Promoting universal financial protection: Contracting faith-based health facilities to expand access – lessons learned from Malawi

Health Research Policy and Systems, Volume 11, No. 1, Year 2013

Interpretação

Background: Public-private collaborations are increasingly being utilized to universalize health care. In Malawi, the Ministry of Health contracts selected health facilities owned by the main faith-based provider, the Christian Health Association of Malawi (CHAM), to deliver care at no fee to the most vulnerable and underserved populations in the country through Service Level Agreements (SLAs). This study examined the features of SLAs and their effectiveness in expanding universal coverage. The study involved a policy analysis focusing on key stakeholders around SLAs as well as a case study approach to analyse how design and implementation of SLAs affect efficiency, equity and sustainability of services delivered by SLAs.Methods: The study employed both qualitative and quantitative research methods to address the research questions and was conducted in five CHAM health facilities: Mulanje Mission, Holy Family, and Mtengowanthenga Hospitals, and Mabiri and Nkope Health Centres. National and district level decision makers were interviewed while providers and clients associated with the health facilities were surveyed on their experiences. A total of 155 clients from an expected 175 were recruited in the study.Results: The study findings revealed key aspects of how SLAs were operating, the extent to which their objectives were being attained and why. In general, the findings demonstrated that SLAs had the potential to improve health and universal health care coverage, particularly for the vulnerable and underserved populations. However, the findings show that the performance of SLAs in Malawi were affected by various factors including lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate human and material resources, and lack of systems to monitor performance of SLAs, amongst others.Conclusions: There was strong consensus and shared interest between the government and CHAM regarding SLAs. It was clear that free services provided by SLAs had a great impact on the impoverished locals that used the facilities. However, lack of supporting systems, inadequate infrastructure and shortage of health care providers affected SLA performance. The paper provides recommendations to policy makers for the replication and strengthening of SLA implementation in the roll-out of universalization policy. © 2013 Chirwa et al.; World Health Organization; licensee BioMed Central Ltd. This study employed a mixed methods approach, whereby both quantitative and qualitative data were used. It consisted of two strands. The first was a policy analysis focusing on the key stakeholders around SLAs, their views, communication and interactions. The second component involved case studies to analyse how SLA design and implementation affected their efficiency, equity and sustainability. The study recruited its participants from national, district and local levels: policy and decision makers who were involved at the establishment of SLAs, DHO and CHAM Health Facility Management teams, health care providers and clients. The study aimed to interview a maximum of 20 participants (10 at central, and 2 at each case study facility). A total of 155 clients from the expected 175 who visited the health care facilities for maternal and child health were recruited in exit interviews. Nine focus group discussions (FGDs) were conducted. The FGDs comprised available community members surrounding each participating facility. Quantitative data were captured from the Health Management Information System (HMIS). Data collectors collected the data using a checklist. Key documents and communications in the form of minutes and memos were reviewed and analysed to understand the context and reform development within which SLAs emerged. The relationship between government and CHAM was investigated using semi-structured interviews, policy analysis tools and techniques around both the design and implementation of the agreement [10]. The questionnaire administered to health care providers used a mixture of Likert scales and closed and open-ended questions. Quantitative data from the questionnaires was analysed using excel. Data from questions and interviews were analysed manually using a thematic content analysis. A coding tree, which was agreed upon by the research team, was developed before data collection. Following data collection and transcription, coding was done by one member of the study team. The coded data was grouped into categories and themes. After coding, the data was independently checked by another member of the study team to ensure validity. Semi-structured interviews with key personnel both at MoH and CHAM central and district levels, were conducted in English. Participants were purposefully sampled through the National Steering Committee on SLAs. The Committee was specifically established to guide the study and was composed of members from the MoH, CHAM and the College of Medicine who were selected according to their involvement and knowledge of the SLA and CHAM. Both district government officers and CHAM facility managers were interviewed to explore SLA incentives and behaviour encouragement activities. The frontline interviews were designed to supplement information collected from HMIS, annual reports and client exit interviews. The findings corroborated the documents reviewed. The client exit interviews were administered to clients who were randomly recruited after they had received health care services at each case study facility. Data on the care process were collected with attention to cost barriers, non-cost barriers and perception of clients on the service provided. The study aimed to interview a maximum of 35 clients per facility. However, due to low number of clients at some facilities, the number of people interviewed was lower. A total of 155 clients, from an expected 175, who visited the health care facilities for maternal and child health were recruited in the interview. The interviews were conducted using an interview guide and administered in the local language of Chichewa. FGDs were conducted with community members nearest to the participating facilities. The FGDs comprised of women only because men felt women were more suitable given that they were the ones who accessed the services. The number of participants per group varied from five to eight. Data from FGDs complemented that from exit interviews, providing information on access and perceived effectiveness. Data from FGDs were also analysed manually using a thematic content analysis following the same process as that of the semi-structured interviews. HMIS data was collected at the facility level, before and after the removal of fees and the introduction of SLAs. The aim was to solicit data on patterns of utilization and was used to assess the interventions covered by SLA at each facility. Due to the limited capacity of staff, it was not possible to access the HMIS data in some facilities. Information from HMIS was collated with the corresponding invoices to compare the cost of provision being passed on to the DHO for reimbursement. Case studies are a useful approach when complex phenomena are under study and the richness of material is more important to understand than breadth of scope [11]. Upon discussion with the National Steering Committee, five case studies in five different health facilities were recommended, leading to the modification of the criteria and selection of the facilities in liaison with CHAM. The facilities selected were: Mtengowanthenga Hospital, Dowa District (Central region). It was the first institution to sign an SLA in 2004 covering maternal health but the contract was later revised to include child health. It caters for a catchment area population of 56,000. Mulanje Mission Hospital, Mulanje District (Southern region). Located 10 km from Mulanje District Hospital. Hence, the catchment areas of the two hospitals overlap. The hospital signed an SLA in 2005, which covers maternal and child health services. Holy Family Hospital, Phalombe District (Southern region). It signed the SLA in 2006 and is located in a rural area. The Holy Family SLA is distinct in that the hospital acts as a district hospital and is therefore used as a referral facility. It covers all elements of the EHP unlike other SLAs that cover only one or two elements. Mabiri Health Centre, Mzimba District (Northern region). It is located in a very remote area where there is no government facility nearby. It signed an SLA in 2006 and covers both maternal and child health services. Nkope Health Centre, Mangochi District (Southern region). The SLA in Nkope was signed in 2006 being one of the newest and covers maternal and child health. The key characteristics for each case study choice relate to reviewing the length of the contractual relationship between the DHOs and CHAM facilities and how the presence of competition might affect this interaction.

