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Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households.

If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the \"hows\" and \"whys\" of processes and pathways are essential for guiding policy and programme actions.

There has been a welcome emphasis on gender issues in global health in recent years in the discourse around human resources for health. Although it is estimated that up to 75% of health workers are female (World Health Organization, Global strategy on human resources for health: Workforce 2030, 2016), this gender ratio is not reflected in the top levels of leadership in international or national health systems and global health organizations (Global Health 50/50, The Global Health 50/50 report: how gender responsive are the world’s leading global health organizations, 2018; Clark, Lancet, 391:918–20, 2018). This imbalance has led to a deeper exploration of the role of women in leadership and the barriers they face through initiatives such as the WHO Global Strategy on Human Resources for Health: Workforce 2030, the UN High Level Commission on Health Employment and Economic Growth, the Global Health 50/50 Reports, Women in Global Health, and #LancetWomen. These movements focus on advocating for increasing women’s participation in leadership. While efforts to reduce gender imbalance in global health leadership are critical and gaining momentum, it is imperative that we look beyond parity and recognize that women are a heterogeneous group and that the privileges and disadvantages that hinder and enable women’s career progression cannot be reduced to a shared universal experience, explained only by gender. Hence, we must take into account the ways in which gender intersects with other social identities and stratifiers to create unique experiences of marginalization and disadvantage.

Background Primary health care (PHC) country case studies provide valuable insights into PHC-oriented transformations. This policy-oriented secondary analysis of country case studies focused on sexual and reproductive health and rights (SRHR), examining: how and where SRHR has been prioritised in country PHC-oriented transformations; the impact of the COVID-19 pandemic on SRHR; and emerging SRHR policy priorities. Methods We conducted a multi-country synthesis through an SRHR lens on three case study series; 52 country case studies total from 42 countries. The sequence of steps included: sampling PHC country case studies; developing and piloting an assessment instrument guided by 8 SRHR areas and PHC levers clustered by structures, inputs and processes; extracting data; analyzing and validating the findings. Elaborative coding and thematic analysis were used to explore the findings by research question. Results Policy interventions reported were skewed towards specific SRH services including HIV/STIs, family planning and reproductive health over other services like reproductive cancers and cross-cutting issues like gender-based rights. Policy interventions were predominately related to structures (governance and financing), followed by processes (models of care). The pandemic caused several disruptions across SRHR areas investigated by exacerbating gender inequalities, increasing gender-based violence, changing service utilization patterns, and suspending services. Common priority areas included extending coverage, implementing integrated models of care, addressing workforce shortages, improving supply management and enhancing engagement with target groups. Conclusions While SRHR has been central to PHC-oriented health system transformations, the analysis suggests uneven implementation of interventions across SRHR areas and dimensions of PHC. This secondary analysis of case studies using SRHR as a tracer policy priority offers a high-level overview of the policy landscape across countries. While reliant on the quality and depth of the original case studies and limited by the data that lies within, methods like that applied here, can facilitate cross-country learning and policy transfer beyond individual cases and merits further application.

Given the unequivocal recognition that reproductive health (and sexual heath) are a cornerstone of sustainable development, global agencies including the World Health Organization (WHO) and the United Nations Population Fund (UNFPA) have remained resolute in their call for the reprioritisation of reproductive health [7, 8]. The reproductive health consequences of STIs include pelvic inflammatory disease with permanent damage to the fallopian tubes, uterus, and surrounding tissues, which can lead to infertility, mother-to-child transmission, adverse pregnancy outcomes and chronic pelvic pain. The majority of countries (103 of 111; 93%) surveyed had policies for antenatal screening and treatment of syphilis in place in 2019–2020. [...]59% of countries included the HPV vaccine in the national immunization schedule [18]. Long-term outcomes of primary prevention strategy should include a paradigm shift from a disease-centered approach to sexual health and reproductive health promotion with a positive attitude towards sexuality, based on the core concept of well-being, and tailored behavioural interventions linked to the evidence-based biomedical approaches in one package to prevent new cases of

Background This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policies – the Uniform Patient Fee Schedule (UPFS) and Patients’ Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems’ people-centeredness and “software”. Methods The research entailed semi-structured interviews (Hospital A n  = 115, Hospital B n  = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n  = 155, Hospital B n  = 77) and Organisational Trust Inventory (Hospital A n  = 185, Hospital B n  = 92) for assessing staff-manager trust. Results Regarding the UPFS, the hospitals’ implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals’ PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people’s values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. Conclusions Achieving equity in practice requires managers to take account of “unseen” but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation “hardware” such as putting in place necessary staff and resources, it emphasises “software” implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers’ status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected.

