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- Amani, Paul Joseph, 1975-
(author)
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Does health insurance contribute to improving responsiveness of the health system? : the case of elderly in rural Tanzania
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas.Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and quantile regression models were applied to analyse the association between health insurance and access to healthcare (sub-study 1) and responsiveness (sub-study 2), respectively. For both sub-studies 3 and 4, qualitative content analysis was used to analyse the data.Results: Sub-studies 1 and 2 involved a total of 1899 insured and uninsured elderly, while sub-studies 3 and 4 included 8 health providers and 78 elderlies respectively. Sub-study 1 showed that about 45% of the elderly were insured and HI ownership improved access and utilization of healthcare, both outpatient and inpatient services. In sub-study two, however, health insurance was associated with a lower responsiveness of the healthcare system. In general, all six domains: cleanliness, access, confidentiality, autonomy, communication, and prompt attention were rated high, but three were of concern: waiting time; cleanliness; and communication. Sub-study 3 uncovered several challenges coexisting alongside the provision of insurance benefits and thus contributing to a lower responsiveness. These included shortage of human resources and medical supplies, as well as operational issues related to delays in funding reimbursement. In sub-study 4, the elderly revealed that HI did not meet their expectations, it failed to promote equitable access, provided limited-service benefits and restricted use of services within residential areas. Conclusion: While HI seems to increase the access to and use of healthcare services by the elderly in rural Tanzania, a lower responsiveness by the healthcare system among the insured elderly was reported. Long waiting times, limited-service benefits, restricted use of services within schemes, lack of health workforce in both numbers and skills as well as shortage of medical supplies were important explanations for the lower responsiveness. The results of this thesis, while supporting the national aim of expanding HI in rural areas, also exposed several weaknesses that require immediate attention. There is a need to, first, review the insurance policy to improve its implementation, expand the scope of services coverage, and where possible, to introduce cross-subsidization between the publicly owned schemes; additionally, improvements in the healthcare infrastructure, increasing the number of qualified health workforce and the availability of essential medicines and laboratory services, especially at the primary healthcare facilities, should be prioritized and further investments allocated.
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- Amani, Paul Joseph, et al.
(author)
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Health insurance and health system (un) responsiveness : a qualitative study with elderly in rural Tanzania
- 2021
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In: BMC Health Services Research. - : BioMed Central. - 1472-6963. ; 21:1
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Journal article (peer-reviewed)abstract
- BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data.RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.
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- Amani, Paul Joseph, et al.
(author)
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Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania : an explorative qualitative study
- 2023
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In: BMC Public Health. - : BioMed Central (BMC). - 1471-2458. ; 23:1
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Journal article (peer-reviewed)abstract
- BACKGROUND: Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania.METHODS: An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data.RESULTS: Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement.CONCLUSION: While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.
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- Amroussia, Nada, et al.
(author)
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"Is the doctor God to punish me?!" : An intersectional examination of disrespectful and abusive care during childbirth against single mothers in Tunisia
- 2017
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In: Reproductive Health. - : Springer Science and Business Media LLC. - 1742-4755. ; 14
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Journal article (peer-reviewed)abstract
- BACKGROUND: Disrespectful and abusive treatment during childbirth is a violation of women's right to dignified, respectful healthcare throughout pregnancy and childbirth. Although reports point out that marginalized groups in society such as single mothers are particularly vulnerable to abusive and disrespectful care, there is a lack of in-depth research exploring single mothers' encounters at the maternal healthcare facilities, especially in Tunisia. In Tunisia, single mothers are particularly vulnerable due to their social stigmatization and socio-economic marginalization. This study examines the self-perceptions and childbirth experiences of single mothers at the public healthcare facilities in Tunisia.METHODS: This study follows a qualitative design. Eleven single mothers were interviewed in regard to their experiences with maternal healthcare services and their perceptions of the attitudes of the health workers towards them. The interviews also addressed the barriers faced by the participants in accessing adequate maternal healthcare services, and their self-perceptions as single mothers. The data were analyzed using an inductive thematic approach guided by the feminist intersectional approach. Emergent codes were grouped into three final themes.RESULTS: Three themes emerged during the data analysis: 1) Experiencing disrespect and abuse, 2) Perceptions of regret and shame attributed to being a single mother, and 3) The triad of vulnerability: stigma, social challenges, and health system challenges. The study highlights that the childbirth experiences of single mothers are shaped by intersectional factors that go beyond the health system. Gender plays a major role in constructing these experiences while intersecting with other social structures. The participants had experienced disrespectful and discriminatory practices and even violence when they sought maternal healthcare services at the public healthcare facilities in Tunisia. Those experiences reflect not only the poor quality of maternal health services but also how health system practices translate the stigma culturally associated with single motherhood in this setting. Social stigma did not only affect how single mothers were treated during the childbirth, but also how they perceived themselves and how they perceived their care.CONCLUSION: Ensuring women's right to dignified, respectful healthcare during childbirth requires tackling the underlying causes of social inequalities leading to women's marginalization and discrimination.
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- Amroussia, Nada, et al.
(author)
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Reproductive health policy in Tunisia : women's right to reproductive health and gender empowerment
- 2016
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In: Health and Human Rights. - 1079-0969 .- 2150-4113. ; 18:2, s. 183-194
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Journal article (peer-reviewed)abstract
- Although Tunisia is regarded as a pioneer in the Middle East and North Africa in terms of women's status and rights, including sexual and reproductive health and rights, evidence points to a number of persisting challenges. This article uses the Health Rights of Women Assessment Instrument (HeRWAI) to analyze Tunisia's reproductive health policy between 1994 and 2014. It explores the extent to which reproductive rights have been incorporated into the country's reproductive health policy, the gaps in the implementation of this policy, and the influence of this policy on gender empowerment. Our results reveal that progress has been slow in terms of incorporating reproductive rights into the national reproductive health policy. Furthermore, the implementation of this policy has fallen short, as demonstrated by regional inequities in the accessibility and availability of reproductive health services, the low quality of maternal health care services, and discriminatory practices. Finally, the government's lack of meaningful engagement in advancing gender empowerment stands in the way as the main challenge to gender equality in Tunisia.
