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Cernasev A, Stillo J, Black J, Batchu M, Bell E, Tschampl CA. Pharmacists' Role in Global TB Elimination: Practices, Pitfalls, and Potential. Healthcare (Basel) 2024; 12:1137. [PMID: 38891212 PMCID: PMC11171989 DOI: 10.3390/healthcare12111137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/15/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Tuberculosis (TB) is the top infectious killer in the world despite efforts to eliminate it. Pharmaceutical care roles are pillars of pharmacy practice, and pharmacists are well equipped to serve a unique role in the pathway to provide education about TB. Previous systematic reviews emphasize pharmacists' role in treating TB; however, pharmacists can and do play much broader roles in overall TB elimination efforts. Five researchers searched five electronic databases (PubMed, PsychInfo, CINAHL, Academic Search Premier, and Embase). Search terms included pharmacy, pharmacist, tuberculosis, antitubercular agents, supply, distribution, and drug therapy. Inclusion criteria were studies published from 2010 through March 2023, in English or Spanish, addressed a specific TB-related role for pharmacists/pharmacies, and were peer-reviewed. Exclusion criteria included pharmacology, pharmacokinetics, clinical trials on drug efficacy, and editorials. Two researchers conducted each level of review; for discordance, a third researcher reviewed, and a decision was reached by consensus. Roles were extracted and cross-referenced with traditional pharmaceutical care steps. Of the initial 682 hits, 133 were duplicates. After further review, we excluded 514 records, leaving 37 articles for full extraction. We found nine roles for pharmacists in TB prevention and classified them as implemented, not implemented, or recommended. These roles were: (1) TB symptom screening; (2) Referring to TB care systems; (3) TB testing; (4) Dispensing TB medication correctly and/or directly observed therapy; (5) Counseling; (6) Looking to reduce socioeconomic barriers; (7) Procurement of TB medications; (8) Quality assurance of TB medications; (9) Maintaining and using pharmacy data systems. Pharmacists are well situated to play a vital role in the global fight against TB. Findings suggested pharmacists in many settings have already expanded their roles related to TB elimination beyond traditional pharmaceutical care. Still others need to increase the understanding of TB procurement and treatment, their power to improve TB care, and their contributions to data systems that serve population health. Pharmacy curricula should increase TB-related training to better equip future pharmacists to contribute to TB elimination.
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Affiliation(s)
- Alina Cernasev
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Nashville, TN 37211, USA;
| | - Jonathan Stillo
- Department of Anthropology, Wayne State University, 656 W. Kirby St. 3054 FA/B, Detroit, MI 48202, USA; (J.S.); (E.B.)
| | - Jolie Black
- Schneider Institutes for Health Policy and Research, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02453, USA;
| | - Mythili Batchu
- Department of Public Health, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Davie, FL 33313, USA;
| | - Elaina Bell
- Department of Anthropology, Wayne State University, 656 W. Kirby St. 3054 FA/B, Detroit, MI 48202, USA; (J.S.); (E.B.)
| | - Cynthia A. Tschampl
- Schneider Institutes for Health Policy and Research, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA 02453, USA;
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Gobir IB, Niyang PM, Nnadozie HO, Agboola S, Adamu H, Sanni FO, Otubo AS, Saliu I, Oniyire A, Bazira D, Olutola A. Acceptability of smart locker technology for dispensing chronic disease medication among patients and healthcare providers in Nigeria. PLoS One 2024; 19:e0294936. [PMID: 38451957 PMCID: PMC10919599 DOI: 10.1371/journal.pone.0294936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/10/2023] [Indexed: 03/09/2024] Open
Abstract
Smart lockers are automated delivery machines. They have been used in dispensing ARVs and Tuberculosis medication to chronically ill patients in South Africa, Kenya, and Eswatini. However, there is no evidence of smart lockers in dispensing chronic disease medication in Nigeria. This study aimed to assess the acceptability of smart lockers in dispensing chronic disease medication and to describe the barriers to accessing care among patients with chronic diseases medication in 5 states in Nigeria. We conducted a cross-sectional study among healthcare workers and patients living with chronic diseases in five Nigerian states of Adamawa, Akwa Ibom, Cross River, Benue, and Niger between November and December 2021. A total of 1,133 participants were recruited (728 patients and 405 healthcare workers). The results revealed that most patients and healthcare workers agreed that using smart lockers for drug dispensing will lead to reduced transportation costs, hospital waiting times, the workload of healthcare workers, and decongestion of health facilities. The majority of the patients living with chronic diseases (43%) and healthcare workers (51%) showed high acceptability for the use of smart lockers. The use of smart lockers in dispensing chronic disease medication in Nigeria is feasible, and patients and healthcare workers are willing to accept the smart lockers, provided that a patient-centred implementation strategy is developed.
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Affiliation(s)
- Ibrahim Bola Gobir
- Center for Global Health Practice and Impact, Georgetown University, Washington, DC, United States of America
| | | | | | - Samson Agboola
- Georgetown Global Health Nigeria, Federal Capital Territory, Abuja, Nigeria
| | - Helen Adamu
- Georgetown Global Health Nigeria, Federal Capital Territory, Abuja, Nigeria
| | | | - Angmun Suzzy Otubo
- Savannah Health System Innovation Limited, Federal Capital Territory, Abuja, Nigeria
| | - Idris Saliu
- Center for Clinical Care and Clinical Research, Federal Capital Territory, Abuja, Nigeria
| | - Adetiloye Oniyire
- Johns Hopkins Program for International Education in Gynecology and Obstetrics, Federal Capital Territory, Abuja, Nigeria
| | - Deus Bazira
- Center for Global Health Practice and Impact, Georgetown University, Washington, DC, United States of America
| | - Ayodotun Olutola
- Center for Global Health Practice and Impact, Georgetown University, Washington, DC, United States of America
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Oga-Omenka C, Rosapep L, Baruwa E, Huria L, Vasquez NA, Faleye BO, Kafi MAH, Sassi A, Nwosu C, Johns B, Adamu A, Chijioke-Akaniro O, Anyaike C, Pai M. Individual journeys to tuberculosis care in Nigeria's private sector during the COVID-19 pandemic. BMJ Glob Health 2024; 9:e013124. [PMID: 38195153 PMCID: PMC10806899 DOI: 10.1136/bmjgh-2023-013124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 10/16/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Pre-COVID-19, individuals with tuberculosis (TB) in Nigeria were often underdiagnosed and untreated. TB services were mostly in the public sector with only 15% of new cases in 2019 reported from the private sector. Reports highlighted challenges in accessing care in the private sector, which accounted for 67% of all initial care-seeking. Our study examined patients' health seeking pathways for TB in Nigeria's private sector and explored any changes to care pathways during COVID-19. METHODS We conducted 180 cross-sectional surveys and 20 in-depth interviews with individuals having chest symptoms attending 18 high-volume private clinics and hospitals in Kano and Lagos States. Questions focused on sociodemographic characteristics, health-seeking behaviour, and pathways to care during the COVID-19 pandemic. All surveys and interviews were conducted in May 2021. RESULTS Most participants were male (111/180), with an average age of 37. Half (96/180) sought healthcare within a week of symptoms, while few (20/180) waited over 2 months. Individuals testing positive for TB had more health-seeking delays, and those testing negative for TB had more provider delays. On average, participants visited two providers in Kano and 1.69 in Lagos, with 61 of 180 in Kano and 48 of 180 in Lagos visiting other providers before the recruitment facility. Private providers were the initial encounters for most participants (60/180 in Kano, 83/180 in Lagos). Most respondents (164/180) experienced short-lived pandemic-related restrictions, affecting access to transportation, and closed facilities. CONCLUSIONS This study showed a few challenges in accessing TB care, necessitating continued investment in healthcare infrastructure and resources, particularly in the private sector. Understanding the different care pathways and delays in care provides opportunities for targeted interventions to improve deployment of services closer to where patients first seek care.