Background This study presents the first process evaluation of an integrated family planning, sexual reproductive health, and wellbeing community-based intervention among Syrian refugee women and girls in Lebanon. This intervention, known as the Self-Efficacy and Knowledge (SEEK) intervention, was developed by the World Health Organization as a low-resource and low-intensity initiative, and led by trained paraprofessionals (community health workers). Methods The intervention was implemented between September and December 2024, a period marked by active conflict in Lebanon. A mixed-methods process evaluation was conducted, triangulating data from satisfaction surveys, field observations, and semi-structured interviews with participants, health workers, and program staff. Quantitative data were analyzed using SPSS, and qualitative data were analyzed using qualitative content analysis. Data collection tools assessed satisfaction, feasibility, fidelity to content, logistical and contextual barriers. Results The evaluation revealed high participant satisfaction, with over 90% of participants rating session quality as good or excellent. Participants valued the program’s relevance, paraprofessionals community alignment, and the inclusion of interactive and visual aids. Paraprofessionals expressed satisfaction with the training and delivery process but, along with attending psychologists and midwives, reported the need for more soft-skills training and presentation skills. Logistical challenges included child care needs, transportation barriers, and the necessity of flexible scheduling. The war on Lebanon posed major implementation hurdles, requiring adaptive strategies such as remote coordination and increased reliance on leadership of local staff. Cultural and gender norms affected engagement, particularly around SRH content, with participants recommending greater involvement of men and household decision-makers. The presence of local women committees, research assistants, and field coordinators was key to maintaining trust, communication, and retention of participants. Conclusions This evaluation demonstrates that SEEK is feasible, acceptable, and adaptable even in the context of active conflict. Its community-led design supported engagement and delivery, underscoring the importance of flexible and locally grounded implementation strategies in fragile settings. Trial registration Retrospectively registered on NIH clinical trials reference# NCT07008950.

Expanding access to sexual and reproductive health (SRH) services is one of the key targets of the Sustainable Development Goals. The extent to which sexual and reproductive health and rights (SRHR) targets will be achieved largely depends on how well they are integrated within Universal Health Coverage (UHC) initiatives. This paper examines challenges and facilitators to the effective provision of three SRHR services (maternal health, gender-based violence (GBV) and safe abortion/post-abortion care) in Ghana. The analysis triangulates evidence from document review with in-depth qualitative stakeholder interviews and adopts the Donabedian framework in evaluating provision of these services. Critical among the challenges identified are inadequate funding, non-inclusion of some SRHR services including family planning and abortion/post-abortion services within the health benefits package and hidden charges for maternal services. Other issues are poor supervision, maldistribution of logistics and health personnel, fragmentation of support services for GBV victims across agencies, and socio-cultural and religious beliefs and practices affecting service delivery and utilisation. Facilitators that hold promise for effective SRH service delivery include stakeholder collaboration and support, health system structure that supports continuum of care, availability of data for monitoring progress and setting priorities, and an effective process for sharing lessons and accountability through frequent review meetings. We propose the development of a national master plan for SRHR integration within UHC initiatives in the country. Addressing the financial, logistical and health worker shortages and maldistribution will go a long way to propel Ghana's efforts to expand population coverage, service coverage and financial risk protection in accessing essential SRH services.

Background The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women’s full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being ‘left behind’ in terms of career development and progression into senior health leadership positions. Methods Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments. Results Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the ‘first’ to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture. Conclusion This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play.

Background Many low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC. Methods Using a cross-sectional survey across four of South Africa’s nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status. Results A quarter of respondents remained uninsured, even higher among 20–29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits. Conclusions By introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country’s financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.