Contents lists available at ScienceDirect Sexual & Reproductive Healthcare journal homepage: www.elsevier.com/locate/srhc Health workforce perspectives of barriers inhibiting the provision of quality care in Nepal and Somalia – A qualitative study Malin Bogren a, ⁎ , Kerstin Erlandsson b , Anders Johansson c , Mohamed Kalid d , Asad Abdi Igal e , Jamal Mohamed f , Fatumo Said g , Christina Pedersen b , Ulrika Byrskog b , Fatumo Osman b a Institute of Health Care and Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden b School of Education, Health and Social Studies, Dalarna University, Falun, Sweden c Ambulanssjukvården, Dalarna, Sweden d Save the Children, Garowe, Somaliland, Somalia e Save the Children, Bosaso, Somaliland, Somalia f Save the Children, Gardo, Somaliland, Somalia g Ministry of Health, Garowe, Puntland, Somalia ARTICLE INFO Keywords: Healthcare providers Healthcare services Health systems Quality care Nepal Somalia ABSTRACT Objective: In this paper settings from Nepal and Somalia are used to focus on the perspectives of healthcare providers within two fragile health systems. The objective of this study was to describe barriers inhibiting quality healthcare in Nepal and Somalia from a health workforce perspective. Methods: Data were collected through 19 semi-structured interviews with healthcare providers working in healthcare facilities. Ten interviews were conducted in Nepal and nine in Somalia. Results: Various structural barriers inhibiting the availability, accessibility, and acceptability of the quality care were similar in both countries. Barriers inhibiting the availability of quality care were linked to healthcare providers being overburdened with multiple concurrent jobs. Barriers inhibiting the accessibility to quality healthcare included long distances and the uncertain availability of transportation, and barriers to acceptability of quality healthcare was inhibited by a lack of respect from healthcare providers, characterised by neglect, verbal abuse, and lack of competence. Conclusions: Inequality, poverty, traditional and cultural practices plus the heavy burden placed on healthcare providers are described as the underlying causes of the poor provision of quality care and the consequential shortcomings that emerge from it. In order to improve this situation adequate planning and policies that support the deployment and retention of the healthcare providers and its equitable distribution is required. Another important aspect is provision of training to equip healthcare providers with the ability to provide respectful quality care in order for the population to enjoy good standard of healthcare services. Background Human resources for healthcare are essential in achieving health- related sustainable development goals (SDGs), and are integral to uni- versal health coverage [1]. Universal health coverage emphasises the fundamental importance of the health and wellbeing of all people. Universal health coverage is thus about ensuring that all people get equitable access and use of the quality healthcare services they need without experiencing financial hardship [1,2]. If health-related targets are to be achieved, health systems will have to be strengthened to deliver a wider range of essential health services. Hence, health systems need to directly address and work towards uni- versal healthcare, including sexual, reproductive, maternal and new- born health, and gender equality [3]. In combination with available health sector policies or reforms, universal health coverage can only be achieved if there is a sufficient number of healthcare workers and available medicines [4]. Compelling evidence shows that a higher number of healthcare providers such as doctors, midwives, nurses, and auxiliaries has a po- sitive effect not only on access to healthcare but also on health out- comes [5]. As many of the SDGs clearly impact on the healthcare workforce and its ability to provide quality care [6], the provision of https://doi.org/10.1016/j.srhc.2019.100481 Received 17 June 2019; Received in revised form 15 November 2019; Accepted 18 November 2019 ⁎ Corresponding author at: Arvid Wallgrens Backe, 405 30 Göteborg, Sweden. E-mail addresses: malin.bogren@gu.se (M. Bogren), ker@du.se (K. Erlandsson), johansson.anders@me.com (A. Johansson), mki@du.se (M. Kalid), cpn@du.se (C. Pedersen), uby@du.se (U. Byrskog), fos@du.se (F. Osman). Sexual & Reproductive Healthcare 23 (2020) 100481 1877-5756/ © 2019 Elsevier B.V. All rights reserved. T