Using data to inform health management decisions is especially vital in lower- and middle-income countries, where resources are limited, and plans are primarily focused on prioritising interventions. Service provision data at the health facilities, referred to as routine facility data, present the largest source for guiding these decisions. Nevertheless, in several settings, these data are perceived as of low quality, which limits their use. We argue that the extent and determinants of data quality vary across different settings. This study examined the quality of routine facility data in the Bahi District Council and Dodoma City Councils in Tanzania. Using a mixed-methods approach, we assessed data quality through completeness, consistency, and timeliness. The study found high quality in the routine facility data, with completeness leading for the outpatient department form in Dodoma CC(98.1%) and for antenatal services in Bahi DC (98.4%). The study also found strong internal and external consistency. Early antenatal visits, for example, were reported at approximately 35% in both facility data and surveys. The study further challenges counting data collection forms as the sole measure of completeness. For example, the number of child health forms indicates that the Bahi scored above 90%, yet only 6% of its facilities completed all essential data in those forms. Relying on counting data collection tools only is not likely to provide a true representation of quality. leaves data quality unconnected to the actual decision. Based on the findings, this study recommends examining completeness on individual data elements to connect them to decisions.
Background Nurses constitute the largest proportion of the health workforce in Nigeria, and their knowledge and perceptions of the newly introduced R21 malaria vaccine are crucial to its implementation, particularly in Northern Nigeria, where the malaria burden is highest. This study explored nurses’ awareness, knowledge, perceptions, and perceived barriers to the introduction of the R21 malaria vaccine in selected tertiary hospitals in Northern Nigeria. Methods A convergent parallel mixed-methods design was used. Quantitative data were collected from 368 nurses using a structured questionnaire and analyzed using descriptive (frequencies, percentages, and means) and inferential statistics (Statistical significance at p < 0.05). Qualitative data obtained through in-depth interviews with nine purposively selected nurses were analyzed thematically using ATLAS.ti version 8. Findings Awareness and knowledge of the R21 malaria vaccine among nurses were generally poor, with social media identified as the primary source of information. No statistically significant differences in knowledge were observed across health facilities (p > 0.05). Overall perception toward the vaccine was positive, although some uncertainty regarding vaccine safety persisted. Key perceived barriers to uptake included inadequate funding, cold chain and logistical challenges, as well as religious and cultural resistance driven by misconceptions. Conclusion Nurses demonstrated low awareness and limited knowledge of the R21 malaria vaccine, although perceptions toward its introduction were generally favorable, with some uncertainty regarding vaccine safety. The prominence of social media as an information source indicates a shift in information dissemination pathways and highlights the need to leverage digital platforms to improve knowledge and counter misinformation.
Background Women are a substantial part of the health workforce and health systems research community, yet gendered patterns in publication roles, concept profiles, collaboration, and recognition remain under-analyzed. Objective To characterize gendered patterns of visible publication leadership in diabetes health services research (HSR). Methods We conducted a bibliometric and co-authorship network analysis of 2,410 diabetes HSR articles published from 2015 to 2025, enriched with OpenAlex, Crossref, and Semantic Scholar data. Corresponding authorship was the primary proxy for visible publication leadership; first authorship was examined in sensitivity analysis. We analyzed concept profiles, team composition, funding, citations, and network centrality. Results Women held 51.8% of corresponding authorship positions. Female-led papers were associated with distinct concept profiles, with greater representation in patient-centered and implementation-oriented domains, and were associated with more gender-inclusive author teams than male-led papers (median women co-authors: 62.5% vs 33.3%). In co-authorship network analyses, women were represented proportionally in brokerage-oriented positions measured by betweenness centrality. Unadjusted citation differences favored male-led papers, but adjusted citation models did not support a persistent citation disadvantage for female-led papers. Conclusion In this diabetes HSR corpus, female-led papers were associated with distinct concept profiles, more gender-inclusive teams, and proportional representation in brokerage-oriented co-authorship positions. Citation-based recognition should be interpreted cautiously because citation counts are influenced by publication year, concept profile, journal visibility, funding, open access, team size, and citation practices.
