Health system capacity for post-abortion care in Java, Indonesia: a signal functions analysis

Background

The quality of obstetric care has been identified as a contributing factor in Indonesia’s persistently high level of maternal mortality, and the country’s restrictive abortion laws merit special attention to the quality of post-abortion care (PAC). Due to unique health policies and guidelines, in Indonesia, uterine evacuation for PAC is typically administered only by Ob/Gyns practicing in hospitals.

Methods

Using data from a survey of 657 hospitals and emergency obstetric-registered public health centers in Java, Indonesia’s most populous island, we applied a signal functions analysis to measure the health system’s capacity to offer PAC. We then used this framework to simulate the potential impact of the following hypothetical reforms on PAC capacity: allowing first-trimester uterine evacuation for PAC to take place at the primary care level, and allowing provision by clinicians other than Ob/Gyns. Finally, we calculated the proportion of PAC patients treated using four different uterine evacuation procedures.

Results

Forty-six percent of hospitals in Java have the full set of services needed to provide PAC, and PAC capacity is concentrated at the highest-level referral hospitals: 86% of referral hospitals have the full set of services, staffing, and equipment compared to 53% of maternity hospitals and 34% of local hospitals. No health centers are adequately staffed or authorized to offer basic PAC services under Indonesia’s current guidelines. PAC capacity at all levels of the health system increases substantially in hypothetical scenarios under which authorization to perform first-trimester uterine evacuation for PAC is expanded to midwives and general physicians practicing in health centers. In 2018, 88% percent of PAC patients were treated using dilation and curettage (D&C).

Conclusions

Offering first-trimester uterine evacuation for PAC in PONEDs and allowing clinicians other than Ob/Gyns to perform this procedure would greatly improve the capacity of Java’s health system to serve PAC patients. Increasing the use of vacuum aspiration and misoprostol for PAC-related uterine evacuation would lower the burden of treatment for patients and facilitate the task-shifting efforts needed to expand access to this life-saving service.

Modeling the elective vascular surgery recovery after coronavirus disease 2019: Implications for moving forward

OBJECTIVE

The delays in elective surgery caused by the coronavirus disease 2019 (COVID-19) pandemic have resulted in a substantial backlog of cases. In the present study, we sought to determine the estimated time to recovery for vascular surgery procedures delayed by the COVID-19 pandemic in a regional health system.

METHODS

Using data from a 35-hospital regional vascular surgical collaborative consisting of all hospitals performing vascular surgery in the state of Michigan, we estimated the number of delayed surgical cases for adults undergoing carotid endarterectomy, carotid stenting, endovascular and open abdominal aortic aneurysm repair, and lower extremity bypass. We used seasonal autoregressive integrated moving average models to predict the surgical volume in the absence of the COVID-19 pandemic and historical data to predict the elective surgical recovery time.

RESULTS

The median statewide monthly vascular surgical volume for the study period was 439 procedures, with a maximum statewide monthly case volume of 519 procedures. For the month of April 2020, the elective vascular surgery procedural volume decreased by ∼90%. Significant variability was seen in the estimated hospital capacity and estimated number of backlogged cases, with the recovery of elective cases estimated to require ∼8 months. If hospitals across the collaborative were to share the burden of backlogged cases, the recovery could be shortened to ∼3 months.

CONCLUSIONS

In the present study of vascular surgical volume in a regional health collaborative, elective surgical procedures decreased by 90%, resulting in a backlog of >700 cases. The recovery time if all hospitals in the collaborative were to share the burden of backlogged cases would be reduced from 8 months to 3 months, underscoring the necessity of regional and statewide policies to minimize patient harm by delays in recovery for elective surgery.

Promoting rational antibiotic use in Turkey and among Turkish migrants in Europe - implications of a qualitative study in four countries

Background

Antimicrobial resistance is considered one of the major threats to global health. The emergence of resistant microorganisms is a consequence of irrational use of antibiotics. In Turkey, the consumption of antibiotics is relatively high and antibiotics are among the most commonly used drugs. However, Turkey has adopted new, more restrictive policies and regulations on antibiotics. In addition, Turkish migrants to EU countries, such as Germany, the Netherlands and Sweden, may encounter health systems that promote a more restrictive and rational antibiotic use.

The objective of this paper was to explore the variation in implemented policies related to rational antibiotic use that citizens in Turkey and Turkish migrants in Germany, the Netherlands and Sweden are subjected to and to discuss the implications for the promotion of rational antibiotic use.

Data were collected through focus groups and individual interviews with citizens, physicians and pharmacists in the four countries. In total, 130 respondents were interviewed. Content analysis was used.

