith based primary healthcare facilities (n=14 urban; n=17 rural) (see online supplemental file 1 for further characteristics of the facilities). The district has a total population of 1.25 million including Blantyre city (64%), the second largest city in Malawi. The study ran from April 2020 to August 2021. This encompassed the first and second waves of the COVID-19 pandemic in Malawi and the national rollout of the preventative vaccine. bmjopen-2021-051125supp001.pdf To understand the impact of COVID-19 on primary healthcare provision, we used a mixed method approach. Combining qualitative and quantitative research methods allowed us to capture data from across the district and gain a deeper understanding of the findings through qualitative interviews. All data collection tools were developed in consultation with the Blantyre DHO and were reviewed regularly through feedback loops to help inform service delivery improvements. Field work was conducted in two phases: For this phase, we aligned qualitative and quantitative approaches to understand the impact of the first wave of the pandemic. Quantitative structured data collection tools were selected to enable real-time data to be captured through direct observations at each healthcare facility. Tools focused on the key components of the National COVID-19 Preparedness and Response Plan,26 reporting on preparedness proxies (eg, hand washing facilities (HWFs), soap and thermometers) and observed behaviour of frontline workers (inclusive of healthcare workers and auxiliary staff) and clients (eg, mask wearing and physical distancing) (see online supplemental file 2). Qualitative interviews were selected because they allowed frontline workers to express their lived realities and explore a range of themes flexibly.27 Conducting interviews at different time points allowed us to capture health workers changing perceptions and experiences across the dynamic period of the pandemic. To reduce the risk of COVID-19 transmission with prolonged contact with participants, we conducted qualitative interviews over the telephone. bmjopen-2021-051125supp002.pdf Following the second wave of the pandemic and the national roll out of the COVID-19 vaccine, we conducted a second phase of qualitative interviews. These interviews sought to understand the perception of, and response to, the vaccine within primary healthcare clinics. Quantitative assessments were only conducted during the first phase of the study (July–November 2020). Working in all 31 rural and urban health facilities in Blantyre District, we collected structured data at three-time points (August, September and October 2020). Experienced researchers administered a questionnaire with the clinician responsible for managing the health facility or their representative. All quantitative data were collected using a preprogrammed questionnaire on KoboCollect (https://www.kobotoolbox.org) (see online supplemental file 3). The questions included data on patient management, physical distancing, WASH provision and practices, the presence and use of PPE and patient attendance at routine health services. The team photographed clinic registers (without any identifying patient data) for OPD, EPI, TB, FP, HIV and cancer screening services; these data were collected from January 2019 to September 2020 to allow for comparison of patient numbers pre-COVID-19. bmjopen-2021-051125supp003.pdf Following analysis of each round of data collection, ‘score cards’ were generated for each health facility. The score cards summarised how the healthcare facilities were implementing COVID-19 preventative measures, including training of frontline staff and WASH materials. This included the location and presence of HWFs (including soap and water), stock and use of PPE including face masks and thermometers, waste management and case management of suspected COVID-19 cases. These scorecards were then provided to the DHO team through monthly feedback loops to provide guidance on which healthcare facilities had managed to adapt their practices and which facilities required further support. Qualitative assessments were undertaken across both phases of the study. Following the generation of the scorecards from initial quantitative data collection, eight healthcare facilities were purposively sampled to be included in the qualitative component. In the sample, we included both rural (n=4) and urban facilities (n=4). In these healthcare facilities, we conducted a total of 81 interviews with 38 participants, all frontline workers. In table 1, we provide a breakdown of the participants included in each round of the interviews and the number conducted at each time point. Semistructured qualitative interviews were conducted over the telephone and guided by a discussion guide (see online supplemental file 4). These interviews happened at five-time points (July–August, September, October–November 2020 and April–May and August 2021) to allow us to capture the dynamic nature of the pandemic and the rollout of the vaccine programme. Summary of qualitative sampling bmjopen-2021-051125supp004.pdf For each round of the interviews, we used a purposive sampling approach that aimed to sample a wide range of frontline workers including those employed in support and operations at the health facilities. In July/August, we included auxiliary staff (guards, ground staff, patient attendants and cleaners) recruiting up to four participants in each healthcare facility. In September 2020, due to time and resource constraints, we repeated interviews with two participants per healthcare facility; this sample included both a health worker and an auxiliary worker. Between October and November 2020, we conducted a third set of interviews with the healthcare facility in-charges, those who manage the clinic (or their representative), these interviews focused more on broader changes to care provision. Between April and August 2021, we undertook a second phase of interviews with in-charges (or their representative). Key themes included experiences delivering care during the COVID-19 pandemic. Participants were asked during the interviews to reflect on the pandemic including preparedness of clinics and training on COVID-19, changes in the provision of care as well as perceived changes in patient behaviour. Finally, the impact of working during the pandemic on frontline workers’ well-being and lives. The second phase of interviews explored the rollout of the COVID-19 vaccination programme and its impacts on patient attendance. We took a pragmatic approach to sampling, constrained by conducting fieldwork during the pandemic and financial limitations and did not seek to achieve data saturation. However, we did generate a significant of data through the 81 interviews from a range of participants that was triangulated with quantitative data and structured observations. Quantitative discrete data related to COVID-19 preparedness within the facility was downloaded from KoboCollect (https://www.kobotoolbox.org) as a.csv file, cleaned and analysed using Microsoft Excel V.16 (Microsoft Corporation, Redmond, Washington, USA). Continuous data related to the department and attendance from health records were abstracted from photographs to Microsoft Excel V.16 for comparative analysis between 2019 and 2020 attendance across specific services. All data were analysed for Blantyre as a whole and as a comparison between urban and rural facilities. For the qualitative data, we used thematic content analysis28 (see online supplemental file 5 for coding strategy). All transcripts were transcribed and imported into NVivo V.12 (QSR, International) to facilitate data management and analysis. Initial themes were identified, and key gaps were included in subsequent rounds of data collection. The study team (drawing together the quantitative and qualitative researchers) held weekly debriefing sessions to allow for discussion of findings from each week’s data collection. Any new avenues of inquiry were incorporated into the data collection. Halfway through the study, we presented initial findings to the DHO to gain feedback and participant checking. bmjopen-2021-051125supp005.pdf For the qualitative interviews, the participant information sheet and consent form were shared on WhatsApp before the interview to allow participants to review the information. Before the research began, the information was reviewed again, and oral consent was taken from the participants. No data WERE collected from the clinic, including clinic registers contained patient’s personal information. This study was developed in partnership with the Blantyre DHO, specifically the team leading the COVID-19 preparedness and response for primary healthcare within Blantyre District. Halfway through the project, we presented our initial findings to the District Health COVID-19 Task Force during their weekly meetings for direct feedback, incorporating their suggestions into the qualitative data collection.