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Affiliation(s)
- Charity Oga-Omenka
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- McGill International TB Center, McGill University Health Centre, Montreal, Vendôme, Canada
| | - Lauren Rosapep
- ABT Associates Inc Bethesda, Bethesda, Maryland, USA
- Sustaining Health Outcomes through the Private Sector (SHOPS) Plus, Abuja, Nigeria
| | - Elaine Baruwa
- ABT Associates Inc Bethesda, Bethesda, Maryland, USA
- Sustaining Health Outcomes through the Private Sector (SHOPS) Plus, Abuja, Nigeria
| | - Lavanya Huria
- McGill International TB Center, McGill University Health Centre, Montreal, Vendôme, Canada
- Faculty of Medicine and Health Sciences, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Nathaly Aquilera Vasquez
- McGill International TB Center, McGill University Health Centre, Montreal, Vendôme, Canada
- Faculty of Medicine and Health Sciences, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | | | - Md Abdullah Heel Kafi
- McGill International TB Center, McGill University Health Centre, Montreal, Vendôme, Canada
| | - Angelina Sassi
- McGill International TB Center, McGill University Health Centre, Montreal, Vendôme, Canada
- Faculty of Medicine and Health Sciences, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Chimdi Nwosu
- VizSight Analytics Inc, Vancouver, British Columbia, Canada
| | | | - Abdu Adamu
- Sustaining Health Outcomes through the Private Sector (SHOPS) Plus, Abuja, Nigeria
| | | | | | - Madhukar Pai
- McGill International TB Center, McGill University Health Centre, Montreal, Vendôme, Canada
- Faculty of Medicine and Health Sciences, Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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Zamorano P, Espinoza MA, Varela T, Abbott T, Tellez A, Armijo N, Suarez F. Economic evaluation of a multimorbidity patient centered care model implemented in the Chilean public health system. BMC Health Serv Res 2023; 23:1041. [PMID: 37773153 PMCID: PMC10543850 DOI: 10.1186/s12913-023-09970-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/26/2023] [Indexed: 10/01/2023] Open
Abstract
Multimorbidity and patient-centered care approaches are growing challenges for health systems and patients. The cost of multimorbidity patients and the transition to a new care strategy is still sightly explored. In Chile, more than 70% of the adult population suffer from multimorbidity, opening an opportunity to implement a Multimorbidity patient-centered care model. The objective of this study was to perform an economic evaluation of the model from the public health system perspective.The methodology used a cost-consequence evaluation comparing seven exposed with seven unexposed primary care centers, and their reference hospitals. It followed three steps. First, we performed a Time-Driven Activity-Based Costing with routinely collected data routinely collected. Second, we run a comparative analysis through a propensity score matching and an estimation of the attributable costs to health services utilization at primary, secondary and tertiary care and health outcomes. Third, we estimated implementation and transaction costs.Results showed savings in aggregate costs of the total population (-0.12 (0.03) p < 0.01) during the period under evaluation. Costs in primary care showed a significant increase, whereas tertiary care showed significant savings. Health outcomes were associated with higher survival in patients under the new care model (HR 0.70 (0.05) p < 0.01). Implementation and transaction costs increased as the number of pilot intervention centers increased, and they represented 0,07% of the total annual budget of the Servicio de Salud Metropolitano Sur Oriente. After three years of piloting, the implementation and transaction cost for the total period was USD 1,838,767 and 393,775, respectively.The study's findings confirm the purpose of the new model to place primary health care at the center of care for people with non-communicable chronic diseases. Thus, it is necessary to consider implementation and transaction costs to introduce a broad health system multimorbidity approach. The health system should assume some of them permanently to guarantee sustainability and facilitate scale-up.
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Affiliation(s)
- Paula Zamorano
- Centro de Innovación en Salud ANCORA UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Manuel Antonio Espinoza
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile.
- Department of Public health, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Teresita Varela
- Centro de Innovación en Salud ANCORA UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tomas Abbott
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alvaro Tellez
- Centro de Innovación en Salud ANCORA UC, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- Department of Family Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Nicolás Armijo
- Health Technology Assessment Unit, Center of Clinical Research, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Suarez
- Unidad de Análisis y Gestión de la información, Servicio de Salud Metropolitano Sur Oriente, Santiago, Chile
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Ong M. A comprehensive framework identifying barriers to global health R&D innovation and access. BMJ Glob Health 2023; 8:e013076. [PMID: 37751936 PMCID: PMC10533694 DOI: 10.1136/bmjgh-2023-013076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/27/2023] [Indexed: 09/28/2023] Open
Abstract
Advancements in research and development (R&D) have the potential to address pressing global health challenges. However, numerous barriers hinder innovation and access, particularly in areas of market failure, and there is an absence of a cohesive consensus on defining these various impediments. This paper presents a framework identifying the barriers that impede global health innovation and hinder equitable access to health technologies.The framework presents clear typologies of barriers across global health R&D thematic areas. These include the market failures that require R&D incentives to stimulate innovation, how the complexity of product registration hinders access within specific regulatory domains and how health system implementation issues prevent affected populations from accessing the tools they require. Current and historical examples are provided for each end-point, and three case studies explore key barriers and how solutions have or may be applied.This analysis contributes by adding to the body of knowledge on global health R&D and provides an analysis tool to policy-makers, researchers and stakeholders involved in addressing the barriers and promoting equitable access to healthcare innovations. The framework serves as a practical tool to guide future research, policy development and implementation efforts towards achieving sustainable global health outcomes.
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Affiliation(s)
- Ming Ong
- Center for Health Science and Security, Georgetown University Medical Center, Washington, District of Columbia, USA
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Muhammad MI, Umoga K, Acquaye A, Fleischer B, Konkwo C, Ogunyemi KO, Ngaruiya C. Provider-identified barriers to performance at seven Nigerian accident & emergency units: A cross-sectional study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001909. [PMID: 37216332 DOI: 10.1371/journal.pgph.0001909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Nigeria hosts much of Africa's morbidity and mortality from emergency medical conditions. We surveyed providers at seven Nigerian Accident & Emergency (A&E) units about (i) their unit's ability to manage six major types of emergency medical condition (sentinel conditions) and (ii) barriers to performing key functions (signal functions) to manage sentinel conditions. Here, we present our analysis of provider-reported barriers to signal function performance. METHODS 503 Health Providers at 7 A&E units, across 7 states, were surveyed using a modified African Federation of Emergency Medicine (AFEM) Emergency Care Assessment Tool (ECAT). Providers indicating suboptimal performance ascribed this performance to any of eight multiple-choice barriers [infrastructural issues, absent and broken equipment, inadequate training, inadequate personnel, requirement of out-of-pocket payment, non-indication of that signal function for the sentinel condition, and hospital-specific policies barring signal function performance] or an open-ended "other" response. The average number of endorsements for each barrier was obtained for each sentinel condition. Differences in barrier endorsement were compared across site, barrier type and sentinel condition using a three-way ANOVA test. Open-ended responses were evaluated using inductive thematic analysis. Sentinel conditions were Shock, Respiratory Failure, Altered Mental Status, Pain, Trauma, and Maternal & Child Health. Study sites were the University of Calabar Teaching Hospital, the Lagos University Teaching Hospital, the Federal Medical Center, Katsina, the National Hospital Abuja, the Federal Teaching Hospital Gombe, the University of Ilorin Teaching Hospital (Kwara), and the Federal Medical Center Owerri (Imo). FINDINGS Barrier distribution varied widely by study site. Just three study sites shared any one barrier to signal function performance as their most common. The two barriers most commonly endorsed were (i) non-indication of, and (ii) insufficient infrastructure to perform signal functions. A three-way ANOVA test found significant differences in barrier endorsement by barrier type, study site and sentinel condition (p<0.05). Thematic analysis of open-ended responses highlighted (i) considerations disfavoring signal function performance and (ii) lack of experience with signal functions as barriers to signal function performance. Interrater reliability, calculated using Fleiss' Kappa, was found to be 0.5 across 11 initial codes and 0.51 for our two final themes. INTERPRETATION Provider perspective varied with regards to barriers to care. Despite these differences, the trends seen for infrastructure reflect the importance of sustained investment in Nigerian health infrastructure. The high level of endorsement seen for the non-indication barrier may signal need for better ECAT adaptation for local practice & education, and for improved Nigerian emergency medical education and training. A low endorsement was seen for patient-facing costs, despite the high burden of Nigerian private expenditure on healthcare, indicating limited representation of patient-facing barriers. Analysis of open-ended responses was limited by the brevity and ambiguity of these responses on the ECAT. Further investigation is needed towards better representation of patient-facing barriers and qualitative approaches to evaluating Nigerian emergency care provision.