Results

Three relevant themes were identified: Implementation of regulations and recommendations, Access to antibiotics and Need for health communication. Irrational use of antibiotics was reported mainly in Turkey. While it had become less likely to get antibiotics without a prescription, non-prescribed antibiotics remained a problem in Turkey. In the three EU countries, there were also alternative ways of getting antibiotics. Low levels of knowledge about the rational antibiotic use were reported in Turkey, while there were several sources of information on this in the EU countries. Communication with and trust in physicians were considered to be important. There were also system barriers, such as lacking opportunities for physicians to manage care in accordance with current evidence in Turkey and factors limiting access to care in EU countries.

Conclusions

Several fields of importance for promoting rational antibiotic use were identified. There is a need for harmonisation of health-related regulations and policy programmes. Antibiotics should only be available with a prescription. Programmes for rational antibiotic use should be implemented on a broad scale, in medical care, at pharmacies and in the population. Methods for health communication and patient-centred care should be further developed and implemented in this field.

The Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I-TREC) program: scalable strategies for the management of hypertension and diabetes within the government healthcare system of India

Background

Hypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed.

Methods

The overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program’s electronic database.

Discussion

I-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India.

Trial registration

The study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.

The 2019 Health Basic Law in Portugal: Political arguments from the left and right

The Portuguese National Health Service (NHS) was established in 1979. Since its inception, the relationship of the NHS with private-for-profit and private-non-profit organisations has been controversially discussed between left and right-wing political parties, and this has also led also to academic debate. In 1990, a Health Basic Law was approved by right-wing parties, which allowed public-private partnerships (PPPs) in the health system and led to an increased role of the private sector in health care provision. During the 2015 general elections, the role of PPPs in the health system was an important topic of discussion, with all left-wing parties calling for an end of PPPs in the NHS. In 2019, after two years of intense political controversies, left-wing parties supporting the minority socialist government approved a new Health Basic Law. This paper analyses the process of policy formulation, tracing the process of adoption and the views of the main political parties involved. Although some parties wished to eliminate PPPs and to mandate that services in the NHS should be provided exclusively by public providers, this was not included in the final version of the law. Nevertheless, the new Health Basic Law re-enhances the central role of the NHS in the health system, clarifying that the private and non-profit sectors should only play a complementary role.

Determining factors in the retention of physicians in rural and underdeveloped areas: a systematic review

Background

Imbalance in distribution of Health Care Workers (HCWs) in a country is a global challenge. Almost all of the rural and underdeveloped areas are struggling with the shortage of HCWs, especially physicians. Therefore, this study aimed to identify factors governing the retention of physicians in rural and underdeveloped areas.

Methods

International databases including Scopus, PubMed, Web of Science, Proquest, and Embase were searched using Mesh terms in order to find peer-reviewed journal articles addressing physicians’ retention factors in rural and underdeveloped areas. The records were screened, and any duplicate results were removed. The quality of the studies was assessed according to the Critical Appraisal Skills Program developed for different types of studies. Then, through content analysis, the related factors were identified from finally selected papers, coded, and categorized.

Results

The initial search resulted in 2312 relevant articles. On the basis of specific selection criteria, 35 full-text articles were finally reviewed.. The major affecting factors in physicians’ retention in rural and underdeveloped regions were classified into the following six categories: 1) financial; 2) career and professional; 3) working conditions; 4) personal; 5) cultural; and 6) living conditions factors.

Conclusion

There is a complex interplay of factors governing physicians’ retention in rural and underdeveloped areas. If health organizations are concerned with physicians’ retention in deprived areas, they should take into account these main factors. Moreover, they should develop policies and strategies to attract and retain physicians in rural and underdeveloped areas.

Regional variation in potentially inappropriate medicine use in older adults. - A national register-based cross-sectional study on economic, health system-related and patient-related characteristics

BACKGROUND

Potentially inappropriate medicines (PIM), i.e. medicines in which the potential harms may outweigh the benefits, use may be associated with e.g. hospitalization, outpatient visits and health care costs. As regional institutions are often responsible for financing pharmaceuticals, understanding the regional variation of PIM use could help to tackle the associated problems and costs.

OBJECTIVE

To explore regional variation in PIM use among older adults and the association with regional health-system related, patient-related and economic characteristics and the frequency of PIM use.

METHODS

This is a nation-wide study based on the Finnish Prescription Register. PIM use was defined according to the Finnish Meds75+ database and regional characteristics derived from national statistics.