Matériaux

Innovations

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

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to rural areas and provide essential maternal health services. These clinics can bring healthcare professionals, equipment, and supplies directly to communities that have limited access to healthcare facilities.

2. Telemedicine: Introducing telemedicine services that allow pregnant women to consult with healthcare professionals remotely. This can help overcome geographical barriers and provide timely advice and guidance to expectant mothers, especially in rural areas.

3. Community Health Workers: Expanding the role of community health workers to provide maternal health education, prenatal care, and postnatal support. These trained individuals can bridge the gap between healthcare facilities and communities, ensuring that pregnant women receive the necessary care and information.

4. Supply Chain Management: Improving the supply chain management system to ensure a consistent availability of essential maternal health resources, such as soap, hand sanitizers, masks, and other necessary supplies. This can help address the reported periodic shortages and ensure that healthcare facilities are well-equipped to provide quality care.

5. Capacity Building: Investing in training programs and capacity building initiatives for frontline health workers to enhance their skills and knowledge in managing maternal health during the COVID-19 pandemic. This can include training on infection prevention and control measures, psychosocial support, and effective communication strategies.

6. Public Awareness Campaigns: Launching public awareness campaigns to educate communities about the importance of maternal health, the available services, and the precautions to take during the pandemic. These campaigns can help reduce stigma, increase utilization of healthcare services, and promote positive health-seeking behaviors.

7. Partnerships and Funding: Strengthening partnerships with international donors, private organizations, and faith-based organizations to secure additional funding and resources for maternal health services. This can help address the chronic underfunding and fragmentation of services in the health sector.

It is important to note that these recommendations are based on the provided information and may need to be further assessed and tailored to the specific context and needs of Malawi.

AI Innovations Description

Based on the information provided, a recommendation to improve access to maternal health in Malawi could be to strengthen the primary healthcare facilities and address the challenges identified in the study. Here are some specific steps that could be taken:

1. Increase funding: Address the chronic underfunding of the health sector by advocating for increased funding from international donors and exploring alternative sources of funding.