Maternal mortality rates remain alarmingly high in low- and middle-income countries (LMICs). A critical challenge is measuring the quality of maternal care. Composite indexes are widely used but often rely on objective indicators that overlook women’s lived experiences. Although participatory approaches are increasingly encouraged, it remains unclear how women’s perspectives can be integrated into existing measures. This review systematically examines the construction of composite indexes for maternal care quality in sub-Saharan Africa, focusing on studies incorporating women’s experiences. A scoping review was conducted. Four reviewers searched four databases (Medline, Embase, Global Health, CINHAL) using English keywords on February 14, 2024, with no publication date limitation. Results were organized using the Organization for Economic Co-operation and Development framework for index construction: theoretical framework selection, metric selection, and weighting. Of 5,347 initial records, 111 articles were included across 40 countries. The Donabedian framework was most cited (n=38), yet 52 studies did not mention a framework. Women’s involvement was largely limited to survey responses (n=102), with only eight studies engaging them in result interpretation and two in indicator selection. No studies involved women in index weighting. Despite calls for inclusive approaches, women’s perspectives remain underrepresented in measuring maternal care quality in sub-Saharan Africa.
The Sri Lankan healthcare landscape is an intricate interplay between the dominant publicly funded sector and the expanding profit oriented private sector. Methods This study analysed over 1600 records of ten surgical procedures across multiple Sri Lankan private hospitals, comparing the fees charged by the two highest -volume clinicians' for each procedure within each hospital using Mann–Whitney U tests. Results Statistically significant differences in clinician fees between clinicians' practicing within the same hospital were observed for the majority of procedure-hospital comparisons (mostly p < 0.001), indicating clinician level variations. Mean clinician fees differed across provinces for all procedures. The economically more affluent western province consistently reported higher average clinician fees than other provinces. Discussion/Conclusion This study demonstrates significant variations in professional fees, even among clinicians' working within the same hospital. The fees of the clinicians' who treated higher numbers of patients may reflect factors other than case complexity and associated with less predictable fee setting. This study also confirmed economic affluency and higher per capita income in a region is associated with a tendency of charging higher fees. These findings highlight the need for strengthened regulatory oversight, greater pricing transparency and policy interventions aimed at improving predictability and fairness in healthcare pricing.
Background The achievement of Universal Health Coverage (UHC) critically relies on a skilled, adequate, equitably distributed and motivated health workforce. Ghana is facing a health workforce crisis in remote areas. This paper explores factors influencing poor retention of primary healthcare workers in severely deprived districts in Ghana, to inform policy re-engineering tailored towards UHC. Material and methods We used exploratory qualitative study design by conducting twenty-one in-depth interviews (IDIs) among purposively selected primary healthcare workers, and nine focus group discussions (FGDs) with community members in three of the most deprived districts in the Eastern Region of Ghana. These IDIs and FGDs were conducted face-to-face in March 2024 using topic guides developed and pre-tested by the researchers. The data were analyzed using a conceptually guided thematic framework approach, aided by NVIVO version 12. Results Our study identified national, local, and workplace environmental factors as drivers of low density and poor health workforce retention in deprived districts. The factors were: (1) poor transportation and road network; (2) inadequate accommodation; (3) inadequate social amenities; (4) poor incentives; (5) safety and security concerns; (6) family ties and commitments; and (7) weak health worker-community relationship. Originality/value This study highlights the multifaceted nature of the factors contributing to the unavailability and retention of health workers in remote areas of Ghana. Identifying these factors will support the development of effective interventions to help maximize retention. Strong health worker-community relationship is critical to retaining health staff in rural areas.