RESULTS

Variation at the hospital district level was large, with the largest difference between the most and least PIM prescribing being 45.2%. The factors associated with high PIM prescribing were a higher share of women and a higher number of private doctor visits per inhabitant in a municipality. The factor associated to lower PIM prescribing was a higher share of Swedish-speaking population. The studied factors explained 23% of the municipal-level variation in PIM.

CONCLUSIONS

Large regional differences may lead to regional inequality in prescribing and in the distribution of pharmaceutical costs. As only a small share of the variation was explained by economic, health system-related and patient-related factors, the key reasons may lie in unobserved prescribing practices.

On redesigning public health in Québec: lessons learned from the pandemic

Over the past few months, our fellow citizens have heard more about public health than ever before. The SARS-CoV-2 pandemic has shed light on the vital role played by public health for health protection and provided telling evidence about current public health capacity as well as the corrective measures to be taken and milestones to be achieved in the future. To this end, we identify several ways forward to re-empower public health in Québec and thus ensure that it can significantly contribute to population health. In particular, we propose that although reforms must continue to bolster health protection, substantial efforts are required to strengthen surveillance systems, prevention systems, health promotion systems, and accessible, effective, and overarching primary care systems.

Late-Stage Diagnosis and Associated Factors Among Breast Cancer Patients in South and Southwest Ethiopia: A Multicenter Study

BACKGROUND

Breast cancer is a leading cause of cancer death in women in low- and middle-income countries, largely because of late-stage diagnosis. Yet studies are very limited in the Ethiopian context. Therefore, we determined the occurrence of late-stage disease and associated factors in selected public hospitals in south and southwest Ethiopia.

PATIENTS AND METHODS

A 5-year retrospective cross-sectional study was conducted on breast cancer patient medical records from January 2013 to December 2017 in 6 hospitals. Multivariable logistic regression was performed to identify factors associated with late-stage disease (stage III and IV). Adjusted odds ratios (AOR) with 95% confidence intervals were used. P < .05 was considered statistically significant.

RESULTS

Overall, 426 breast cancer patients were identified, and 72.5% were diagnosed with late-stage disease. The mean ± standard deviation patient age was 42.8 ± 13.4 years. Factors associated with late diagnosis were patient delay in seeking care (AOR = 2.50; 95% confidence interval [CI], 1.51-4.16); health system delays (AOR = 1.62; 95% CI, 1.02-2.59); female sex (AOR = 3.46; 95% CI, 1.50-7.98); rural residence (AOR = 2.37; 95% CI, 1.45-3.86); chief complaint of breast lump (AOR = 3.01; 95% CI, 1.49-6.07); and history of comorbidities (AOR = 1.72; 95% CI, 1.02-2.91).

CONCLUSION

The majority of patients were diagnosed with late-stage diagnosis of breast cancer. Patient delays in seeking care, health system delays, being female, rural residence, and patient comorbidities were associated factors. These findings provide evidence that efforts to increase public and health provider awareness to promote early breast cancer diagnosis, particularly in rural areas, are needed in south and southwest Ethiopia.

Global health policy in the 21st century: Challenges and opportunities to arrest the global disability burden from musculoskeletal health conditions

The profound burden of disease associated with musculoskeletal health conditions is well established. Despite the unequivocal disability burden and personal and societal consequences, relative to other non-communicable diseases (NCDs), system-level responses for musculoskeletal conditions that are commensurate with their burden have been lacking nationally and globally. Health policy priorities and responses in the 21st century have evolved significantly from the 20th century, with health systems now challenged by an increasing prevalence and impact of NCDs and an unprecedented rate of global population ageing. Further, health policy priorities are now strongly aligned to the 2030 Sustainable Development Goals. With this background, what are the challenges and opportunities available to influence global health policy to support high-value care for musculoskeletal health conditions and persistent pain? This paper explores these issues by considering the current global health policy landscape, the role of global health networks, and progress and opportunities since the 2000-2010 Bone and Joint Decade for health policy to support improved musculoskeletal health and high-value musculoskeletal health care.

A qualitative study exploring the needs related to the health system in women with experience of pregnancy termination due to fetal anomalies in Iran

Background

In order to provide appropriate and adequate care to women who have experienced termination of pregnancy due to fetal anomalies, the health needs of this group should be assessed. Considering the lack of information about the care and services required by these women in Iran, this study was conducted with the aim of exploring the needs related to the health system in women with experience of pregnancy termination due to fetal anomalies.

Methods

This study was conducted with a qualitative approach. 40 participants were selected through purposive sampling, and the data were collected through in-depth semi structured interviews and field notes, and analyzed using conventional qualitative content analysis.

