Aims: Empirical research has proven that a strong primary health care (PHC) system produces better health outcomes and therefore, PHC is an important part of a country's health system. This systematic review focuses on the intended aims and targets of PHC reforms conducted in Finland from 1993 onwards. It describes the challenges that the Finnish PHC system has faced, comparing the objectives and the problem with other similar countries, providing lessons from the Finnish experiences for other countries. Methods: A Campbell-styled systematic review was conducted. Databases including Ebsco, Pubmed/MEDLINE, Scopus, Google Scholar and a Finnish health science database Medic were searched. The keywords and MeSH Terms for the review included terms relating to 'health systems', 'primary care', 'reform', and 'Finland' (see Appendix B). English terms were used when using Medline, Scopus and EBSCO, and both Finnish and English terms were used when using Medic. Reference lists of included papers were also searched. Data was extracted and analysed by utilising thematic analysis. Results: 13 relevant papers were found that dealt with PHC policies or reforms implemented in Finland between 1993 and 2015. The aims of the reforms were classified under five themes, which were developed based on a prior scoping review and then tested during data extraction. The themes were: efficient governance and financing, adequate and equitable access, improved quality, increased patient choice and cooperation and integration of services. Conclusions: A number of policies and reforms have been implemented which have directly or indirectly aimed to strengthen the Finnish PHC system. Some policies have intended to strengthen PHC overall while others have focused on only one aspect or challenge. There has recently been a strong tendency to re-centralise health services, and the importance of patient choice and service integration have become increasingly important. Integration and cooperation of different service providers is one of the newest solutions when finding ways to strengthen weak PHC systems. This study shows that in policy success context matters. PHC strengthening needs to be high on the political agenda, and enough resources are needed. This study showed that there have been few durable or sustainable solutions, and further research is needed especially from the overall health systems perspective.

Background. Common mental disorders (CMDs), including depression and anxiety disorders, and risky alcohol use are highly prevalent among people living with HIV. Yet, many studies have found that most people who suffer from mental disorders do not receive treatment, especially in low-income countries. Given people living with HIV frequent health services, this represents a missed opportunity for identification and treatment that could improve physical and mental health outcomes. The aim of this study was to identify missed opportunities to address mental health of people living with HIV in Malawi. Four types of missed opportunities were operationalised for this study. The first two address missed opportunities for screening or identification For missed opportunity #1, a respondent had to screen positive for mental health problem (depression/anxiety or alcohol use ; and in any of their visits to the clinic in the past 12 months, the clinical officer or nurse did not ask about their mental health. Missed opportunity definition #2 was a more nuanced missed opportunity for identification of probable mental health problems. A respondent had to be undetected for mental health problems; and in any of his or her visits to the clinic in the past 12 months, the clinical officer or nurse did not ask about his or her mental health and s/he wanted to receive advice or treatment about his or her mental health problems. The second to definitions address missed opportunities for treatment. For missed opportunity definition #3, a respondent had to screen positive for mental health problem and if in any of his or her visits to the clinic in the past 12 months, and s/he did not receive advice or treatment. For missed opportunity definition #4, a more nuanced missed opportunity for the treatment of probable mental health problem: a respondent had to screen positive for a mental health problem; s/he wanted to receive advice or treatment about his or her mental health problems/alcohol use; and in any of their visits to the clinic in the past 12 months, s/he did not receive treatment for a mental disorder/risky alcohol use. Methods. A a random of participants receiving HIV care were approached while they were waiting for their consultation at three ART clinics namely: Tisungane, Matawale and Domasi. Those who consented to participants were interviewed in a private room. The Self-Reporting Questionnaire-20 (SRQ-20) and the Alcohol Use Disorders Identification Test (AUDIT) were used to detect probable cases of CMDs and clients consuming alcohol at risky levels. Following v administration of the SRQ-20 and AUDIT, participants were asked if clinical officers (COs) or nurses inquired about their feelings (sad or worried) or alcohol consumption during their routine visits to ART clinics, thus eliciting data on identification by healthcare workers or identification of CMD symptoms. The participants were also asked whether advice or treatment was recommended and whether they would have liked to receive advice or treatment regarding their feelings or risky alcohol use. Descriptive statistics were utilized to calculate prevalence estimates of missed opportunities and multiple logistic regression models were used to determine the factors associated with missed opportunities for mental health service provision. Results. The study had 382 participants. The proportion of participants who screened at risk was 77 (20.2%) for probable CMDs and 16 (4.2%) for risky alcohol use. The proportion of participants who screened at risk for any mental health problem (depression, anxiety and risky alcohol use) was 87 (22.8%). Participants who were asked by clinical officers and nurses about CMD symptoms and alcohol use were 92 (24.1%) and 89 (23.3%) respectively. Of the entire sample, 351 (91.9%) participants wanted to receive advice or treatment and 26 (29.9%) received advice or treatment. Missed opportunities to address the mental health of people living with HIV were found to be as follows: definition #1, 40 participants (46.0%); definition #2, 35 participants (40.2%); definition #3, 87 participants (100%) and definition #4, 66 participants (75.9%). After adjusting for other variables in the model female gender was significantly associated with missed opportunity definition #1. After adjusting for other variables in the model female participants were more likely to meet criteria for missed opportunity definition #2 than male participants. Furthermore, older participants were less likely to meet criteria for missed opportunity definition #2 compared to younger participants. Participants who were employed were less likely to meet criteria for missed opportunity definition #2. In the same vein, participants who were spending less were less likely to meet criteria for missed opportunity definition #2. Given all participants met criteria, we were unable to develop logistic regression models. There were no significant associations for missed opportunity definition #4. Conclusion. Approximately one fifth of the sample recruited screened at risk for CMDs and most clients wanted to receive advice or treatment. Despite over 40% of the participants reporting being asked about CMD symptoms, PHC workers did not provide advice or treatments to 75.9% of clients. There is need to advocate for screening of mental health problems including alcohol use and treatment in all ART clinics in Malawi.