Access to quality primary healthcare is a fundamental human right and a determinant of an equitable healthcare system which influenced by multidimensional factors, including geographical characteristics. Disparity in access to primary healthcare services increases the inequality of health status and obstructs the universal primary healthcare coverage, especially in Purulia where predominant inhabitants are from multiple tribal communities and conserving unique socio-cultural characteristics of their own. Simultaneously, Purulia comprises with the scattered hills, ridges and undulating landscape, similar to Sub-Saharan Africa which topographically hinders access to healthcare services. This study conducted in 2024 to systematically explores the complex association between topography and primary healthcare access using the ‘Framework of Access’ by Penchansky and Thomas along with geospatial mapping. Here, the Availability refers to the adequacy of infrastructural and human resources of healthcare, Accessibility denote the geographical reachability, Affordability denote the financial capability to access the healthcare services, the functional capacity of the healthcare services is accessed under Accommodation and Acceptability represent the socio-cultural compatibility. Digital Elevation Model and Pearson’s Correlation Coefficient is incorporated to delineate the topographic elevation and its association with primary healthcare access at Community Development Blocks (C.D. blocks) level. C.D. blocks characterised with higher topographic elevation have been identified with significant inequality in availability and accessibility of primary healthcare services. Deployment of mobile primary healthcare units and expansion of transport networks can reduce the disparities.
Over half the global population lives in urban areas, projected to reach 70% by 2050. Urban poor populations face immunization gaps due to mobility, governance challenges, and limited healthcare access. The Urban Immunization Toolkit (2018) was developed to support district-level managers in addressing these challenges, yet there is limited empirical evidence on how such global toolkits are used, adapted or implemented in urban contexts, and specifically perspectives of end users, particularly district-level program managers remain underexplored. This study addresses this gap by examining the toolkit’s real-world application across multiple settings. Using human-centered design, this study assessed the toolkit’s use across four domains: effectiveness, adaptability, value-added, and ease of use. Phase 1 (June 2023–March 2024) included a global survey with 23 respondents from eight countries. Phase 2 (March–August 2024) involved co-creation workshops in Lagos and Edo States, Nigeria, with caregivers of zero-dose children, immunization managers, and policymakers who applied the toolkit to address challenges related urban immunization in their local contexts. Phase 1 survey respondents rated the toolkit favorably across all domains, though qualitative feedback revealed weaker perceptions about its effectiveness and adaptability. Workshop participants in Phase 2 emphasized the need for context-specific strategies, simpler language, and private sector engagement guidance. Across both phases, participants recommended clearer adaptation guidance, practical job aids, regular updates with country-specific feedback to create a living catalog of solutions, multilingual translation of the toolkit, and its integration into national-level policy guidelines to increase accessibility and use across all levels of government. Findings from both phases informed recommendations to revise the toolkit’s usability and uptake, while also showcasing the application of human-centered design approaches to adapt and evaluate toolkits. These results contributed to the revision and release of a revised toolkit in 2026.From a policy and practice perspective, these findings underscore the importance of designing global implementation tools with built-in flexibility and embedding local co-creation processes that actively engage end users, such as district managers and frontline implementers, to adapt tools and guidance to their operational contexts. At the same time, these tools must align with existing institutional systems to effectively support district-level decision-making. At the global level, the findings highlight the need for ongoing iteration, expanded access to evidence-based toolkits for end users, and sustained collaboration with countries and implementing partners. Systematically capturing and sharing lessons learned from urban immunization strategies would strengthen the evidence base, support continuous program improvement, and inform the development of policy decisions and evidence-based tools.
Objectives This study examined how structural and organizational features of Ontario's mental health system shape care access and delivery for people living with Borderline Personality Disorder (BPD). Drawing on social workers' experiences, we explored how system fragmentation, funding, age-based service divisions, and social determinants of health interact to sustain inequities in service provision. Methods Between April 2020 and January 2021, 41 semi-structured interviews were conducted with social workers across hospital, community, and private-practice settings in Ontario. Guided by a critical realist framework, data were analyzed through a four-stage process of description, abstraction, abduction, and retroduction to identify underlying generative mechanisms that structure BPD care delivery. Results Four interrelated mechanisms were identified: (1) constrained service availability, structural stigma, and exclusionary program criteria restrict timely access; (2) siloed organizational structures that limit coordination and default to emergency-based responses; (3) intersecting social, structural, and cultural determinants of health,(4) the absence of system-level coordination and standards to support collaborative, integrated approaches. Conclusion Findings reveal how health system fragmentation and structural stigma operate as mechanisms that reproduce inequitable care for people with BPD. The exclusion of community-based mental health services from the Canada Health Act and age-based service divisions that disrupt continuity at critical developmental transitions are identified as key structural features sustaining these inequities. Addressing them requires system-wide reform that integrates funding, governance, and service delivery across sectors and age groups. Embedding standardized care pathways, cross-sector collaboration, and lived-experience leadership into governance are critical for developing a more equitable and responsive mental health system.