2. Improve infrastructure and capacity: Invest in improving the infrastructure and capacity of primary healthcare facilities, especially in rural areas. This could include expanding and upgrading facilities, ensuring access to essential equipment and supplies, and addressing staffing shortages.

3. Enhance training and resources: Provide comprehensive training for frontline health workers on maternal health, including COVID-19 prevention and management. Ensure that they have access to necessary resources such as soap, hand sanitizers, water, masks, and personal protective equipment (PPE).

4. Strengthen COVID-19 prevention measures: Address the periodic shortages of resources by establishing reliable supply chains for essential items like soap, hand sanitizers, water, masks, and PPE. Implement strategies to ensure consistent use of masks and proper physical distancing in healthcare facilities.

5. Provide psychosocial support: Recognize the impact of the COVID-19 pandemic on frontline workers’ well-being and provide them with psychosocial support to manage the stress, fatigue, and stigma they may experience. This could include counseling services, peer support programs, and initiatives to promote work-life balance.

6. Improve coordination and oversight: Strengthen the role of the District Health Office (DHO) in providing management and oversight of primary healthcare facilities. Ensure regular communication and feedback loops between the DHO and healthcare facilities to identify areas for improvement and provide guidance and support.

7. Monitor and evaluate: Establish a system for monitoring and evaluating the implementation of COVID-19 prevention measures and the impact on maternal health services. Regularly assess the preparedness of healthcare facilities, patient attendance, and the quality of care provided.

By implementing these recommendations, it is expected that access to maternal health services in Malawi can be improved, even in the context of the COVID-19 pandemic.

AI Innovations Methodology

To improve access to maternal health in Malawi, here are some potential recommendations:

1. Strengthening primary healthcare facilities: Enhance the infrastructure and capacity of primary healthcare facilities, particularly those in rural areas, to provide comprehensive maternal health services. This can include improving facilities, ensuring the availability of essential equipment and supplies, and increasing the number of skilled healthcare providers.

2. Mobile health clinics: Implement mobile health clinics that can reach remote and underserved areas, providing maternal health services directly to communities. These clinics can offer antenatal care, postnatal care, family planning services, and health education.

3. Community health workers: Train and deploy community health workers who can provide basic maternal health services, health education, and referrals in their communities. These workers can bridge the gap between communities and healthcare facilities, improving access to care for pregnant women.

4. Telemedicine and teleconsultations: Utilize telemedicine and teleconsultation services to connect pregnant women in remote areas with healthcare providers. This can help address geographical barriers and provide timely advice and support during pregnancy.

5. Health education and awareness campaigns: Conduct targeted health education and awareness campaigns to improve knowledge and understanding of maternal health issues, including the importance of antenatal care, skilled birth attendance, and postnatal care. These campaigns can be conducted through various channels, such as community meetings, radio, and mobile messaging.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline data collection: Gather data on the current state of maternal health access in the target areas, including information on healthcare facilities, healthcare providers, service utilization rates, and health outcomes.

2. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the number of pregnant women accessing antenatal care, the percentage of births attended by skilled healthcare providers, and maternal mortality rates.

3. Model development: Develop a simulation model that incorporates the recommendations and their potential effects on the identified indicators. The model should consider factors such as population demographics, healthcare facility capacity, and geographical distribution.

4. Data input and validation: Input relevant data into the simulation model, ensuring that the data accurately represent the target population and healthcare system. Validate the model by comparing its outputs with available real-world data.

5. Scenario analysis: Run the simulation model with different scenarios, representing the implementation of the recommendations. This can include variations in the scale and timing of interventions, as well as different resource allocation strategies.

6. Impact assessment: Analyze the outputs of the simulation model to assess the impact of the recommendations on the identified indicators. Compare the results of different scenarios to determine the most effective strategies for improving access to maternal health.

7. Sensitivity analysis: Conduct sensitivity analysis to explore the robustness of the model and assess the potential influence of uncertainties or variations in input parameters.

8. Policy recommendations: Based on the findings of the simulation model, provide evidence-based policy recommendations for improving access to maternal health. These recommendations should consider the feasibility, cost-effectiveness, and sustainability of the proposed interventions.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of different innovations and interventions on improving access to maternal health in Malawi.

Auteur

Dima Health

Statistics:

Citations: 2

Identifiers:

DOI: 10.1136/bmjopen-2021-051125

Research Areas:

Cancer, Community Interventions, COVID, Disparities, Environmental, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care

Study Countries:

Malawi

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

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