AI Digest

Study Justification:

– The study examined the features and effectiveness of Service Level Agreements (SLAs) in expanding universal health care coverage in Malawi.
– It aimed to understand how the design and implementation of SLAs affect efficiency, equity, and sustainability of services delivered by faith-based health facilities.
– The study provided insights into the potential of SLAs to improve health and universal health care coverage for vulnerable and underserved populations.

Study Highlights:

– SLAs have the potential to improve health and universal health care coverage, particularly for vulnerable and underserved populations.
– However, the performance of SLAs in Malawi is affected by various factors, including lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate resources, and lack of monitoring systems.

Study Recommendations:

– Policy makers should replicate and strengthen the implementation of SLAs in the roll-out of universalization policy.
– Clear guidelines should be developed for SLAs, including revised pricing and timely payment of bills.
– Transparency and communication between stakeholders should be improved.
– Adequate resources, both human and material, should be provided to support SLA implementation.
– Systems to monitor the performance of SLAs should be established.

Key Role Players:

– Ministry of Health (MoH)
– Christian Health Association of Malawi (CHAM)
– National Steering Committee on SLAs
– District Health Officers (DHOs)
– Health Facility Management teams
– Health care providers
– Clients

Cost Items for Planning Recommendations:

– Development of clear guidelines for SLAs
– Revision of pricing for SLAs
– Timely payment of bills
– Improvement of transparency and communication
– Provision of adequate human and material resources
– Establishment of monitoring systems for SLAs

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are areas for improvement. The study employed a mixed methods approach, which is a strength. It included both qualitative and quantitative research methods, and involved interviews with key stakeholders and surveys with providers and clients. However, the abstract does not provide specific details about the sample size or the response rate for the surveys. Additionally, while the findings demonstrate the potential of Service Level Agreements (SLAs) to improve health and universal health care coverage, they also highlight various factors that affect the performance of SLAs. To improve the strength of the evidence, the abstract could provide more information about the methodology, including the sample size and response rate, as well as the limitations of the study. It could also include more specific details about the findings and recommendations.