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Affiliation(s)
| | - Kelechi Umoga
- Harvard Medical School, Massachusetts General Hospital/Brigham Women's Hospital, Cambridge, Massachusetts, United States of America
| | - Amber Acquaye
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Brian Fleischer
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Chigoziri Konkwo
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Kehinde Olawale Ogunyemi
- Department of Community Medicine, Babcock University Teaching Hospital, Ilisham-Remo, Ogun State, Nigeria
| | - Christine Ngaruiya
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
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Etiaba E, Eboreime EA, Dalglish SL, Lehmann U. Aspirations and realities of intergovernmental collaboration in national- level interventions: insights from maternal, neonatal and child health policy processes in Nigeria, 2009-2019. BMJ Glob Health 2023; 8:bmjgh-2022-010186. [PMID: 36810159 PMCID: PMC9945032 DOI: 10.1136/bmjgh-2022-010186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 02/05/2023] [Indexed: 02/23/2023] Open
Abstract
In Nigeria's federal government system, national policies assign concurrent healthcare responsibilities across constitutionally arranged government levels. Hence, national policies, formulated for adoption by states for implementation, require collaboration. This study examines collaboration across government levels, tracing implementation of three maternal, neonatal and child health (MNCH) programmes, developed from a parent integrated MNCH strategy, with intergovernmental collaborative designs, to identify transferable principles to other multilevel governance contexts, especially low-income countries.National-level setting was Abuja, where policymaking is domiciled, while two subnational implementation settings (Anambra and Ebonyi states) were selected based on their MNCH contexts. A qualitative case study triangulated information from 69 documents and 44 in-depth interviews with national and subnational policymakers, technocrats, academics and implementers. Emerson's integrated collaborative governance framework was applied thematically to examine how governance arrangements across the national and subnational levels impacted policy processes.The results showed that misaligned governance structures constrained implementation. Specific governance characteristics (subnational executive powers, fiscal centralisation, nationally designed policies, among others) did not adequately generate collaboration dynamics for collaborative actions. Collaborative signing of memoranda of understanding happened passively, but the contents were not implemented. Neither state adhered to programme goals, despite contextual variations, because of an underlying disconnect in the national governance structure.Collaboration across government levels could be better facilitated via full devolution of responsibilities by national authorities to subnational governments, with the national level providing independent evaluation and guidance only. Given the existing fiscal structure, innovative reforms which hold government levels accountable should be linked to fiscal transfers. Sustained advocacy and context-specific models of achieving distributed leadership across government levels are required across similar resource-limited countries. Stakeholders should be aware of what drivers are available to them for collaboration and what needs to be built within the system context.
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Affiliation(s)
- Enyi Etiaba
- SOPH, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa .,Health Administration and Management, Faculty of Health Sciences and Technology, University of Nigeria, Enugu, Nigeria
| | | | - Sarah L Dalglish
- Department of International Health, University College London, London, UK,Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Uta Lehmann
- SOPH, Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa,South African Medical Research Council, Tygerberg, South Africa
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Chaikumbung M. Democracy, Culture and Cancer Patients' Willingness to Pay for Healthcare Services: A Meta-analysis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2021; 58:469580211024894. [PMID: 34253073 PMCID: PMC8280846 DOI: 10.1177/00469580211024894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cancer is one of the leading causes of death globally and expenditure associated with cancer is quite high. Efficient resource allocation needs information on economic evaluations of healthcare interventions. The purposes of the study are to provide a comprehensive overview of cancer patients’ willingness to pay (WTP) for healthcare services and to investigate the influence of democracies, culture dimensions, and other factors on WTP. A meta-analysis was conducted using PubMed, Scopus, and Google Scholar to identify all studies of stated preference approach to estimate cancer patients’ WTP healthcare services. A set of criteria was constructed for selecting relevant studies. A total of 79 studies were related to selection criteria and held sufficient information for the purposes of meta-analysis. A total of 393 estimates of WTP from 79 healthcare valuation studies were pooled to identify the links between WTP and influential factors. The findings suggest that values of benefits in healthcare services are higher in more democratic nations, but they are lower in cultural traits that are stronger indulgence and uncertainty avoidance. Further, the types of cancer matter. Compared to breast cancer, WTP is higher for skin cancer, yet lower for liver cancer and lymphoma. A higher national income and public health expenditure increase WTP for healthcare services, while a higher death rate by cancer leads to lower values of healthcare benefits.
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Kirubi B, Ong'ang'o J, Nguhiu P, Lönnroth K, Rono A, Sidney-Annerstedt K. Determinants of household catastrophic costs for drug sensitive tuberculosis patients in Kenya. Infect Dis Poverty 2021; 10:95. [PMID: 34225790 PMCID: PMC8256229 DOI: 10.1186/s40249-021-00879-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 06/24/2021] [Indexed: 11/19/2022] Open
Abstract
Background Despite free diagnosis and treatment for tuberculosis (TB), the costs during treatment impose a significant financial burden on patients and their households. The study sought to identify the determinants for catastrophic costs among patients with drug-sensitive TB (DSTB) and their households in Kenya. Methods The data was collected during the 2017 Kenya national patient cost survey from a nationally representative sample (n = 1071). Treatment related costs and productivity losses were estimated. Total costs exceeding 20% of household income were defined as catastrophic and used as the outcome. Multivariable Poisson regression analysis was performed to measure the association between selected individual, household and disease characteristics and occurrence of catastrophic costs. A deterministic sensitivity analysis was carried using different thresholds and the significant predictors were explored. Results The proportion of catastrophic costs among DSTB patients was 27% (n = 294). Patients with catastrophic costs had higher median productivity losses, 39 h [interquartile range (IQR): 20–104], and total median costs of USD 567 (IQR: 299–1144). The incidence of catastrophic costs had a dose response with household expenditure. The poorest quintile was 6.2 times [95% confidence intervals (CI): 4.0–9.7] more likely to incur catastrophic costs compared to the richest. The prevalence of catastrophic costs decreased with increasing household expenditure quintiles (proportion of catastrophic costs: 59.7%, 32.9%, 23.6%, 15.9%, and 9.5%) from the lowest quintile (Q1) to the highest quintile (Q5). Other determinants included hospitalization: prevalence ratio (PR) = 2.8 (95% CI: 1.8–4.5) and delayed treatment: PR = 1.5 (95% CI: 1.3–1.7). Protective factors included receiving care at a public health facility: PR = 0.8 (95% CI: 0.6–1.0), and a higher body mass index (BMI): PR = 0.97 (95% CI: 0.96–0.98). Pre TB expenditure, hospitalization and BMI were significant predictors in all sensitivity analysis scenarios. Conclusions There are significant inequities in the occurrence of catastrophic costs. Social protection interventions in addition to existing medical and public health interventions are important to implement for patients most at risk of incurring catastrophic costs. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00879-4.
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Affiliation(s)
- Beatrice Kirubi
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,WHO Collaborating Centre for Tuberculosis and Social Medicine, Stockholm, Sweden.,The Health and Social Protection Action Research & Knowledge Sharing Network (SPARKS), Stockholm, Sweden
| | - Jane Ong'ang'o
- Centre for Respiratory Disease Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Peter Nguhiu
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Program, Nairobi, Kenya
| | - Knut Lönnroth
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,WHO Collaborating Centre for Tuberculosis and Social Medicine, Stockholm, Sweden.,The Health and Social Protection Action Research & Knowledge Sharing Network (SPARKS), Stockholm, Sweden
| | - Aiban Rono
- Monitoring, Evaluation & Research, National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | - Kristi Sidney-Annerstedt
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden. .,WHO Collaborating Centre for Tuberculosis and Social Medicine, Stockholm, Sweden. .,The Health and Social Protection Action Research & Knowledge Sharing Network (SPARKS), Stockholm, Sweden.
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10
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Foster N, Cunnama L, McCarthy K, Ramma L, Siapka M, Sinanovic E, Churchyard G, Fielding K, Grant AD, Cleary S. Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis. PLoS One 2021; 16:e0251547. [PMID: 33989317 PMCID: PMC8121360 DOI: 10.1371/journal.pone.0251547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 04/28/2021] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm. METHODS Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness. FINDINGS Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits. INTERPRETATION Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.
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Affiliation(s)
- Nicola Foster
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Health Research, Lancaster University, Lancaster, United Kingdom
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Kerrigan McCarthy
- Division of Public Health, Surveillance and Response, National Institute for Communicable Disease of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lebogang Ramma
- Department of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa
| | - Mariana Siapka
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Gavin Churchyard
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Aurum Institute, Johannesburg, South Africa
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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11
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Kadota JL, Nabwire S, Nalugwa T, White JS, Cattamanchi A, Katamba A, Shete PB. Patient Perspectives and Willingness to Accept Incentives for Tuberculosis Diagnostic Evaluation in Uganda. Value Health Reg Issues 2021; 25:48-56. [PMID: 33773327 DOI: 10.1016/j.vhri.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/02/2020] [Accepted: 12/10/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES We assessed attitudes and perceptions and willingness to accept (WTA) varying incentive structures for completing tuberculosis (TB) diagnostic evaluation among patients in Uganda. METHODS We surveyed 177 adult patients undergoing TB evaluation at 10 health centers between September 2018 and March 2019. We collected household sociodemographic information and assessed attitudes and perceptions of incentives. We surveyed patients regarding their willingness to complete TB diagnostic evaluation in exchange for incentives ranging in value from 500 Ugandan shillings (USh) to 25 000USh (~$0.15-$6.75). We compared associations between WTA and patient characteristics using ordered logistic regression. RESULTS Participant willingness to return to the health center to complete TB diagnostic evaluation increased proportionally with incentive amount. The median participant accepted between 2000 and 5000 USh. Cash (52%) and transportation vouchers (34%) were the most popular incentive types. Half of respondents preferred unconditional incentives; for a multiday evaluation, 84% preferred conditioning incentive receipt upon returning to the health center. In multivariate models, we found the pairwise difference between the third and lowest income quartile (aOR = 2.38, 95% CI: 1.20-4.69; P = .01), younger age, and difficulty returning to the health center to be significantly associated with WTA higher incentive thresholds. CONCLUSIONS In Uganda, incentives such as cash transfers or transportation vouchers are an acceptable intervention for facilitating adherence to TB diagnostic evaluation. Household income is associated with preferred incentive structure and amount, especially for those at the cusp of the poverty threshold who are more likely to prefer unconditional and higher valued incentives. Targeted and context-specific socioeconomic supports for at-risk patients are needed to optimize outcomes.
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Affiliation(s)
- Jillian L Kadota
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA.
| | - Sarah Nabwire
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Talemwa Nalugwa
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Justin S White
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology & Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Priya B Shete
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
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12
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Oga-Omenka C, Wakdet L, Menzies D, Zarowsky C. A qualitative meta-synthesis of facilitators and barriers to tuberculosis diagnosis and treatment in Nigeria. BMC Public Health 2021; 21:279. [PMID: 33535990 PMCID: PMC7860048 DOI: 10.1186/s12889-021-10173-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 01/05/2021] [Indexed: 11/23/2022] Open
Abstract
Background Despite progress in tuberculosis (TB) control globally, TB continues to be a leading cause of death from infectious diseases, claiming 1.2 million lives in 2018; 214,000 of these deaths were due to drug resistant strains. Of the estimated 10 million cases globally in 2018, 24% were in Africa, with Nigeria and South Africa making up most of these numbers. Nigeria ranks 6th in the world for TB burden, with an estimated 4.3% multi-drug resistance in new cases. However, the country had one of the lowest case detection rates, estimated at 24% of incident cases in 2018 - well below the WHO STOP TB target of 84%. This rate highlights the need to understand contextual issues influencing tuberculosis management in Nigeria. Our synthesis was aimed at synthesizing qualitative evidence on factors influencing TB care in Nigeria. Methods A three-stage thematic meta-synthesis of qualitative studies was used to identify barriers and facilitators to tuberculosis case finding and treatment in Nigeria. A search of eleven databases was conducted. The date of publication was limited to 2006 to June 2020. We analyzed articles using a three-stage process, resulting in coding, descriptive subthemes and analytical themes. Results Our final synthesis of 10 articles resulted in several categories including community and family involvement, education and knowledge, attitudes and stigma, alternative care options, health system factors (including coverage and human resource), gender, and direct and indirect cost of care. These were grouped into three major themes: individual factors; interpersonal influences; and health system factors. Conclusion Case finding and treatment for TB in Nigeria currently depends more on individual patients presenting voluntarily to the hospital for care, necessitating an understanding of patient behaviors towards TB diagnosis and treatment. Our synthesis has identified several related factors that shape patients’ behavior towards TB management at individual, community and health system levels that can inform future interventions.
