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Collaboration between non-governmental organizations and public services in health - a qualitative case study from rural Ecuador
Karolinska Institute, Sweden.
Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Emergency Medicine. Linköping University, Department of Medical and Health Sciences, Division of Community Medicine.ORCID iD: 0000-0002-3606-1329
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Primary Health Care in Central County.ORCID iD: 0000-0001-9116-8156
Linköping University, Department of Medical and Health Sciences, Division of Community Medicine. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Local Health Care Services in West Östergötland, Research & Development Unit in Local Health Care.
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2016 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 9, article id 32237Article in journal (Refereed) Published
Abstract [en]

Background: Non-governmental organizations (NGOs) have a key role in improving health in low-and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. Design: A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. Results: Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the providers structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. Conclusions: To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the populations trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the providers structure, and regarding partners roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations.

Place, publisher, year, edition, pages
CO-ACTION PUBLISHING , 2016. Vol. 9, article id 32237
Keywords [en]
community participation; healthcare services; perception; primary healthcare; public private partnership
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:liu:diva-134110DOI: 10.3402/gha.v9.32237ISI: 000390858600001PubMedID: 27852423OAI: oai:DiVA.org:liu-134110DiVA, id: diva2:1067516
Note

Funding Agencies|Karolinska Institutet; Linkoping University; Ecuador

Available from: 2017-01-22 Created: 2017-01-22 Last updated: 2018-07-26
In thesis
1. The Bumpy Road to Universal Health Coverage: Access to Primary and Emergency Care in Rural Tropical Ecuador
Open this publication in new window or tab >>The Bumpy Road to Universal Health Coverage: Access to Primary and Emergency Care in Rural Tropical Ecuador
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: By the turn of the new millennium 84% of families in rural coastal Ecuador had difficulties to access health services. A health reform some years earlier to improve this situation had not been implemented. In 2001, the non-governmental organization (NGO) Foundation Human Nature together with a rural population established a primary health care center in North-Western Ecuador. A public private partnership with the Ministry of Public Health was formed. Services depended on out-of-pocket payments, restricting the poor’s access to care. In order to increase access to primary and emergency care, Foundation Human Nature planned to establish a community-based health insurance. In the meantime, a major health reform was initiated by a new government in 2008. It aimed at universal health coverage, providing qualitative services for all based on primary health care, while ensuring protection from financial hardship. The aims of this thesis were to appraise the feasibility of community- based health insurance in Ecuador; to study how rural stakeholders perceived the 2008 reform and its effects on rural health services; to explore the local population’s perception of the NGO in service delivery; and to measure the scope and describe the nature of perceived emergencies, the related health care seeking behavior and health expenditure.

Methods: Quantitative and qualitative methods were applied to tackle the research objectives. Data collection for the health insurance study and the study of perceived emergencies was carried out through cross-sectional household surveys. For each of the studies 210 households were sampled with two-stage cluster sampling. Structured questionnaires were used with on the spot household interviews. Focus group discussions with local stakeholders were performed to explore their perceived effects of the 2008 health reform. The population’s perception of the NGO was also studied through focus group discussions, which were complemented by key-informant interviews with local stakeholders. Inductive qualitative content analysis, focusing on the manifest content was applied.

Results: 69% of interviewees were willing to join the presented community-based health insurance scheme for 30 US$ per household and year. Attitudes towards the scheme were positive and 92% of interviewees stated they would increase their health service utilization with affiliation. The implementation of the 2008 health reform was perceived as top-down, lacking communication. However, the reform’s effects were mainly perceived as positive with free medical attendance and drugs. Increased service utilization was described as leading to a relative shortage of drugs and appointments. Access problems for remote dwellers were found, who were described of having to seek private care, also in emergencies. The NGO and its services were perceived positively by the population due to health care improvements in the region. The structure of the public private partnership was unclear, leading to dissatisfaction. Community participation was found to be rather weak. Perceived emergencies occurred to at least 90/1,000 inhabitants in the past year. Fever, traumatic injury and abdominal pain were the most frequent chief complaints. The first contacted providers in 57% of all cases were private for-profit providers, including traditional healers. Public health services treated one third of all cases. Health expenditure was found to be high and catastrophic health expenditure occurred in 24% of all cases.

Conclusions: Prior to the 2008 reform community-based health insurance was found to be feasible in the study region. This financing instrument may have a role in the post-reform system, to cover services that the government does not yet sufficiently provide. The effects of the 2008 reform were mainly perceived positively, but an adjustment of the system is needed to improve the relative lack of drugs and appointments, especially for remote dwellers. Free health services may not be sufficient to reach universal health coverage for patients with perceived emergencies. Changes in public emergency departments and improved financial protection for emergency patients may improve the situation. The NGO’s role was perceived positively by the population. A lack of communication about the public private partnership and relatively weak community participation restricted the NGO’s full potential and should be improved.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2018. p. 100
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1630
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-149812 (URN)10.3384/diss.diva-149812 (DOI)9789176852705 (ISBN)
Public defence
2018-09-21, Belladonna, Hus 511, Campus US, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2018-07-26 Created: 2018-07-26 Last updated: 2018-08-29Bibliographically approved

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