Resumo

This study employed a mixed methods approach, whereby both quantitative and qualitative data were used. It consisted of two strands. The first was a policy analysis focusing on the key stakeholders around SLAs, their views, communication and interactions. The second component involved case studies to analyse how SLA design and implementation affected their efficiency, equity and sustainability. The study recruited its participants from national, district and local levels: policy and decision makers who were involved at the establishment of SLAs, DHO and CHAM Health Facility Management teams, health care providers and clients. The study aimed to interview a maximum of 20 participants (10 at central, and 2 at each case study facility). A total of 155 clients from the expected 175 who visited the health care facilities for maternal and child health were recruited in exit interviews. Nine focus group discussions (FGDs) were conducted. The FGDs comprised available community members surrounding each participating facility. Quantitative data were captured from the Health Management Information System (HMIS). Data collectors collected the data using a checklist. Key documents and communications in the form of minutes and memos were reviewed and analysed to understand the context and reform development within which SLAs emerged. The relationship between government and CHAM was investigated using semi-structured interviews, policy analysis tools and techniques around both the design and implementation of the agreement [10]. The questionnaire administered to health care providers used a mixture of Likert scales and closed and open-ended questions. Quantitative data from the questionnaires was analysed using excel. Data from questions and interviews were analysed manually using a thematic content analysis. A coding tree, which was agreed upon by the research team, was developed before data collection. Following data collection and transcription, coding was done by one member of the study team. The coded data was grouped into categories and themes. After coding, the data was independently checked by another member of the study team to ensure validity. Semi-structured interviews with key personnel both at MoH and CHAM central and district levels, were conducted in English. Participants were purposefully sampled through the National Steering Committee on SLAs. The Committee was specifically established to guide the study and was composed of members from the MoH, CHAM and the College of Medicine who were selected according to their involvement and knowledge of the SLA and CHAM. Both district government officers and CHAM facility managers were interviewed to explore SLA incentives and behaviour encouragement activities. The frontline interviews were designed to supplement information collected from HMIS, annual reports and client exit interviews. The findings corroborated the documents reviewed. The client exit interviews were administered to clients who were randomly recruited after they had received health care services at each case study facility. Data on the care process were collected with attention to cost barriers, non-cost barriers and perception of clients on the service provided. The study aimed to interview a maximum of 35 clients per facility. However, due to low number of clients at some facilities, the number of people interviewed was lower. A total of 155 clients, from an expected 175, who visited the health care facilities for maternal and child health were recruited in the interview. The interviews were conducted using an interview guide and administered in the local language of Chichewa. FGDs were conducted with community members nearest to the participating facilities. The FGDs comprised of women only because men felt women were more suitable given that they were the ones who accessed the services. The number of participants per group varied from five to eight. Data from FGDs complemented that from exit interviews, providing information on access and perceived effectiveness. Data from FGDs were also analysed manually using a thematic content analysis following the same process as that of the semi-structured interviews. HMIS data was collected at the facility level, before and after the removal of fees and the introduction of SLAs. The aim was to solicit data on patterns of utilization and was used to assess the interventions covered by SLA at each facility. Due to the limited capacity of staff, it was not possible to access the HMIS data in some facilities. Information from HMIS was collated with the corresponding invoices to compare the cost of provision being passed on to the DHO for reimbursement. Case studies are a useful approach when complex phenomena are under study and the richness of material is more important to understand than breadth of scope [11]. Upon discussion with the National Steering Committee, five case studies in five different health facilities were recommended, leading to the modification of the criteria and selection of the facilities in liaison with CHAM. The facilities selected were: Mtengowanthenga Hospital, Dowa District (Central region). It was the first institution to sign an SLA in 2004 covering maternal health but the contract was later revised to include child health. It caters for a catchment area population of 56,000. Mulanje Mission Hospital, Mulanje District (Southern region). Located 10 km from Mulanje District Hospital. Hence, the catchment areas of the two hospitals overlap. The hospital signed an SLA in 2005, which covers maternal and child health services. Holy Family Hospital, Phalombe District (Southern region). It signed the SLA in 2006 and is located in a rural area. The Holy Family SLA is distinct in that the hospital acts as a district hospital and is therefore used as a referral facility. It covers all elements of the EHP unlike other SLAs that cover only one or two elements. Mabiri Health Centre, Mzimba District (Northern region). It is located in a very remote area where there is no government facility nearby. It signed an SLA in 2006 and covers both maternal and child health services. Nkope Health Centre, Mangochi District (Southern region). The SLA in Nkope was signed in 2006 being one of the newest and covers maternal and child health. The key characteristics for each case study choice relate to reviewing the length of the contractual relationship between the DHOs and CHAM facilities and how the presence of competition might affect this interaction.

Materiais

N/A

Inovações

The study mentioned in the description focused on the use of Service Level Agreements (SLAs) to improve access to maternal health in Malawi. The study employed a mixed methods approach, using both quantitative and qualitative data. It consisted of a policy analysis and case studies to analyze the design and implementation of SLAs. The study recruited participants from national, district, and local levels, including policy and decision makers, health care providers, and clients. Data was collected through interviews, surveys, focus group discussions, and analysis of key documents and communications. The findings highlighted the potential of SLAs to improve health care coverage, but also identified challenges such as lack of clear guidelines, late payment of bills, and inadequate resources. The study provided recommendations to policy makers for the replication and strengthening of SLA implementation.

AI Innovations Description

The recommendation from the study is to promote universal financial protection by contracting faith-based health facilities to expand access to maternal health. The study found that Service Level Agreements (SLAs) between the Ministry of Health and the Christian Health Association of Malawi (CHAM) had the potential to improve health and universal health care coverage for vulnerable and underserved populations. However, the performance of SLAs was affected by various factors such as lack of clear guidelines, non-revised prices, late payment of bills, lack of transparency, poor communication, inadequate resources, and lack of monitoring systems.

To address these challenges and improve access to maternal health, the study provides the following recommendations:

1. Develop clear guidelines: Establish clear guidelines for SLAs to ensure consistent implementation and performance.

2. Revise pricing: Regularly review and update the pricing structure to ensure fair and reasonable reimbursement for services provided by faith-based health facilities.

3. Timely payment: Ensure timely payment of bills to faith-based health facilities to maintain their financial stability and sustainability.

4. Enhance transparency: Improve transparency in the SLA process by providing clear information on the selection criteria, contract terms, and performance indicators.

5. Improve communication: Strengthen communication channels between the Ministry of Health, CHAM, and other stakeholders to facilitate effective collaboration and coordination.

6. Allocate adequate resources: Provide sufficient human and material resources to faith-based health facilities to ensure they can deliver quality maternal health services.

7. Establish monitoring systems: Develop systems to monitor the performance of SLAs, including regular evaluation of service delivery, patient satisfaction, and health outcomes.

By implementing these recommendations, policymakers can replicate and strengthen the implementation of SLAs to improve access to maternal health and achieve universal health care coverage.

AI Innovations Methodology

The study described in the provided text employed a mixed methods approach to analyze the effectiveness of Service Level Agreements (SLAs) in expanding universal coverage of maternal health care in Malawi. The study consisted of two components: a policy analysis and case studies.

The policy analysis focused on key stakeholders involved in SLAs, their views, communication, and interactions. This analysis involved interviews with national and district level decision makers, as well as a review of key documents and communications such as minutes and memos. The aim was to understand the context and development of SLAs and the relationship between the government and the Christian Health Association of Malawi (CHAM), the main faith-based provider.

The case studies aimed to analyze how the design and implementation of SLAs affected their efficiency, equity, and sustainability. The study recruited participants from CHAM health facilities and conducted interviews with policy and decision makers, health care providers, and clients. Exit interviews were conducted with clients who had received maternal and child health care services, and focus group discussions were conducted with community members near the participating facilities.

Quantitative data were also collected from the Health Management Information System (HMIS) to assess patterns of utilization and the interventions covered by SLAs at each facility. The data collected from interviews, exit interviews, and focus group discussions were analyzed using thematic content analysis, and quantitative data from questionnaires were analyzed using Excel.

The study selected five case study facilities based on criteria such as the length of the contractual relationship between the District Health Offices (DHOs) and CHAM facilities and the presence of competition. The selected facilities were Mtengowanthenga Hospital, Mulanje Mission Hospital, Holy Family Hospital, Mabiri Health Centre, and Nkope Health Centre.

Overall, the study aimed to assess the effectiveness of SLAs in expanding universal coverage of maternal health care in Malawi and identify factors that affected their performance. The findings of the study provided recommendations to policy makers for the replication and strengthening of SLA implementation in the roll-out of universalization policy.

Autor

Dima Health

Statistics:

Citations: 27

Identifiers:

DOI: 10.1186/1478-4505-11-27

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care

Study Countries:

Malawi

Study Design:

Case Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male & Female

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