Alleviating the global shortage of health workers, particularly nurses, is critical for health systems and health worker performance. Nurses are mostly women and make up the majority of the health workforce. Several factors have been identified as key players in the shortage crisis and migration is one of these factors. Nurses' migration from Sub Saharan Africa (SSA) increases the nurse shortage in the region and further constraints the already struggling health systems. Migration literature has dominantly focused on macro push-pull, brain drain and ethics theories of migration with limited exploration of relationships, interaction, norms, beliefs and values shaping migration trajectories and decisions. Despite the potential role of gender as an influential component of migration trajectories, there has been little research done to investigate gender in the context of migration of SSA nurses. This review aims to identify, describe, and summarize SSA nurses' migration experiences by assessing the influence of gender on these experiences. The dissertation is organized into 3 parts. Part A is a systematic review protocol that describes the background, justification and methodology of the review. A scoping exercise is conducted to to familiarize with the literature. This is followed by a qualitative systematic approach is utilised and the literature in eight databases is searched using key words and terms derived from an initial scoping exercise and the review questions. Suitable articles are defined and selected using a set inclusion and exclusion criteria. The suitable articles are then appraised and a thematic analysis using a gender focal lens is applied to them. Part B is a literature review of existing primary and theoretical research on health worker shortages; migration and gender analysis in health worker migration and shortages. It provides a background for the systematic review by defining migration, gender and gender analysis as well as presenting the scope on health worker and nurse shortages. The literature review encompasses the scoping exercise and concludes on the relevance of a gender-focused research on nurse migration. Part C. is the full systematic review presented as an article for Human Resources for Health Journal. Articles published on Sub-Saharan African (SSA) nurses' migration experiences between 2005 and 2016 are presented, subjected to a gender analysis to illuminate the results. The discussion and conclusion then follow. The results indicate that there is a paucity of empirical work on nurse migration experiences that is explicitly gender-focused. Gender analysis that is situated in social contexts and identifiers revealed that SSA nurses continuously renegotiate and reconfigure gender roles in child care as they move from one social context to another. Moreover migrating SSA nurse face challenges and limitations at macro, meso and micro levels of the system- that are linked to their identities as either professionals, African migrants and/or women. Therefore, the review underscores the importance of the relationships between gender and local/individual nuances and global/national determinants of migration. However, these studies are limited in their explicit gender and social focus and how it contextually affects health worker performance and quality care provision. More empirical studies are needed to investigate gender influences for migrating male nurses; nurses who remain; and by different geographical & cultural region – to allow comparison across different groups of nurses and determine conceptual generalizations for doing gender research. This dissertation will likely increase understanding of the role of gender in migration decision-making and experiences for SSA nurses across different professional, migrant and woman identities. This understanding has impacts on nurse motivation, capacity and capability as well quality care provision. Additionally, the dissertation provides a better understanding for incorporating gender analysis in health systems research, and also identifies avenues for future research.

As nations are encouraged to move towards achieving Universal Health coverage (UHC), access to essential medicines needs to be prioritized. In ensuring access to medicines, an important factor to be considered is the uninterrupted availability of essential medicines at the primary health care (PHC) level which is usually the first point of entry into the health system for patients. If South Africa is to move towards achieving UHC, the government must address the issue of unavailability of medicines due to frequent stock outs at the public health facilities. The increase in prevalence of HIV/AIDS and TB has resulted in an increase in the demand for medicines used in the management and treatment of these diseases. Surveys have revealed the extent of stock outs and shortages of medicines used in the management of HIV and TB in South Africa. It has also been predicted that the burden of disease in relation to these diseases is likely to increase in the coming years therefore, it is important for the South African government to address the issues of stock outs. Using a qualitative multiple case study approach, we explored the factors which may influence the management of medicine stock thus causing medicine stock outs at four PHC facilities in two of the districts in the study province. A conceptual framework on the factors influencing medicine stock outs at health facilities was developed from reviewing literature on the subject and this was used to guide data collection and analysis. Our findings revealed that the factors influencing the management of medicine stock leading to medicine stock outs include the lack of capacity in terms of human resources and physical resources at the PHC facilities. Insufficient supervision and support from the district level also had an influence as health workers at the facilities did not always follow the recommended procedures for medicine stock management. We also found that there were gaps in communication between the health workers at the facilities and stakeholders at other levels, particularly the pharmaceutical depot from which the facilities obtained their medicines. The inadequate information systems contributed to this gap in communication. Whilst many studies have focused on the factors that may influence the availability of medicine at higher levels, this study focused on what may influence it at the ground level, the PHC facility level. We anticipate that our findings will inform policy makers on how the availability of medicines at PHC facilities may be improved by focusing on improving the processes in medicine stock management at this level.

Bibliography: leaves 121-130. / Zimbabwe like many other countries in Sub-Saharan Africa is being ravaged by the effects of HIV/AIDS. Prevalence levels currently stand at between 15-35% (for women aged between 25-29), and are expected to grow to 50% by the year 2010. The economy is suffering from the loss of productive labour, the health sector is over-burdened and unable to cope with the increased demand for health services due to ADS related illnesses. Many households have lost their principal breadwinners to the disease and have become impoverished as a result. Despite a myriad of interventions aimed at preventing the spread of the infection, and mitigating its effects on the health system, the economy, and households, the infection still presents a problem for the country. Poor urban households in particular, are susceptible to poverty induced by the effects of this illness. It is therefore important to not only assess the costs of the disease on these households, but also to understand the strategies which .they employ to cope with the impact of the illness. The main aim of this study was to assess the costs (direct and indirect) incurred by poor households as a result of HIV /AIDS, and to explore the strategies which they make use of in dealing with the effects of the disease. Social capital was examined as a resource which households utilize in order to mitigate the impact of HIV/AIDS related ill health on the household. Data was collected from interviews of people living with HIV/AIDS (using a structured questionnaire), focus group discussions and key informant interviews. The sample of 110 people living with HIV/AIDS was drawn from two poor urban communities with different wealth profiles. The questionnaire was structured in order to obtain information on the costs incurred by households as a result of the disease and about the strategies employed to cope with the disease. The results indicate that HIV/AIDS places a heavy economic burden on affected households, many of whom already struggle to meet their basic needs. The results show that that most households (72%) enter into debt, and few make use of household savings and Medical Insurance as mechanisms for coping with the high costs of ill health. Both communities exhibited high levels of certain types of social capital resources, with the lower income community exhibiting higher levels of social capital resources in general. A pattern in the results reveals that the resources and forms of assistance (financial and non-financial) that households in the two communities had available to them for coping with the disease differed according to the type of social capital held by the respondents in the each community. An analysis of these results suggests that introducing structures to assist affected households in meeting their basic needs such as food and education would improve the ability of households to cope with the economic impact of the disease. The institution of means tested exemption systems for health care services for these people would greatly improve the ability of their households to cope with the high illness costs. The results also suggest that organisations and actors involved in HIV/AIDS interventions should co- ordinate their efforts so as to be effective in mitigating the effects of the disease on these households. It is also suggested that policy makers develop capacity in the area of social capital and HIV/AIDS so that interventions targeted at assisting communities affected by AIDS are informed by an understanding of the complete resource set (including differing social capital endowments) that households have at their disposal.