Results

After analyzing the texts, the needs related to the health system in women with experience of pregnancy termination due to fetal anomalies were categorized in the three main categories: “efficient treatment team”, “optimal organizational structure in providing services” and “financial support for families”.

Conclusions

The findings of the present study by exploring and highlighting the needs related to the health system in different dimensions in women with experience of pregnancy termination due to fetal anomalies can be helpful for designing and providing basic and comprehensive care programs.

A roadmap for implementing general policies of resistance economy in the Isfahan Universities of Medical Sciences

CONTEXT AND AIMS

The country development can be promoted through applying policies of the resistance economy in the health system and universities. Therefore, this paper aimed to provide a scientific analysis of resistance economy policies and providing a roadmap for their implementation in the field of health care of Isfahan University of Medical Sciences.

MATERIALS AND METHODS

This is a qualitative study. The basis, general purposes, and strategies of the resistance economy were extracted from the review of the policy of the resistance economy with a political research approach. Then, effective programs and indicators to achieve the goals of the resistance economy were proposed by holding 10 sessions of a centralized group discussion. Finally, the implementation of the resistance economy in the deputies of the University of Medical Sciences was approved by these programs and indicators along with other components and Delphi questionnaire to 30 experts. Framework analysis and descriptive statistics were used to analyze the data from the group discussion and the Delphi stage, respectively.

RESULTS

Implementation of general policies of resistance economy in the field of health and treatment of Isfahan University of Medical Sciences with eight thematic bases, 39 goals, 54 strategies, and 98 programs and indicators were approved by experts. The eight areas of people-centered, economic growth, economic justice, support for internal services, economic flexibility, economic stability, economic influence, and economic health were identified as the thematic bases of communicative policies of the resistance economy in the field of health.

CONCLUSION

The implementation of resistance economy policies entails planning in the long run, culture-building, appreciating the resistance economy in health issues, cooperation, and synergy among different institutions, restructuring the education system at different levels of the health system, and entrepreneurship training.

Training health providers to address unhealthy alcohol use in primary care: a cross-sectional, multicenter study

BACKGROUND

Health professionals' training is a key element to address unhealthy alcohol use in Primary Care (PC). Education about alcohol use can be effective in improving PC provider's knowledge and skills addressing alcohol-related problems. The aim of the study was to evaluate the training of health professionals to address unhealthy alcohol use in PC.

METHODS

An observational, descriptive, cross-sectional, multicenter study was performed.

LOCATION

PC centres of the Spanish National Health System (SNHS).

PARTICIPANTS

Family physicians, residents and nurses completed an online questionnaire that inquired about their training (none, basic, medium or advanced), knowledge and preventive practices aimed at reducing unhealthy alcohol use. The study population was recruited via random sampling, stratified by the regions of the SNHS's PC centre, and by email invitation to members of two Spanish scientific societies of Family Medicine.

RESULTS

A total of 1760 professionals participated in the study. Sixty-seven percent (95% CI: 67.5-71.8) reported not having received specific training to address unhealthy alcohol use, 30% (95% CI: 27.4-31.7) reported having received basic training, and 3% (95% CI: 2.3-4.0) medium/advanced training. The training received was greater in younger providers (p < 0.001) who participated in the PAPPS (Preventive Activities and Health Promotion Programme) (p < 0.001). Higher percentages of providers with intermediate or advanced training reported performing screening for unhealthy alcohol use (p < 0.001), clinical assessment of alcohol consumption (p < 0.001), counselling of patients to reduce their alcohol intake (p < 0.001) or to abstain, in the cases of pregnant women and drivers (p < 0.001).

CONCLUSION

Our study reveals a low level of training among Spanish PC providers to address unhealthy alcohol use. A higher percentage of screening, clinical assessment and counselling interventions aimed at reducing unhealthy alcohol use was reported by health professionals with an intermediate or advanced level of training.

Health system plan for implementation of Paris agreement on climate change (COP 21): a qualitative study in Iran

BACKGROUND

Ensuring public health is crucial in any policy debate on climate change. Paris Agreement on climate change is a global contract, through which countries have committed themselves to a public health treaty. The agreement has laid the foundation for mitigation and adaptation. This study was conducted to provide an evidence-based framework for policy-making in the health system of Iran in order to reduce the adverse effects of climate change on public health and to increase the adaptation of the health system as a result.

METHODS

This is a qualitative study. We first used Delphi method to extract the components of Paris Agreement on climate change that were related to the functions and policymaking of health system in Iran. Twenty-three experts in health and climate change were identified purposefully and through snowball sampling as participants in Delphi. Data collection instrument was a structured questionnaire. We used SPSS software version 25 for data analysis based on the descriptive indices including the mean, the percentage of consensus above 75%, and the Kendall coordination coefficient.

RESULTS

Seventy-nine components classified within nine categories were extracted. The most important examples of the implementation of Paris Agreement on climate change in the health system of Iran were: participation in the formulation of strategies for mitigation and adaptation, identifying vulnerable groups, assessing vulnerability, increasing the capacity of health services delivery during extreme events, using early warning systems, using new technologies to increase the adaptation, evaluation of interventions, financial support, increasing the number of researches, increasing the knowledge and skills of staff, and finally public awareness.

CONCLUSIONS

Evidence-based policy-making is pivotal to develop effective programs to control the health effects of climate change. This research provided policy translation and customization of micro and macro provisions of Paris Agreement on climate change, in line with the political context of health system in Iran. Our finding will pave the ground, we envisage, for further steps towards capacity building and enhancement of resiliency of the health system, adaptation interventions, and evaluation, identification of barriers and facilitators for adaptation and decreasing the adverse health effects caused by the climate change, in Iran and perhaps beyond.

The COVID-19 pandemic in Ireland: An overview of the health service and economic policy response

Objectives

To outline the situation in Ireland with regard to the COVID-19 pandemic.

Methods

Analyse the evolution of the COVID-19 pandemic in Ireland. Review the key public health and health system responses.

Results

Over 1700 people have died with COVID-19 by July 19th while almost 3000 people had been admitted to hospital with COVID-19. A high proportion of the deaths occurred in nursing homes and other residential centres who did not receive sufficient attention during the early phase of the pandemic.

Conclusions

Ireland's response to the COVID-19 crisis has been comprehensive and timely. Transparency, a commitment to a relatively open data policy, the use of traditional and social media to inform the population, and the frequency of updates from the Department of Health and the Health Services Executive are all commendable and have led to a high level of compliance among the general public with the various non-medical measures introduced by the government.

Prevention in COVID-19 time: from failure to future

The COVID-19 pandemic has developed as a consequence of sheer prevention failures, leading in many countries to a sizeable number of deaths and over-saturation of intensive care units. This triggered the imposition of generalisd quarantine ('lockdown') of variable stringency in different countries: with the decrease of the epidemic, the lockdown is now gradually relaxed and replaced by tight tracing and isolation of new cases and their contacts. Prevention, however, remains not a constant priority, as the objective may be avoidance of saturation of intensive care beds or more generally of healthcare facilities rather than the minimisation of the disease incidence. This combined with the fact that notwithstanding repeated warnings in past years the epidemic occurred as a surprise denotes a way of thinking in which prevention is an important option but not a guiding principle of choice and action within the health system. To modify this way of thinking and place prevention at the core of the system, non-negligible changes are required: they may become possible in light of emerging hazards like new viruses and climate change, huge economic costs of failed prevention and initial changes in the health system already induced by the COVID-19 epidemic.

COVID-19 pandemic in Finland - Preliminary analysis on health system response and economic consequences

•

During pandemic the overall resilience of the Finnish society has been comparatively high.

•

Decentralized public health functions have made it possible to engage in active public health actions at local level

•

Pandemic has possibly accelerated the development of digital health services and telemedicine in various part of the Finnish healthcare system

•

COVID-19 will have far-reaching systemic effects on the entire society.

Objectives

The objective of this study was to describe and analyze the impact of the coronavirus disease COVID-19 on health policy, social- and health system, and economic and financing system to prevent, treat, contain and monitor the virus in Finland.

Methods

This study provides early outcomes of health policy measures, social- and health system capacity as well as economic challenges in COVID-19 pandemic in Finland. This paper is based available documents and reports of different ministries and social, health and economic authorities collected online. This was complemented by other relevant pandemic data from Finland.

Results

The impact of COVID-19 pandemic on the Finnish society has been unpredictable although it has not been as extensive and massive than in many other countries. As the situation evolved the Government took strict measures to stop the spread of the virus (e.g. Emergency Powers Act). Available information shows that the economic consequences will be drastic also in Finland, albeit perhaps less dramatic than in large industrial economies.

Conclusions

Finland has transferred gradually to a “hybrid strategy”, referring to a move from extensive restrictive measures to enhanced management of the epidemic. However, health system must be prepared for prospective setback. It is possible, that COVID-19 pandemic has accelerated the development of digital health services and telemedicine in Finnish healthcare system.

Cardiovascular disease trends in Nepal - An analysis of global burden of disease data 2017

Cardiovascular diseases (CVDs) are the leading cause of disease burden globally, disproportionately affecting low and middle-income countries. The continued scarcity of literature on CVDs burden in Nepal has thwarted efforts to develop population-specific prevention and management strategies. This article reports the burden of CVDs in Nepal including, prevalence, incidence, and disability basis as well as trends over the past two decades by age and gender. We used the Institute of Health Metrics and Evaluation's Global Burden of Diseases database on cardiovascular disease from Nepal to describe the most recent data available (2017) and trends by age, gender and year from 1990 to 2017. Data are presented as percentages or as rates per 100,000 population. In 2017, CVDs contributed to 26·9% of total deaths and 12·8% of total DALYs in Nepal. Ischemic heart disease was the predominant CVDs, contributing 16·4% to total deaths and 7·5% to total DALYs. Cardiovascular disease incidence and mortality rates have increased from 1990 to 2017, with the burden greater among males and among older age groups. The leading risk factors for CVDs were determined to be high systolic blood pressure, high low density lipoprotein cholesterol, smoking, air pollution, a diet low in whole grains, and a diet low in fruit. CVDs are a major public health problem in Nepal contributing to the high DALYs with unacceptable numbers of premature deaths. There is an urgent need to address the increasing burden of CVDs and their associated risk factors, particularly high blood pressure, body mass index and unhealthy diet.

Health system's readiness to provide cardiovascular, diabetes and chronic respiratory disease related services in Nepal: analysis using 2015 health facility survey

BACKGROUND

The burgeoning rise of non-communicable diseases (NCDs) is posing serious challenges in resource constrained health facilities of Nepal. The main objective of this study was to assess the readiness of health facilities for cardiovascular diseases (CVDs), diabetes and chronic respiratory diseases (CRDs) services in Nepal.

METHODS

This study utilized data from the Nepal Health Facility Survey 2015. General readiness of 940 health facilities along with disease specific readiness for CVDs, diabetes, and CRDs were assessed using the Service Availability and Readiness Assessment manual of the World Health Organization. Health facilities were categorized into public and private facilities.

RESULTS

Out of a total of 940 health facilities assessed, private facilities showed higher availability of items of general service readiness except for standard precautions for infection prevention, compared to public facilities. The multivariable adjusted regression coefficients for CVDs (β = 2.87, 95%CI: 2.42-3.39), diabetes (β =3.02, 95%CI: 2.03-4.49), and CRDs (β = 15.95, 95%CI: 4.61-55.13) at private facilities were higher than the public facilities. Health facilities located in the hills had a higher readiness index for CVDs (β = 1.99, 95%CI: 1.02-1.39). Service readiness for CVDs (β = 1.13, 95%CI: 1.04-1.23) and diabetes (β = 1.78, 95%CI: 1.23-2.59) were higher in the urban municipalities than in rural municipalities. Finally, disease-related services readiness index was sub-optimal with some degree of variation at the province level in Nepal. Compared to province 1, province 2 (β = 0.83, 95%CI: 0.73-0.95) had lower, and province 4 (β =1.24, 95%CI: 1.07-1.43) and province 5 (β =1.17, 95%CI: 1.02-1.34) had higher readiness index for CVDs.

CONCLUSION

This study found sub-optimal readiness of services related to three NCDs at the public facilities in Nepal. Compared to public facilities, private facilities showed higher readiness scores for CVDs, diabetes, and CRDs. There is an urgent need for policy reform to improve the health services for NCDs, particularly in public facilities.

Secure and energy-efficient framework using Internet of Medical Things for e-healthcare

In various fields, the internet of things (IoT) gains a lot of popularity due to its autonomous sensors operations with the least cost. In medical and healthcare applications, the IoT devices develop an ecosystem to sense the medical conditions of the patients' such as blood pressure, oxygen level, heartbeat, temperature, etc. and take appropriate actions on an emergency basis. Using it, the healthcare-related data of patients is transmitted towards the remote users and medical centers for post-analysis. Different solutions have been proposed using Wireless Body Area Network (WBAN) to monitor the medical status of the patients based on low powered biosensor nodes, however, preventing increased energy consumption and communication costs are demanding and interesting problems. The issue of unbalanced energy consumption between biosensor nodes degrades the timely delivery of the patient's information to remote centers and gives a negative impact on the medical system. Moreover, the sensitive data of the patient is transmitting over the insecure Internet and prone to vulnerable security threats. Therefore, data privacy and integrity from malicious traffic are another challenging research issue for medical applications. This research article aims to a proposed secure and energy-efficient framework using Internet of Medical Things (IoMT) for e-healthcare (SEF-IoMT), which primary objective is to decrease the communication overhead and energy consumption between biosensors while transmitting the healthcare data on a convenient manner, and the other hand, it also secures the medical data of the patients against unauthentic and malicious nodes to improve the network privacy and integrity. The simulated results exhibit that the proposed framework improves the performance of medical systems for network throughput by 18%, packets loss rate by 44%, end-to-end delay by 26%, energy consumption by 29%, and link breaches by 48% than other states of the art solutions.