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Affiliation(s)
- Charity Oga-Omenka
- School of Public Health of the University of Montreal (ESPUM), Montreal, Canada. .,Centre de Recherche en Santé Publique, Université de Montréal (CReSP), Montreal, Canada. .,McGill University International TB Centre, Montreal, Quebec, Canada.
| | | | - Dick Menzies
- McGill University International TB Centre, Montreal, Quebec, Canada.,Department of Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | - Christina Zarowsky
- School of Public Health of the University of Montreal (ESPUM), Montreal, Canada.,Centre de Recherche en Santé Publique, Université de Montréal (CReSP), Montreal, Canada.,School of Public Health, University of the Western Cape, Cape Town, South Africa
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13
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Affiliation(s)
- Seye Abimbola
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
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14
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Walcott RL, Ingels JB, Corso PS, Zalwango S, Whalen CC, Sekandi JN. There's no such thing as a free TB diagnosis: Catastrophic TB costs in Urban Uganda. Glob Public Health 2020; 15:877-888. [PMID: 32027555 DOI: 10.1080/17441692.2020.1724313] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Identifying and reducing TB-related costs is necessary for achieving the End TB Strategy's goal that no family is burdened with catastrophic costs. This study explores costs during the pre-diagnosis period and assesses the potential for using coping costs as a proxy indicator for catastrophic costs when comprehensive surveys are not feasible. Detailed interviews about TB-related costs and productivity losses were conducted with 196 pulmonary TB patients in Kampala, Uganda. The threshold for catastrophic costs was defined as 20% of household income. Multivariable regression analyses were used to assess the influence of patient characteristics on economic burden, and the positive predictive value (PPV) of coping costs was estimated. Over 40% of patients experienced catastrophic costs, with average (median) pre-diagnosis costs making up 30.6% (14.1%) of household income. Low-income status (AOR = 2.91, 95% CI = 1.29, 6.72), hospitalisation (AOR = 8.66, 95% CI = 2.60; 39.54), and coping costs (AOR = 3.84, 95% CI = 1.81; 8.40) were significantly associated with the experience of catastrophic costs. The PPV of coping costs as an indicator for catastrophic costs was estimated to be 73% (95% CI = 58%, 84%). TB patients endure a substantial economic burden during the pre-diagnosis period, and identifying households that experience coping costs may be a useful proxy measure for identifying catastrophic costs.
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Affiliation(s)
- Rebecca L Walcott
- Evans School of Public Policy & Governance, University of Washington, Seattle, WA, USA
| | - Justin B Ingels
- College of Public Health, University of Georgia, Athens, GA, USA
| | - Phaedra S Corso
- Office of Research, Kennesaw State University, Kennesaw, GA, USA
| | - Sarah Zalwango
- Directorate of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda
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15
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Olufemi AO, Chikaodinaka AA, Abimbola P, Oluwatoyin AT, Oluwafunmilola A, Fasanmi KT, Efosa EG. Health-Related Quality of Life (HRQoL) scores vary with treatment and may identify potential defaulters during treatment of tuberculosis. Malawi Med J 2019; 30:283-290. [PMID: 31798808 PMCID: PMC6863409 DOI: 10.4314/mmj.v30i4.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Nigeria ranks third among the 22 high-burden TB countries in the world. With the availability of effective treatment strategies, and more patients surviving the disease, assessment of Patient Reported Outcomes (PROs) has become imperative to assist with patient evaluation of measured outcomes and thus improve morbidity. Literature is scarce on assessment and impact of chemotherapy on Health-Related Quality of Life (HRQoL) for patients with tuberculosis. Aim This study evaluates the variation in Health-Related Quality of Life (HRQoL) in pulmonary TB patients during the intensive phase of treatment. Methods We recruited patients with pulmonary TB (PTB), from 3 different TB clinics across Ife Ijesha Zone, Osun State, Nigeria. Consenting patients were administered Short Form-36 HRQoL questionnaire at recruitment and at the end of intensive phase of treatment. HRQoL scores were compared at these two-time points, the degrees of changes were calculated and relationships with some. Directly Observed Therapy-Short (DOTS) course outcome measures were obtained. Logistic regression was used to identify factors associated with greatest change in HRQoL scores. Results Of the 130 recruited patients, we analysed data for 126 patients who met the inclusion criteria. Mean age was 36.7(SD15.5). The overall mean HRQoL score obtained at enrolment was 43.18 (SD 17.2) and 60.22 (SD19.83) at end of 2 months; mean change =17.04 p<0.001). The least change was on the emotional well-being domain (mean change = 4.24, p=0.05). Predictor of significant change in HRQoL scores were previous history of TB, HIV status and TB severity, p<0.05 each. High physical functioning score was a strong predictor of defaulters (OR = 5.3; 95%CI: 2.11–9.05, p = 0.01). Conclusion Emotional domain is least affected by PTB while younger patients with no physical impairment are more likely to default treatment. Various aspects of HRQoL can be a useful tool for patient's evaluation and outcome prediction.
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Affiliation(s)
| | | | - Philips Abimbola
- Department of Community Health, Obafemi Awolowo University Teaching Hospitals, Ile Ife, Nigeria
| | | | - Alabi Oluwafunmilola
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Ile Ife, Nigeria
| | - Kolawole Tope Fasanmi
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Ile Ife, Nigeria
| | - Erhabor Gregory Efosa
- Department of Medicine, Obafemi Awolowo University Teaching Hospital Ile Ife, Nigeria
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16
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Oshi D, Chukwu J, Nwafor C, Chukwu NE, Meka AO, Anyim M, Ukwaja KN, Alobu I, Ekeke N, Oshi SN. Support and unmet needs of patients undergoing multidrug-resistant tuberculosis (MDR-TB) treatment in southern Nigeria. Int J Health Plann Manage 2019; 35:832-842. [PMID: 31849112 DOI: 10.1002/hpm.2929] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 10/10/2019] [Indexed: 01/01/2023] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is presently a major public health threat. MDR-TB patients face diverse financial and psychosocial difficulties. Researchers conducted in-depth interviews based on interview guides with 42 participants. Data were analyzed using categorization, coding, generation of themes, and thematic memo writing. The key findings were as follows: Out of the 42 patients, 30 (71.4%) were males and 12 (28.6%) were females. All patients received financial stipends for transport and monthly social support. The patients however needed more financial support than they received (suggesting high unmet financial needs). Patients suffered depressive mood before and during treatment but received inadequate mental health/psychosocial care and treatment. Patients developed hearing impairment as a major adverse drug reaction, but the care and treatment they received were inadequate. In conclusion, the programmatic support provided for MDR-TB patients' financial and mental health/psychosocial needs and auditory drug side effects fell short of their need. Programmes for control of MDR-TB should increase budgetary allocations and ramp up mechanisms for provision of mental health/psychosocial support and care/treatment for drug side effects.
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Affiliation(s)
- Daniel Oshi
- Department of Community Health and Psychiatry, University of West Indies, Mona, Jamaica.,German Leprosy and TB Relief Association, Enugu, Nigeria
| | - Joseph Chukwu
- German Leprosy and TB Relief Association, Enugu, Nigeria
| | - Charles Nwafor
- German Leprosy and TB Relief Association, Enugu, Nigeria
| | - Ngozi E Chukwu
- Department of Social Work, Faculty of Social Sciences, University of Nigeria, Nsukka, Nigeria
| | - Anthony O Meka
- German Leprosy and TB Relief Association, Enugu, Nigeria
| | - Moses Anyim
- German Leprosy and TB Relief Association, Enugu, Nigeria
| | - Kingsley N Ukwaja
- Department of Internal Medicine, Alex Ekwueme Federal Teaching Hospital (AE-FETHA), Abakaliki, Nigeria
| | - Isaac Alobu
- Ebonyi State Tuberculosis and Leprosy Control Programme, State Ministry of Health, Abakaliki, Nigeria
| | - Ngozi Ekeke
- German Leprosy and TB Relief Association, Enugu, Nigeria
| | - Sarah N Oshi
- Centre for Development and Reproductive Health, Enugu, Nigeria
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17
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Abimbola S, Baatiema L, Bigdeli M. The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence. Health Policy Plan 2019; 34:605-617. [PMID: 31378811 PMCID: PMC6794566 DOI: 10.1093/heapol/czz055] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2019] [Indexed: 10/28/2022] Open
Abstract
One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: 'Voting with feet' (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); 'Close to ground' (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and 'Watching the watchers' (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, Faculty of Medicine and Health, University of Sydney, NSW, Australia
- National Primary Health Care Development Agency, Abuja, FCT, Nigeria
- The George Institute for Global Health, Sydney, NSW, Australia
- Health Systems Governance Collaborative, Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia 20, Geneva, Switzerland
| | - Leonard Baatiema
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana
| | - Maryam Bigdeli
- Health Systems Governance Collaborative, Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia 20, Geneva, Switzerland
- World Health Organization, 3 Avenue S.A.R. Sidi Mohamed, Rabat, Morocco
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18
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Abimbola S, Keelan S, Everett M, Casburn K, Mitchell M, Burchfield K, Martiniuk A. The medium, the message and the measure: a theory-driven review on the value of telehealth as a patient-facing digital health innovation. HEALTH ECONOMICS REVIEW 2019; 9:21. [PMID: 31270685 PMCID: PMC6734475 DOI: 10.1186/s13561-019-0239-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 06/18/2019] [Indexed: 05/07/2023]
Abstract
By what measure should a policy maker choose between two mediums that deliver the same or similar message or service? Between, say, video consultation or a remote patient monitoring application (i.e. patient-facing digital health innovations) and in-person consultation? To answer this question, we sought to identify measures which are used in randomised controlled trials. But first we used two theories to frame the effects of patient-facing digital health innovations on - 1) transaction costs (i.e. the effort, time and costs required to complete a clinical interaction); and 2) process outcomes and clinical outcomes along the care cascade or information value chain, such that the 'value of information' (VoI) is different at each point in the care cascade or value chain. From the trials, we identified three categories of measures: outcome (process or clinical), satisfaction, and cost. We found that although patient-facing digital health innovations tend to confer much of their value by altering process outcomes, satisfaction, and transaction costs, these measures are inconsistently assessed. Efforts to determine the relative value of and choose between mediums of service delivery should adopt a metric (i.e. mathematical combination of measures) that capture all dimensions of value. We argue that 'value of information' (VoI) is such a metric - it is calculated as the difference between the 'expected utility' (EU) of alternative options. But for patient-facing digital health innovations, 'expected utility' (EU) should incorporate the probability of achieving not only a clinical outcome, but also process outcomes (depending on the innovation under consideration); and the measures of utility should include satisfaction and transaction costs; and also changes in population access to services, and health system capacity to deliver more services, which may result from reduction in transaction costs.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, University of Sydney, Sydney, Australia
- Royal Far West, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Sarah Keelan
- School of Public Health, University of Sydney, Sydney, Australia
- Royal Far West, Sydney, Australia
| | | | | | | | | | - Alexandra Martiniuk
- School of Public Health, University of Sydney, Sydney, Australia
- Royal Far West, Sydney, Australia
- The George Institute for Global Health, Sydney, Australia
- University of Toronto, Toronto, Canada
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19
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Ogbuabor DC, Onwujekwe OE. Governance of tuberculosis control programme in Nigeria. Infect Dis Poverty 2019; 8:45. [PMID: 31203814 PMCID: PMC6572737 DOI: 10.1186/s40249-019-0556-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/28/2019] [Indexed: 12/01/2022] Open
Abstract
Background The role of governance in strengthening tuberculosis (TB) control has received little research attention. This review provides evidence of how institutional designs and organisational practices influence implementation of the national TB control programme (NTP) in Nigeria. Main text We conducted a scoping review using a five-stage framework to review published and grey literature in English, on implementation of Nigeria’s NTP and identified themes related to governance using a health system governance framework. We included articles, of all study designs and methods, which described or analysed the processes of implementing TB control based on relevance to the research question. The review shows a dearth of studies which examined the role of governance in TB control in Nigeria. Although costed plans and policy coordination framework exist, public spending on TB control is low. While stakeholders’ involvement in TB control is increasing, institutional capacity is limited, especially in the private sector. TB-specific legislation is absent. Deployment and transfer of staff to the NTP are not transparent. Health workers are not transparent in communicating service entitlements to users. Despite existence of supportive policies, integration of TB control into the community and general health services have been weak. Willingness to pay for TB services is high, however, transaction cost and stigma among patients limit equity. Effectiveness and efficiency of the NTP was hindered by inadequate human resources, dilapidated service delivery infrastructure and weak drug supply system. Despite adhering to standardized recording and reporting format, regular monitoring and evaluation, revision of reporting formats, and electronic data management system, TB surveillance system was found to be weak. Delay in TB diagnosis and initiation of care, poor staff attitude to patients, lack of privacy, poor management of drug reactions and absence of infection control measures breach ethical standards for TB care. Conclusions This scoping review of governance of TB control in Nigeria highlights two main issues. Governance for strengthening TB control programmes in low-resource, high TB burden settings like Nigeria, is imperative. Secondly, there is a need for empirical studies involving detailed analysis of different dimensions of governance of TB control. Electronic supplementary material The online version of this article (10.1186/s40249-019-0556-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel Chukwuemeka Ogbuabor
- Department of Health Systems and Policy, Sustainable Impact Resource Agency, University of Nigeria Enugu Campus (UNEC), 22 Ogidi Street, Asata, Enugu, P.O. Box 15534, Enugu, Enugu State, Nigeria. .,Department of Health Administration and Management, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria.
| | - Obinna Emmanuel Onwujekwe
- Department of Health Administration and Management, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria.,Health Policy Research Group, College of Medicine, University of Nigeria Enugu Campus, Enugu, Enugu State, Nigeria
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20
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Abimbola S. Beyond positive a priori bias: reframing community engagement in LMICs. Health Promot Int 2019; 35:598-609. [DOI: 10.1093/heapro/daz023] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Showing the causal link between community engagement and improved health outcomes is a ‘holy grail’ of health policy. This article argues that this ‘holy grail’ has remained elusive because community engagement in primary health care is under-theorized, having been based on positive a priori assumptions, e.g. that people necessarily want to be engaged in governing their health system. By adopting a theory-driven approach and an agnostic premise, we show that understanding why, how and when community engagement may emerge or function spontaneously is important for informing efforts to support community engagement in primary health care primary health care governance. We draw on empirical research on community engagement in Nigeria and on the literature to identify the ‘why’ (coalition of service users can emerge in response to under-governance); the ‘how’ (five modes: through meetings; reaching out within their community; lobbying governments; augmenting government support; and taking control of service delivery) and the ‘when’ (as geographical, socio-economic and institutional context align, such that the benefits of action outweigh costs). Understanding the broad patterns of mechanisms and of contextual factors that apply across communities is, after all, our ‘holy grail’—and this understanding should inform efforts to tailor support for community engagement in governance in different settings.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, University of Sydney, Sydney, NSW, Australia
- National Primary Health Care Development Agency, Abuja, FCT, Nigeria
- The George Institute for Global Health, Sydney, NSW, Australia
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21
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de Freitas Quintero MC, Figueiredo Vendramini SH, Sperli Geraldes Santos MDL, Rocha Dos Santos M, Gazetta CE, Garcia Lourenção L, Sperli Geraldes Soler ZA, da Cruz Oliveira SA, Geraldes Marin Dos Santos Sasaki NS, Zanon Ponce MA, Domingues Wysocki A, Scatena LM, Scatena Villa TC. [Access to diagnosis of tuberculosis in Brazilian medium-sized municipality]. ACTA ACUST UNITED AC 2019; 20:103-109. [PMID: 30183892 DOI: 10.15446/rsap.v20n1.64177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/07/2017] [Indexed: 11/09/2022]
Abstract
OBJETIVO Evaluating access to tuberculosis diagnosis, from the perspective of patients. METHODS Cross-sectional study with 108 tuberculosis patients. Data were collected using the brazilian instrument Primary Care Assessment Tool - PCAT-Brazil, adapted for attention to tuberculosis, including socio-economic and demographic indicators, location of diagnosis and diagnostic access tuberculosis. The analysis of the data was of frequency, average, standard deviation, confidence interval and Chi-square test. RESULTS Most cases were diagnosed in hospitals (52.8%). The patient sought the Health Unit on average three times until receiving medical care. The indicators of difficulty of displacement, expenditure on motorized transport and consultation within 24 hours to discover the disease were not satisfactory and regular. The chi-square test showed a statistical association between diagnosis location and seeking the nearest health unit from home. CONCLUSIONS There are weaknesses in the early diagnosis of tuberculosis in primary care. There are many challenges to be faced to strengthen this level of health care, with organizational capacity to overcome the shortcomings related to the patient and the service that make it difficult to access the diagnosis of the disease.
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Affiliation(s)
- Maria Celeste de Freitas Quintero
- MQ: Enf. M. Sc. Ciências da Saúde, Secretaria Municipal de Saúde de São José do Rio Preto. São José do Rio Preto. São Paulo, Brasil.
| | | | | | - Marilene Rocha Dos Santos
- MR: Enf. Doutora em Ciências da Saúde. Faculdade de Medicina de São José do Rio Preto. São José do Rio Preto. SP, Brasil.
| | - Claudia Eli Gazetta
- CG: Enf. Doutora em Enfermagem. Faculdade de Medicina de São José do Rio Preto. São José do Rio Preto. SP, Brasil.
| | - Luciano Garcia Lourenção
- LL: Enf. Doutor em Ciências da Saúde. Escola de Enfermagem, Universidade Federal do Rio Grande. Rio Grande. Rio Grande do Sul, Brasil.
| | | | - Sonia Aparecida da Cruz Oliveira
- SO: Enf. Mestre em Enfermagem em Saúde Pública. Faculdade de Medicina de São José do Rio Preto. São José do Rio Preto. SP, Brasil.
| | | | - Maria Amélia Zanon Ponce
- MP: Enf. Doutora em Enfermagem em Saúde Pública, Secretaria Municipal de Saúde de São José do Rio Preto. São José do Rio Preto. São Paulo, Brasil.
| | - Anneliese Domingues Wysocki
- AW: Enf. Doutora em Ciências. Universidade Federal do Mato Grosso do Sul, Três Lagoas. Mato Grosso do Sul, Brasil.
| | - Lucia Marina Scatena
- LS: Eng. Produção Química, Doutora em Engenharia de Produção Hidráulica e Saneamento. Universidade Federal do Triângulo Mineiro. Uberaba. Minas Gerais, Brasil.
| | - Tereza Cristina Scatena Villa
- TV: Enf. Livre-docente. Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo. Ribeirão Preto. São Paulo, Brasil.
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Determinants of Health Care-Seeking Delay among Tuberculosis Patients in Rural Area of Central China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15091998. [PMID: 30217043 PMCID: PMC6164791 DOI: 10.3390/ijerph15091998] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/17/2022]
Abstract
Background The prevalence of tuberculosis (TB) in low and middle-income countries is a significant public health and social concern. TB is a common infectious disease caused by the Mycobacterium tuberculosis infection, which has a widespread infection rate. Health care-seeking delay maybe one of the most important neglected risk factors for the spread of TB. Objectives The aim of this study was to understand the situation of health care-seeking delay among rural tuberculosis patients in Hubei Province, and explore its risk factors. Methods A total of 1408 rural tuberculosis patients were surveyed using a standard structured questionnaire in three cities of Hubei Province during the past two years. Results For the 1408cases of pulmonary tuberculosis, 39.70% of them were health care-seeking delayed. Logistic regressions indicate that the Han nationality, farming careers, the over 45 min walk to the township’s hospital, and awareness of the national TB free treatment policy, were significantly associated with higher odds of a delay in care seeking. Conclusions The prevalence of health care-seeking delay among tuberculosis patients was high in rural areas. It is essential to take comprehensive targeted interventions to reduce care-seeking delay.
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Pyone T, Smith H, van den Broek N. Frameworks to assess health systems governance: a systematic review. Health Policy Plan 2017; 32:710-722. [PMID: 28334991 PMCID: PMC5406767 DOI: 10.1093/heapol/czx007] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 12/02/2022] Open
Abstract
Governance of the health system is a relatively new concept and there are gaps in understanding what health system governance is and how it could be assessed. We conducted a systematic review of the literature to describe the concept of governance and the theories underpinning as applied to health systems; and to identify which frameworks are available and have been applied to assess health systems governance. Frameworks were reviewed to understand how the principles of governance might be operationalized at different levels of a health system. Electronic databases and web portals of international institutions concerned with governance were searched for publications in English for the period January 1994 to February 2016. Sixteen frameworks developed to assess governance in the health system were identified and are described. Of these, six frameworks were developed based on theories from new institutional economics; three are primarily informed by political science and public management disciplines; three arise from the development literature and four use multidisciplinary approaches. Only five of the identified frameworks have been applied. These used the principal–agent theory, theory of common pool resources, North’s institutional analysis and the cybernetics theory. Governance is a practice, dependent on arrangements set at political or national level, but which needs to be operationalized by individuals at lower levels in the health system; multi-level frameworks acknowledge this. Three frameworks were used to assess governance at all levels of the health system. Health system governance is complex and difficult to assess; the concept of governance originates from different disciplines and is multidimensional. There is a need to validate and apply existing frameworks and share lessons learnt regarding which frameworks work well in which settings. A comprehensive assessment of governance could enable policy makers to prioritize solutions for problems identified as well as replicate and scale-up examples of good practice.
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Affiliation(s)
- Thidar Pyone
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA
| | - Helen Smith
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA
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Pyone T, Smith H, van den Broek N. Implementation of the free maternity services policy and its implications for health system governance in Kenya. BMJ Glob Health 2017; 2:e000249. [PMID: 29177098 PMCID: PMC5687545 DOI: 10.1136/bmjgh-2016-000249] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 09/19/2017] [Accepted: 10/25/2017] [Indexed: 11/12/2022] Open
Abstract
Introduction To move towards universal health coverage, the government of Kenya introduced free maternity services in all public health facilities in June 2013. User fees are, however, important sources of income for health facilities and their removal has implications for the way in which health facilities are governed. Objective To explore how implementation of Kenya’s financing policy has affected the way in which the rules governing health facilities are made, changed, monitored and enforced. Methods Qualitative research was carried out using semistructured interviews with 39 key stakeholders from six counties in Kenya: 10 national level policy makers, 10 county level policy makers and 19 implementers at health facilities. Participants were purposively selected using maximum variation sampling. Data analysis was informed by the institutional analysis framework, in which governance is defined by the rules that distribute roles among key players and shape their actions, decisions and interactions. Results Lack of clarity about the new policy (eg, it was unclear which services were free, leading to instances of service user exploitation), weak enforcement mechanisms (eg, delayed reimbursement to health facilities, which led to continued levying of service charges) and misaligned incentives (eg, the policy led to increased uptake of services thereby increasing the workload for health workers and health facilities losing control of their ability to generate and manage their own resources) led to weak policy implementation, further complicated by the concurrent devolution of the health system. Conclusion The findings show the consequences of discrepancies between formal institutions and informal arrangements. In introducing new policies, policy makers should ensure that corresponding institutional (re)arrangements, enforcement mechanisms and incentives are aligned with the objectives of the implementers.
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Affiliation(s)
- Thidar Pyone
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Helen Smith
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nynke van den Broek
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Amoah PA, Phillips DR. Strengthening the Referral System through Social Capital: A Qualitative Inquiry in Ghana. Healthcare (Basel) 2017; 5:healthcare5040080. [PMID: 29068366 PMCID: PMC5746714 DOI: 10.3390/healthcare5040080] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 11/29/2022] Open
Abstract
The referral system in health care has been noted as very influential in determining which services are accessed and when. Nonetheless, existing studies have relied on specific measurable factors relating to health personnel, transportation and communication infrastructure, and finance to explain the challenges facing the referral policy in developing countries. While this is understandable, the role of social capital remains mostly uncharted even though it is implicit in the well-known lay referral system. Using various facets of the social capital concept, this paper empirically examines how the resources embedded in both structural and cognitive aspects of social relationships influence knowledge of, and adherence to, referral policy. This study is based on semi-structured in-depth interviews conducted with 79 adults in the Ashanti Region of Ghana in 2015. Of the 79 participants, 28 lived in urban areas and 51 in rural localities. Eight health personnel and eight community leaders also contributed to the study. Additionally, six focus group discussions were held. The findings indicated that both cognitive and structural forms of social capital considerably underpinned the ability and willingness of people to adhere to the referral process. Moreover, the role of social capital was double-barrelled. It contributed in a significant way to encouraging or dissuading potential patients from rightly embracing the policy. In addition, precepts of social capital reinforced both positive and adverse effects of the other determinants of the policy such as finance and transportation. However, the magnitude of such impact was linked to how ‘resourceful’ and ‘trustworthy’ one’s available social acquaintances were. The paper suggests that a cautious engagement with social capital will make it a potentially powerful tool for understanding the gaps in and improving the effectiveness of referral policy.
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Affiliation(s)
- Padmore Adusei Amoah
- Division of Graduate Studies and Asia Pacific Institute of Ageing Studies, Lingnan University, 8 Castle Peak Rd, Hong Kong, China.
| | - David R Phillips
- Department of Sociology and Social Policy, Lingnan University, Hong Kong, China.
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26
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Abimbola S, Negin J, Martiniuk AL, Jan S. Institutional analysis of health system governance. Health Policy Plan 2017; 32:1337-1344. [DOI: 10.1093/heapol/czx083] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Seye Abimbola
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- National Primary Health Care Development Agency, Abuja, FCT 900247, Nigeria
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
| | - Joel Negin
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
| | - Alexandra L Martiniuk
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
- Dalla Lana School of Public Health, University of Toronto, ON M4N 3 M5, Canada
| | - Stephen Jan
- School of Public Health, Sydney Medical School, University of Sydney, NSW 2006, Australia
- The George Institute for Global Health, Sydney, NSW 2042, Australia and
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Ukwaja KN, Alobu I, Mustapha G, Onazi O, Oshi DC. 'Sustaining the DOTS': stakeholders' experience of a social protection intervention for TB in Nigeria. Int Health 2017; 9:112-117. [PMID: 28204499 DOI: 10.1093/inthealth/ihx001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/09/2017] [Indexed: 11/14/2022] Open
Abstract
Background Social protection for TB patients can lower patient costs and improve adherence. The aim of this study was to explore patients' and health workers' experiences of a social protection intervention for TB in order to inform a more patient-centred approach for the Nigeria National TB Programme strategy. Methods This was a qualitative study consisting of 103 in-depth interviews and two focus group discussions with patients who received the intervention, and 10 key informant interviews with health workers. A thematic content analysis of the interviews was performed. Results Of those who completed the interviews, 53 (51.5%) were male, and 69 (67.0%) were below 40 years. Most of the participants received care and support from their families but delayed access to TB services due to lack of funds for transportation, nutritional supplementation and non-TB drugs. The intervention had a high level of acceptability and uptake; particularly clear benefits emerged for most patients who used the social protection funds to purchase food and supplements, other drugs, transportation and additional personal necessities. Some patients assert that the financial incentive package increased their awareness of timing of their follow-up visits. In addition, health workers observed increased enthusiasm to treatment and improvement in adherence among participants. Conclusions Patients and health workers reported positive experiences with the financial incentives provided for TB treatment.
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Affiliation(s)
- Kingsley N Ukwaja
- Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
| | - Isaac Alobu
- National Tuberculosis and Leprosy Control Programme, Ministry of Health, Abakaliki, Ebonyi State, Nigeria
| | - Gidado Mustapha
- KNCV Tuberculosis Foundation/TB CARE I Project, Abuja, Nigeria
| | - Olajumoke Onazi
- KNCV Tuberculosis Foundation/TB CARE I Project, Abuja, Nigeria
| | - Daniel C Oshi
- Department of Community Health and Psychiatry, University of West Indies (UWI), Mona, Kingston 7, Jamaica
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Sullivan BJ, Esmaili BE, Cunningham CK. Barriers to initiating tuberculosis treatment in sub-Saharan Africa: a systematic review focused on children and youth. Glob Health Action 2017; 10:1290317. [PMID: 28598771 PMCID: PMC5496082 DOI: 10.1080/16549716.2017.1290317] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/30/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is the deadliest infectious disease globally, with 10.4 million people infected and more than 1.8 million deaths in 2015. TB is a preventable, treatable, and curable disease, yet there are numerous barriers to initiating treatment. These barriers to treatment are exacerbated in low-resource settings and may be compounded by factors related to childhood. OBJECTIVE Timely initiation of tuberculosis (TB) treatment is critical to reducing disease transmission and improving patient outcomes. The aim of this paper is to describe patient- and system-level barriers to TB treatment initiation specifically for children and youth in sub-Saharan Africa through systematic review of the literature. DESIGN This review was conducted in October 2015 in accordance with preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Six databases were searched to identify studies where primary or secondary objectives were related to barriers to TB treatment initiation and which included children or youth 0-24 years of age. RESULTS A total of 1490 manuscripts met screening criteria; 152 met criteria for full-text review and 47 for analysis. Patient-level barriers included limited knowledge, attitudes and beliefs regarding TB, and economic burdens. System-level barriers included centralization of services, health system delays, and geographical access to healthcare. Of the 47 studies included, 7 evaluated cost, 19 health-seeking behaviors, and 29 health system infrastructure. Only 4 studies primarily assessed pediatric cohorts yet all 47 studies were inclusive of children. CONCLUSIONS Recognizing and removing barriers to treatment initiation for pediatric TB in sub-Saharan Africa are critical. Both patient- and system-level barriers must be better researched in order to improve patient outcomes.
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Affiliation(s)
| | - B. Emily Esmaili
- Duke Global Health Institute
- Department of Science and Society, Duke University, Durham, NC, USA
| | - Coleen K. Cunningham
- Duke Global Health Institute
- School of Medicine, Duke University, Durham, NC, USA
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Abimbola S, Ogunsina K, Charles-Okoli AN, Negin J, