Department of Public Administration and Health Services Management, University of Ghana Business School, Box LG 78, Legon, Accra, Ghana.
Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra Region, Ghana.
Soc Sci Med. 2018 Mar;201:27-34. doi: 10.1016/j.socscimed.2018.02.001. Epub 2018 Feb 5.
Policy analysis on why women and children in low- and middle-income settings are still disadvantaged by access to appropriate care despite Primary Health Care (PHC) programmes implementation is limited. Drawing on the street-level bureaucracy theory, we explored how and why frontline providers (FLP) actions on their own and in interaction with health system factors shape Ghana's community-based PHC implementation to the disadvantage of women and children accessing and using health services. This was a qualitative study conducted in 4 communities drawn from rural and urban districts of the Upper West region. Data were collected from 8 focus group discussions with community informants, 73 in-depth interviews with clients, 13 in-depth interviews with district health managers and FLP, and observations. Data were recorded, transcribed and coded deductively and inductively for themes with the aid of Nvivo 11 software. Findings showed that apart from FLP frequent lateness to, and absenteeism from work, that affected care seeking for children, their exercise of discretionary power in determining children who deserve care over others had ripple effects: families experienced financial hardships in seeking alternative care for children, and avoided that by managing symptoms with care provided in non-traditional spaces. FLP adverse behaviours were driven by weak implementation structures embedded in the district health systems. Basic obstetric facilities such as labour room, infusion stand, and beds for deliveries, detention and palpation were lacking prompting FLP to cope by conducting deliveries using a patchwork of improvised delivery methods which worked out to encourage unassisted home deliveries. Perceived poor conditions of service weakened FLP commitment to quality maternal and child care delivery. Findings suggest the need for strategies to induce behaviour change in FLP, strengthen district administrative structures, and improve on the supply chain and logistics system to address gaps in CHPS maternal and child care delivery.
尽管实施了初级卫生保健（PHC）计划，但针对中低收入环境中妇女和儿童获得适当护理的机会受限问题的政策分析仍然有限。本文借鉴街头官僚理论，探讨了一线服务提供者（FLP）的行动如何以及为何自行以及与卫生系统因素相互作用，从而影响加纳以社区为基础的 PHC 的实施，使妇女和儿童在获取和使用卫生服务方面处于不利地位。这是一项在乌阿西区农村和城市地区的 4 个社区进行的定性研究。数据来自社区线人 8 次焦点小组讨论、客户 73 次深度访谈、区卫生经理和 FLP 的 13 次深度访谈以及观察。借助 Nvivo 11 软件，通过演绎和归纳方法对数据进行记录、转录和编码，以提取主题。研究结果表明，除了 FLP 经常迟到和旷工，这影响了儿童的求诊外，他们在决定谁应该得到照顾方面行使自由裁量权的行为也产生了连锁反应：家庭在为孩子寻求替代护理时遇到了经济困难，并通过在非传统场所提供的护理来管理症状来避免这种情况。FLP 的不良行为是由区卫生系统中嵌入的薄弱实施结构驱动的。基本的产科设施，如产房、输液架和分娩、拘留和触诊用床，都缺乏，促使 FLP 通过使用拼凑的临时分娩方法来应对，这些方法鼓励了无人帮助的家庭分娩。服务条件差使 FLP 对提供优质母婴保健服务的承诺减弱。研究结果表明，需要采取策略来改变 FLP 的行为，加强区行政结构，并改善供应链和物流系统，以解决 CHPS 母婴保健服务提供方面的差距。