Introduction Digital transformation in health requires information systems that produce complete, consistent, and standardized records to support routine data quality analyses. Although District Health Information Software 2 (DHIS2) is a global reference, challenges remain regarding data quality, interoperability, governance, and the translation of information into actionable evidence. In Brazil, the Vida Immunization Information System is analyzed as a local case capable of providing transferable lessons for DHIS2-enabled health information systems. Method: This quantitative, retrospective, and exploratory study analyzed nominal records of the measles-mumps-rubella (MMR) vaccine. The analysis covered three dimensions: (i) volume and temporal trend of records; (ii) data quality and completeness; and (iii) territorial distribution of vaccine administration. Segmented regression (Joinpoint Regression Program) and spatial analysis (QGIS) were applied. Results: Completeness was 100% for sex and date of birth, whereas race/color completeness improved to 85.7% (2024). Valid postal codes (CEP) increased from 82.0% (2017) to 97.7% (2024) after the implementation of automatic CEP filling in 2022, reducing missing and invalid records. Installed service capacity remained stable. Approximately 37.7% of doses were administered outside the district of residence, indicating substantial within the municipality mobility and the analytical potential of nominal records for territorial planning. Conclusion: This case shows that local computerized systems can generate high-quality nominal data and reveal temporal and territorial patterns. The findings mirror challenges observed in DHIS2 ecosystems, highlighting the importance of governance, standardization, and analytical use for strengthening health management.
Introduction In Liberia, traditional and faith healers hold significant influence in the management of neglected tropical diseases (NTDs) as they are often the first point of contact. Despite their central role in community care, traditional and faith healers are rarely engaged as partners within formal NTD programmes. This study evaluated a participatory intervention, co-designed with traditional and faith healers as partners, to identify symptoms of NTDs for early referral, addressing stigma and provide basic psychological support. Methods We conducted a participatory qualitative study in three counties in Liberia. At baseline, focus group discussions (FGDs), reflective diaries with traditional and faith healers and in-depth interviews (IDIs) with persons affected by skin NTDs were conducted. A co-designed training was delivered to 588 healers, including recognising symptoms, referral pathways, basic psychological support and addressing stigma. Reflective diaries were maintained alongside the intervention as process evaluation. At endline, FGDs, IDIs and key informant interviews with Ministry of Health stakeholders were conducted. Data was analysed thematically using a framework approach. Results Participants reported increased awareness of skin NTDs, perceived improvements in referral practices and strengthened collaboration between formal and informal actors. Dialogue and supervision were identified as critical to building trust. However, challenges related to remuneration and sustainability remain. Conclusion Integrating informal healthcare providers into health systems offers a holistic, culturally embedded and person-centred approach to strengthening NTD care. Collaboration can lead to early case detection and timely referral, reducing delays in treatment. Further research on supporting and sustaining ethical and equitable partnerships is required.
Social values are central to understanding how health systems operate and the rationale behind their transformation. This work examines how the values associated with psychiatric reform and the transition from institutional to community-based mental health care are mobilized in delayed discharges in Argentina’s general hospitals, amid a political context marked by policies centered on fiscal austerity and public spending cuts. Drawing on interviews conducted in 55 general hospitals nationwide with public-sector mental health workers, the study analyzes tensions among three social values derived from the Latin American Psychiatric Reform framework: dignity and rights, technical rationality and community-based living. Findings reveal seven components shaping whether delayed discharges are considered justified or unacceptable. Five components frame delays as justified: structural shortcomings in community services, limitations in family support networks, the holistic nature of care, the hospital’s role as a care-providing institution, and internal tensions surrounding standardized care. Two additional components frame delays as unacceptable: pressures related to bed management and inadequate infrastructure, particularly from the standpoint of technical rationality and patients’ dignity and rights. The study shows that delayed discharges operate as a site of value-based tension within the public health system, reflecting broader struggles over care, responsibility, and resource allocation. In the current Argentine context of State retrenchment, these findings highlight the need to understand delayed discharges not only as an organizational inefficiency, but as a health systems problem shaped by complex and competing social values.
Introduction Adolescent mothers in Rwanda often face stigma, discrimination, and various forms of violence (interpersonal and structural), leading to mental health challenges. Without trauma- and violence-informed care (TVIC), perinatal services may unintentionally re-traumatize adolescent mothers. Aim To develop strategies for integrating TVIC into perinatal services in primary healthcare settings in Rwanda to support adolescent mothers. Methods This interpretive descriptive study purposively selected 46 participants, including 15 adolescent mothers, 12 perinatal nurses and midwives, 12 maternal community health workers, and seven key informants from eight primary healthcare settings. Data collection was conducted from December 2021 to April 2022. Two practice guidelines (Antenatal Care and Maternal Community Health Workers Training Module) were reviewed. Data were sorted and organized using Dedoose software and deductively and inductively analyzed. Results Four overarching implementation strategy domains and operational sub-strategies were developed. First, the participants emphasized the need to increase awareness of trauma and violence through education, training, and sensitive care practices. Second, they highlighted the importance of building safety and trust by creating welcoming, confidential, and inclusive perinatal environment. The third implementation strategy domain focused on amplifying adolescent mothers’ voices and promoting collaboration, flexibility, and shared decision-making in care. Finally, participants stressed the value of strength-based practices that recognize and build on adolescent mothers’ resilience. Conclusions Emergent strategies provide actionable guidance that can be effectively implemented within perinatal services in resource-constrained settings with contexts like Rwanda. Governments and health authorities in comparable settings can build on these strategies to advance equitable, compassionate, and adolescent-responsive perinatal care.
The use and the application of health security, both as a frame and a set of practices, have increased and become central to global health governance. Nigeria navigates complex pressure in health priority setting, shaped by domestic political realities, economic constraints and a longstanding relationship with international donors. Yet how the framing of health as security interacts with these dynamics, and how the actors involved shape health system priorities and practices, remains under-examined. We conducted 28 realist-informed interviews with national and state government actors, actors working at international organisations, and implementing partners across eight states and the Federal Capital Territory. Analysis was informed by an existing realist framework and focused on how contextual conditions activate actor reasoning (uncertainty, self-protection, self-preservation, self-reliance, and norm-setting) to generate the outcomes of securitised responses. We identified four interrelated outcome patterns (1) centralisation of governance, where priorities were steered by global agendas and reinforced through federal structures; (2) shaping of resource allocation, often prioritising diseases of international concern over locally salient health needs; (3) reconfiguration of health services, including vertical programming and administrative reporting burdens; and (4) institutionalisation of security norms, normalising military and security actor involvement in health response. Our findings show that health security is more than a technical exercise; it is a dynamic phenomenon co-created across multiple dimensions, including global norms and domestic governance. To mitigate the negative consequences of this phenomenon, we recommend that policy, practice, and research actors – internationally, in Nigeria, and elsewhere – engage more critically with global framings of health and security.
Universal healthcare (UHC) is recognised as both a moral and policy imperative central to advancing equity and realising the right to health. Yet its translation into national reform remains uneven, and ambiguity surrounding its meaning, scope, and implementation allows policy actors to reinterpret UHC in ways that align with prevailing institutional arrangements and ideological commitments. In Ireland, successive governments since 2011 have committed to UHC, culminating in the 2017 Sláintecare reform programme and its vision of a ‘single-tier universal health system’. However, implementation has been incremental and fragmented within a historically embedded mixed public–private system. This study examines how UHC is defined, justified, and enacted within the Irish policy process, foregrounding the interpretive and ideational dynamics shaping reform trajectories. A retrospective qualitative case study was conducted, combining documentary analysis of 143 national policy documents (2014–2024) with 19 elite semi-structured interviews. Data were analysed using reflexive thematic analysis. Findings indicate that UHC in Ireland functions as a politically unifying yet substantively elastic policy frame. Sláintecare operated as a coalition-forming reform vision whose conceptual breadth enabled political consensus while leaving redistributive questions of entitlement unsettled. UHC was repeatedly specified, displaced, and repurposed through moral reasoning about fairness, need, and the role of the state, and was further constrained by crisis-driven governance, electoral incentives, and institutional path dependency. UHC thus achieves strong normative legitimacy while remaining only partially institutionalised, revealing reform as an ongoing arena of political contestation rather than a linear progression toward comprehensive entitlement.
Kindness is widely recognised as important in healthcare yet remains poorly defined and is often conflated with related concepts such as compassion and empathy. This lack of conceptual clarity limits how kindness can be studied, measured, and embedded into healthcare practice and systems. This qualitative interview study explored how kindness is defined and conceptualised in healthcare, and how it is distinguished from empathy and compassion, from the perspectives of international experts recognised for their work in this field. Fifteen semi-structured interviews were conducted with healthcare leaders, clinicians, researchers, and patient advocates across seven countries. These are people who talk about kindness all the time – but do they have a shared definition as experts in this space? Data were analysed using a constructivist grounded theory approach informed by participatory action research principles. Participants consistently described kindness as a deliberate, proactive action that supports human dignity, fosters meaningful connection, and contributes to others' well-being. Kindness was viewed as broader and more inclusive than compassion, less emotionally demanding, and applicable across a wide range of everyday healthcare interactions. Unlike empathy, which was described as an internal process, kindness was defined by observable actions and impact. Participants also highlighted that kindness may involve honesty, candour, and engagement with conflict, challenging assumptions that kindness is synonymous with niceness. Beyond individual behaviour, kindness was conceptualised as an organisational value that can be supported or constrained by systems, leadership practices, and workplace environments. This study presents an empirically grounded definition of kindness in healthcare, laying the groundwork for future research and supporting efforts to embed kindness as a practical, operational value within healthcare systems.
South Africa contains large numbers of long-term care facilities (LTCFs) and experienced high rates of COVID-19 infection during the pandemic. This paper examines how state agencies in the Province of Western Cape engaged with facilities before and during the pandemic, and whether this represented an effective form of state stewardship. We draw on semi-structured interviews with LTCF managers and observational/documentary data obtained through collaborative engagement with government agencies. Pre-pandemic, state engagement with LTCFs mainly entailed funding for poor residents and tokenistic rule enforcement. There was little coordination between the two main regulatory agencies, with many facilities unregistered and entirely unregulated. There was an evident disconnect between official standards and the capacity of LTCFs to achieve them, which regulators did little to address. During the pandemic, many LTCFs turned to state agencies for guidance and support, but they were slow to respond. As the pandemic progressed, state agency coordination and responsiveness improved to some degree, especially during the roll-out of COVID-19 vaccines. The pandemic experience revealed the dysfunction of the established LTCF regulatory model, which focussed on largely performative rule enforcement and limited state funding. It calls for an approach based on partnerships between regulators and providers, establishing achievable goals and shared responsibility for service improvement.
Cross-border healthcare, which involves the use of health services across international borders, is gaining increased global attention. Much of the existing literature focuses on patient flows between high-income and low- and middle-income countries, with limited attention paid to regional mobility and the influence of migration and diaspora networks. Despite the high levels of cross-border movement in West Africa, research on healthcare use in this region remains limited. This study examined cross-border healthcare use between Senegal and The Gambia, exploring the drivers, management and potential coordination mechanisms at various health system levels. We conducted a qualitative case study in two border regions of The Gambia and Senegal, through semi-structured interviews with health professionals and a structured data-validation workshop involving researchers, health professionals, and representatives from Ministries of Health from both countries. Data analysis was guided by Anzaldua’s theory of borders and Adam and de Savigny’s “Systems thinking for health systems strengthening” framework. We identified three distinct types of cross-border patients. Key motivations for cross-border healthcare use included accessibility, perceived care quality, and social capital. Patient networks played a substantial role in shaping patients’ choice of country to access healthcare. Additionally, both providers and patients reported barriers to access healthcare services, highlighting systemic gaps. Our findings underscore the need for cross-border healthcare policies that build on existing practices to address current limitations. This study contributes valuable insights into regional cross-border healthcare dynamics in West Africa, providing implications for decision makers and health practitioners to strengthen cross-border health systems coordination.