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- Anyango, Cartrine, et al.
(author)
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"A One-size-fit-all model is not good"? : Ambivalent perceptions and experiences of African immigrant parents towards Swedsih sexual and reproductive health services for young people
- 2020
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In: BMC Research Notes. - : BioMed Central (BMC). - 1756-0500. ; 13
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Journal article (peer-reviewed)abstract
- Objective: Parents have a key role regarding young people’s access to sexual and reproductive health services, thus their perceptions go a long way towards promoting or discouraging young people from using such services. Research has revealed that immigrant young people in Sweden access these essential services to a lesser extent than their native peers, and that they perceive their parents as unsupportive of such visits. This pilot study’s objective was to explore immigrant parents’ perceptions and experiences of the sexual and reproductive health services provided by Swedish youth clinics.Results: Two categories were developed from the data analysis: (i) Youth clinics are well-known (to some) and appreciated (to a certain extent), and (ii) Parents feel left out from youth clinics and that the clinics have taken over parental responsibility. This study presents an ambivalent scenario connected to immigrant parents’ experiences and perceptions of having neither a space nor a voice within the existing youth clinic model. Parents expressed the desire for the youth clinics to recognise their cultural backgrounds, norms, and beliefs while providing sexual and reproductive health services to their children.
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- Anyango, Cartrine, et al.
(author)
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Women with disabilities’ experiences of intimate partner violence : a qualitative study from Sweden
- 2023
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In: BMC Women's Health. - : BioMed Central (BMC). - 1472-6874. ; 23:1
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Journal article (peer-reviewed)abstract
- Background: Intimate Partner Violence (IPV) is a prevalent form of gender-based violence affecting one in three women globally. It is also a preventable cause of ill-health, disability, and death. Current research suggests that women with disabilities are at a significantly higher risk of experiencing violence throughout their lifetime. They are almost twice as likely to experience violence compared to men with disabilities or men and women without disabilities. Additionally, they experience higher rates of all types of violence. This increased vulnerability may be due to factors related to disability such as dependence on others for support, mistrust, and social and physical isolation. Although there is existing research on IPV against women in general, there is limited knowledge on IPV against women with disabilities. To address this gap in knowledge, this study aimed to explore women with disabilities’ perceptions and experiences of being victims/survivors of IPV in Sweden.Methods: This was a qualitative study conducted through in-depth interviews with eleven women with disabilities. The participants were aged eighteen years upwards. The collected data was analyzed using reflexive thematic analysis with a constructivist epistemological standpoint.Results: We developed four themes. Theme one: “multiple abuse by multiple abusers, over time,” describes the participants’ experiences of various types of violence from different perpetrators for prolonged periods. Theme two: “psychological abuse—harmful, but neglected and difficult to prove,” explains how women with disabilities’ perceive psychological abuse as harmful, but not given the same level of seriousness as physical violence. It also expresses the difficulties they encountered in providing tangible evidence to prove instances of psychological abuse. Theme three: “abuse does not end with separation,” highlights how abuse can continue beyond separation/divorce. Theme four: “surviving abusive relationships” describes the different and evolving ways the participants used to navigate their abusive relationships.Conclusions: Women with disabilities face all forms of abuse. They find it challenging to prove psychological abuse, and the system is inadequate in addressing its harm. The abuse also continues after separation or divorce. The support system should consider the needs of women with disabilities who experience violence, both during and after the abusive relationship. Service providers should be better equipped to detect and handle all types of IPV, especially psychological abuse.
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- Banda, Emmanuel, et al.
(author)
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Acceptability of an economic support component to reduce early pregnancy and school dropout in Zambia : a qualitative case study
- 2019
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In: Global Health Action. - : Taylor & Francis. - 1654-9716 .- 1654-9880. ; 12:1
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Journal article (peer-reviewed)abstract
- Background: Cash Transfer (CT) schemes have become popular poverty reducing measures in many low and middle-income countries. Research indicates that when provided to girls in resource poor settings, cash transfers can increase education and postpone marriage and pregnancy. However, a few studies indicate that they can also have negative effects which can affect their acceptability, such as generating intra-community tensions.Objective: Conceptually informed by Rogers’ diffusion of innovation theory, this paper explores factors affecting the acceptability of economic support in a randomized controlled trial in rural Monze and Pemba Districts of Southern Province in Zambia.Methods: Qualitative data were collected through five focus group discussions and six in-depth, semi-structured interviews and analysed using thematic analysis. This study was done in the combined arm of a trial where girls received both economic support and participated in youth clubs offering sexuality and life-skills education.Results: In the study communities, acceptability was encouraging by the belief that economic support provided benefits beyond beneficiaries and that it improved access to education, and reduced teen pregnancies, marriages and school drop-out. However, provision of economic support only to selected girls and their parents and fear among some that the support was linked to satanic practices negatively affected acceptability. These fears were mitigated through community sensitisations.Conclusion: The study demonstrated that relative advantage, observability, simplicity and compatibility were key factors in influencing acceptability of the economic support. However, to enhance acceptability of cash transfer schemes aimed at addressing early marriage and pregnancy, it is important to explore socio-cultural factors that create suspicions and negative perceptions and to provide schemes that are perceived as relatively better than available similar schemes, understood, compatible and viable beyond the immediate beneficiary.
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