Bibliography: leaves 107-112. / This study examined the current resource allocation decision-making processes, and the distribution of both financial and non-financial resources in the health sector. The study explored how the current resource allocation process has impacted on equity between provinces (equity being defined as equal resources for equal need). It went further to look at possible alternatives that could lead the Kenyan health sector towards geographical equity. The study focused on the public health sector because it is the largest provider of health care services in Kenya. The basic argument underlying the study was that, raising additional funds for health care (e.g. through user fees) might not lead to equity, if the additional resources were to be allocated within the current resource allocation process. Instead, the study argues that the first step towards equity in health care in Kenya is to distribute the current resources in a more equitable manner. This can only be done through the development and implementation of a better resource allocation process.

Health services utilisation, which is sometimes used as a proxy measure for equity is a complex subject to study. Identifying and explaining the important factors determining health care utilisation is a key to a better assessment of whether countries' health policies address the equity concerns of their populations in a comprehensive way. It is extensively documented that meeting the health needs of people especially those disadvantaged by such factors as geographical location, joblessness, low income, gender inequalities and lack of education among others, is an important strategy to preventing the increase in poverty and eventually reducing equity gaps. Realising this goal is not easy unless studies are done to establish policy and theoretical arguments related to why some sections of populations are more likely to use/or not to use available health care services than others. This cross-sectional study principally aims at assessing the impact of perceived quality and costs of health care on utilisation of PHC services in rural and urban areas of Tanzania. Using both quantitative and qualitative methods, it intends to explore whether there are differences between rural and urban users in terms of their perceptions of quality of health services and how these perceptions affect household decisions in utilising health services. It further examines the extent to which costs of health care are important determinant in health services utilisation and how rural and urban users are affected by this factor when it comes to deciding to use or not to use government health facilities. The study concludes that consumers of health care in rural Tanzania are highly responsive to health care costs than they are to quality concerns. As the two categories of rural and urban are affected differently by costs and their perceptions of quality when it comes to health care utilisation, it is possible that the observed utilisation trends can partly be attributed to these two factors. Furthermore, the study highlights that socio-economic variables such as gender, income, education, wealth and household size are important not only in determining user's decision making on the amount and appropriate time to seek care but also mitigates effectively on the extent to which costs and perception of quality of care affect rural and urban users of health care services. The study recommends that the government should strive to provide better "quality " information to its consumers. It further recommends that a critical evaluation of important quality aspects be done to see which mostly determine household decisions on utilisation of care among rural and urban users of care. The study has found that the kit system has had some problems, hence the study recommends that government devises mechanisms of ensuring that drugs are available at points of service. Acknowledging the existing geographical inequities, the need to incorporate the private sector in PHC provision and improve quality of health care, the study recommends for more resources to be devoted to research and venture on new opportunities provided by the ongoing reforms as a way of introduction, chapter one of the study report presents the country background information and how the health system is organised. The remainder of the report is organised as follows. In chapter two, the report presents the literature review whilst chapter three covers conceptual framework and methodology. This is followed by presentation of results and analysis in chapter four before putting forward a brief discussion of the findings in chapter five. In chapter six, conclusions and policy recommendations are presented.

Stakeholder analysis (SHA) is an important tool in policy analysis, used to understand the actors who are affected by or have an effect on a particular policy. Its implementation spans a variety of sectors from government to corporate, and conservation to health. The widespread application of SHA naturally causes some confusion with regards to terminology and methodology, but also serves as an opportunity for cross-sectoral and cross-discipline learning. This mini-dissertation discusses methods used to conduct stakeholder analyses (SHAs). It presents, first, the results of a broad scoping review investigating SHA methods described in 28 articles outside the health sector spanning low, middle and high income geographical regions. This scoping review, together with the seminal Varvasovszky and Brugha (2000) health policy SHA guide is, second, used to inform a systematic review – that entails a more critical assessment of the application of SHA across 21 articles addressing the use of SHAs within health policy analysis work undertaken within low to middle income country (LMIC) settings. A variety of methodological approaches to SHAs are used outside of the health sector, including creative ways to generate information in collaboration with SHs, as well as to present SHA findings. Future health policy analysts and researchers would do well to look outside the health sector for more creative and participative data collection and presentation approaches. Notwithstanding the widespread citing of Varvasovsky and Brugha (2000) across health policy SHAs, many of the articles were found wanting in their reflection on key issues presented by Varvasovsky and Brugha (2000). Health policy SH analysts and researchers should consider the use of a two- step SH identification strategy in order to include a greater variety of SHs; offer reflection on their own role within the process of focus and the potential impact of this on the analysis; as well as expand on how context is accounted for in the SHA process, rather than just describing it.

The specific objective of this report is the assessment and analysis of the current financial management capacity at the district level in Mount Frere. It will specifically address the assessment and analysis of financial management capacity in the Mount Frere district, Region E in the EC Province, Department of Health.

The equitable provision of accessible quality health services and the achievement of universal health coverage (UHC) continue to be prominent on the global health agenda, yet remains an elusive target for many low- and middle-income countries (LMIC). In these contexts, the private not-for-profit (PNFP) sector plays a significant role, and in many African countries, faith-based non-profit (FBNP) providers dominate this sector. Robust public-private partnerships are increasingly being recognised as important to building and maintaining strong, resilient health systems. However, there is a lack of evidence on whether collaborations between FBNPs and the public sector are complementary, have achieved their intended aims, or exactly how these relationships developed over time to shape these health systems. Furthermore, reliable information on both the historical and current spatial distribution of services and how this relates to geographic accessibility and the achievement of UHC is limited. This study explores this in Ghana, a country with a large FBNP sector, mostly networked under the Christian Health Association of Ghana (CHAG) which has an influential and now formalised relationship with the government. The following health systems research study utilises a mixed methods approach, synthesising geospatial mapping with varied documentary resources (secondary and primary, current and archival). The evolution of the FBNP sector and the shifts in service footprint are reflected in the geospatial maps, aligned with key historical events and contextualised by a narrative analysis. The study highlights that many faith-based facilities were initially located in rural and remote areas beyond colonial governance control (or boundaries), and many of these facilities still exist, demonstrating resilience to change over time. However, this service footprint has changed and today, public and private health facilities are located in similar areas throughout the country. This trend is in-line with social and political events, changing population dynamics and an increasing population of urban poor. The analysis assesses how the growth of the public sector, and these shifts in presence and profile for the FBNPs has influenced their perceived and measured contribution to UHC - in particular geographic accessibility. This study provides a model for representing the evolution of the relationship between public and a particular type of non-state provider over time, characterising the historical development of the health system, which should be considered in efforts to strengthen and develop the Ghanaian health system, and other relatable LMIC health systems.