BMC Health Services Research
(Accessed 26 April 2014)
http://www.biomedcentral.com/bmchealthservres/content

Research article
Effective access to health care in Mexico
Juan Pablo Gutiérrez, Sebastián García-Saisó, Germán Fajardo Dolci and Mauricio Hernández Ávila
Author Affiliations
BMC Health Services Research 2014, 14:186 doi:10.1186/1472-6963-14-186
Published: 23 April 2014
Abstract (provisional)
Background
Effective access measures are intended to reflect progress toward universal health coverage. This study proposes an operative approach to measuring effective access: in addition to the lack of financial protection, the willingness to make out-of-pocket payments for health care signifies a lack of effective access to pre-paid services.
Methods
Using data from a nationally representative health survey in Mexico, effective access at the individual level was determined by combining financial protection and effective utilization of pre-paid health services as required. The measure of effective access was estimated overall, by sex, by socioeconomic level, and by federal state for 2006 and 2012.
Results
In 2012, 48.49% of the Mexican population had no effective access to health services. Though this represents an improvement since 2006, when 65.9% lacked effective access, it still constitutes a major challenge for the health system. Effective access in Mexico presents significant heterogeneity in terms of federal state and socioeconomic level.
Conclusions
Measuring effective access will contribute to better target strategies toward universal health coverage. The analysis presented here highlights a need to improve quality, availability, and opportuneness (location and time) of health services provision in Mexico.

Research article
A scoping study on task shifting; the case of Uganda
Sebastian Olikira Baine and Arabat Kasangaki
Author Affiliations
BMC Health Services Research 2014, 14:184 doi:10.1186/1472-6963-14-184
Published: 23 April 2014
Abstract (provisional)
Background
Task shifting has been implemented in Uganda for decades with little documentation. This study’s objectives were to; gather evidence on task-shifting experiences in Uganda, establish its acceptability and perceptions among health managers and policymakers, and make recommendations.
Methods
This was a qualitative study. Data collection involved; review of published and gray literature, and key informant interviews of stakeholders in health policy and decision making in Uganda. Data was analyzed by thematic content analysis.
Results
Task shifting was the mainstay of health service delivery in Uganda. Lower cadre of health workers performed duties of specialized health workers. However, Uganda has no task shifting policy and guidelines, and task shifting was practiced informally.
Lower cadre of health workers were deemed to be incompetent to handle shifted roles and already overworked, and support supervision was poor.
Advocates of task shifting argued that lower cadre of health workers already performed the roles of highly trained health workers. They needed a supporting policy and support supervision.
Opponents argued that lower cadre of health workers were; incompetent, overworked, and task shifting was more expensive than recruiting appropriately trained health workers.
Conclusions
Task shifting was unacceptable to most health managers and policy makers because lower cadres of health workers were; incompetent, overworked and support supervision was poor. Recruitment of existing unemployed well trained health workers, implementation of human resource motivation and retention strategies, and government sponsored graduates to work for a defined mandatory period of time were recommended.

Study protocol
Design of an impact evaluation using a mixed methods model – an explanatory assessment of the effects of results-based financing mechanisms on maternal healthcare services in Malawi
Stephan Brenner, Adamson S Muula, Paul Jacob Robyn, Till Bärnighausen, Malabika Sarker, Don P Mathanga, Thomas Bossert and Manuela De Allegri
Author Affiliations
BMC Health Services Research 2014, 14:180 doi:10.1186/1472-6963-14-180
Published: 22 April 2014
Abstract (provisional)
Background
In this article we present a study design to evaluate the causal impact of providing supply-side performance-based financing incentives in combination with a demand-side cash transfer component on equitable access to and quality of maternal and neonatal healthcare services. This intervention is introduced to selected emergency obstetric care facilities and catchment area populations in four districts in Malawi. We here describe and discuss our study protocol with regard to the research aims, the local implementation context, and our rationale for selecting a mixed methods explanatory design with a quasi-experimental quantitative component.
Design
The quantitative research component consists of a controlled pre- and post-test design with multiple post-test measurements. This allows us to quantitatively measure ‘equitable access to healthcare services’ at the community level and ‘healthcare quality’ at the health facility level. Guided by a theoretical framework of causal relationships, we determined a number of input, process, and output indicators to evaluate both intended and unintended effects of the intervention. Overall causal impact estimates will result from a difference-in-difference analysis comparing selected indicators across intervention and control facilities/catchment populations over time.
To further explain heterogeneity of quantitatively observed effects and to understand the experiential dimensions of financial incentives on clients and providers, we designed a qualitative component in line with the overall explanatory mixed methods approach. This component consists of in-depth interviews and focus group discussions with providers, service user, non-users, and policy stakeholders. In this explanatory design comprehensive understanding of expected and unexpected effects of the intervention on both access and quality will emerge through careful triangulation at two levels: across multiple quantitative elements and across quantitative and qualitative elements.
Discussion
Combining a traditional quasi-experimental controlled pre- and post-test design with an explanatory mixed methods model permits an additional assessment of organizational and behavioral changes affecting complex processes. Through this impact evaluation approach, our design will not only create robust evidence measures for the outcome of interest, but also generate insights on how and why the investigated interventions produce certain intended and unintended effects and allows for a more in-depth evaluation approach.