What contributes to inappropriate antibiotic dispensing among qualified and unqualified healthcare providers in Bangladesh? A qualitative study

Background

Over-prescribing and inappropriate use of antibiotics contributes to the emergence of antimicrobial resistance (AMR). Few studies in low and middle-income settings have employed qualitative approaches to examine the drivers of antibiotic sale and dispensing across the full range of healthcare providers (HCPs). We aimed to explore understandings of the use and functions of antibiotics; awareness of AMR and perceived patient or customer demand and adherence among HCPs for human and animal medicine in Bangladesh.

Methods

We used an ethnographic approach to conduct face-to-face, in-depth interviews with 46 community HCPs in one urban and one rural area (Gazipur and Mirzapur districts respectively). We purposefully selected participants from four categories of provider in human and veterinary medicine: qualified; semi-qualified; auxiliary and unqualified. Using a grounded theory approach, thematic analysis was conducted using a framework method.

Results

Antibiotics were considered a medicine of power that gives quick results and works against almost all diseases, including viruses. The price of antibiotics was equated with power such that expensive antibiotics were considered the most powerful medicines. Antibiotics were also seen as preventative medicines. While some providers were well informed about antibiotic resistance and its causes, others were completely unaware. Many providers mistook antibiotic resistance as the side effects of antibiotics, both in human and animal medicine. Despite varied knowledge, providers showed concern about antibiotic resistance but responsibility for inappropriate antibiotic use was shifted to the patients and clients including owners of livestock and animals.

Conclusions

Misconceptions and misinformation led to a wide range of inappropriate uses of antibiotics across the different categories of human and animal healthcare providers. Low awareness of antibiotic action and antibiotic resistance were apparent among healthcare providers, particularly those with little or no training and those in rural areas. Specific and targeted interventions to address AMR in Bangladesh should include educational messages on the rational use of antibiotics and how they work, targeting all types of healthcare providers. While tailored training for providers may increase understanding of antibiotic action and improve practices, more far-reaching structural changes are required to influence and increase responsibility for optimising antibiotic dispensing among all HCPs.

Security from above and below: A critical ethnography of the health response to violence against women in Timor-Leste

International advocacy and evidence have been critical for shifting the pervasive issue of violence against women onto the health agenda. Guidelines and training packages, however, can be underpinned by Western principles of responding to individual survivors of violence and availability of specialist referral services, which may not be available in many countries. As Timor-Leste and other nations begin to build their health system response to violence against women, it is important to understand the current practices of health providers and the broader sociocultural context of providing care to survivors of violence. During 11 months in the field (February-December 2016), we conducted qualitative interviews with 48 midwives and community leaders in three municipalities in Timor-Leste. The findings reveal that midwives engage at both the individual and collective levels, providing medical care, advice and moral support to survivors of violence as well as gathering support for women within families and communities. Midwives therefore navigate both formal and informal spaces as they respond to domestic and sexual violence. In doing so, they are influenced by their own experiences as women, as health providers imbued with authoritative knowledge, and as part of the wider sociocultural system. We argue that while much progress has been made in frameworks for health systems responding to survivors of violence, more work needs to be done to understand how to support health providers in low- and middle-income countries as they engage with perpetrators, families and communities. There is a need for further discussion of how health systems can address the issue of domestic and sexual violence as a collective social problem, while foregrounding the needs and rights of those experiencing violence. This research has implications for the content of guidelines and training, and importantly, for developing mechanisms to deal with complex social issues within local health services.

Universities as catalysts of social innovation in health systems in low-and middle-income countries: a multi-country case study

Background

Social innovation (SI) in health holds potential to contribute to health systems strengthening and universal health coverage (UHC). The role of universities in SI has been well described in the context of high-income countries. An evidence gap exits on SI in healthcare delivery in the context of low- and middle-income countries (LMICs) as well as on the engagement of universities from these contexts. There is thus a need to build capacity for research and engagement in SI in healthcare delivery within these universities. The aim of this study was to examine the adoption and implementation of network of university hubs focused on SI in healthcare delivery within five countries across Africa, Asia and Latin America. The objectives were to describe the model, components and implementation process of the hubs; identify the enablers and barriers experienced and draw implications that could be relevant to other LMIC universities interested in SI.

Methods

A case study design was adopted to study the implementation process of a network of university hubs. Data from documentation, team discussions and post-implementation surveys were collected from 2013 to 2018 and analysed with aid of a modified policy analysis framework.

Results/discussion

SI university-based hubs serve as cross-disciplinary and cross-sectoral platforms, established to catalyse SI within the local health system through four core activities: research, community-building, storytelling and institutional embedding, and adhering to values of inclusion, assets, co-creation and hope. Hubs were implemented as informal structures, managed by a small core team, in existing department. Enablers of hub implementation and functioning were the availability of strong in-country social networks, legitimacy attained from being part of a global network on SI in health and receiving a capacity building package in the initial stages. Barriers encountered were internal institutional resistance, administrative challenges associated with university bureaucracy and annual funding cycles.

Conclusions

This case study shows the opportunity that reside within LMIC universities to act as eco-system enablers of SI in healthcare delivery in order to fill the evidence gap on SI and enhance cross-sectoral participation in support of achieving UHC.

Assessing the efficiency of Iran health system in making progress towards universal health coverage: a comparative panel data analysis

BACKGROUND

Building upon decades of continuous reforms, Iran has been implementing various initiatives to reach universal health coverage (UHC). Improving efficiency is a crucial intermediate policy objective for UHC. Therefore, this article aimed to measure the efficiency and productivity changes of the Iranian health system in making progress towards UHC during 2010-2015 in comparison with 36 selected other upper-middle-income countries.

METHODS

We used panel data to measure the variations in technical efficiency (TE) and total factor productivity (TFP) through an extended data envelopment analysis (EDEA) and Malmquist productivity index, respectively. General government health expenditure (GGHE) per capita (International dollar) was selected as the input variable. Service coverage of diphtheria, tetanus and pertussis; family planning; antiretroviral therapy; skilled attendants at birth; Tuberculosis treatment success rate; and GGHE as  % of total health expenditure (THE) were considered as output variables. The data for each indicator were taken from the Global Health Observatory data repository and World Development Indicator database, for 6 years (2010-2015).

RESULTS

The TE scores of Iran's health system were 0.75, 0.77, 0.74, 0.74, 0.97, and 0.84 in the period 2010-2015, respectively. TFP improved in 2011 (1.02), 2013 (1.01), and 2014 (1.30, generally). The overall efficiency and TFP increased in 2014. Changes made in CCHE per capita and GGHE/THE attributed to the increase of efficiency.

CONCLUSION

There is a growing demand for efficiency improvements in the health systems to achieve UHC. While there are no defined set of indicators or precise methods to measure health system efficiency, EDEA helped us to draw the picture of health system efficiency in Iran. Our findings highlighted the essential need for targeted and sustained interventions, i.e., allocation of enough proportion of public funds to the health sector, to improve universal financial coverage against health costs aiming to enhance the future performance of Iran's health system, ultimately. Such tailored interventions may also be useful for settings with similar context to speed up their movement towards improving efficiency, which in turn might lead to more resources to reach UHC.

Health and healthcare in North Korea: a retrospective study among defectors

Background

To gain insights into the socio-economic and political determinants of ill health and access to healthcare in North Korea.

Methods

A retrospective survey using respondent-driven sampling conducted in 2014–15 among 383 North Korean refugees newly resettling in South Korea, asking about experiences of illness and utilization of healthcare while in North Korea, analyzed according to measures of political, economic and human rights indicators.

Results

Although the Public Health Act claims that North Korea provides the comprehensive free care system, respondents reported high levels of unmet need and, among those obtaining care, widespread informal expenditure. Of the respondents, 55.1% (95%CI, 47.7–63.7%) had received healthcare for the most recent illness episode. High informal costs (53.8%, 95%CI, 45.1–60.8%) and a lack of medicines (39.5%, 95%CI, 33.3–47.1%) were reported as major healthcare barriers resulting in extensive self-medication with narcotic analgesics (53.7%, 95%CI, 45.7–61.2%). In multivariate logistic regressions, party membership was associated with better access to healthcare (Adjusted OR (AOR) = 2.34, 95%CI, 1.31–4.18), but household income (AOR = 0.40, 95%CI 0.21–0.78) and informal market activity (AOR = 0.29, 95%CIs 0.15–0.50) with reduced access. Respondents who could not enjoy political and economic rights were substantially more likely to report illness and extremely reduced access to care, even with life-threatening conditions.

Conclusions

There are large disparities in health and access to healthcare in North Korea, associated with political and economic inequalities. The scope to use these findings to bring about change is limited but they can inform international agencies and humanitarian organizations working in this unique setting.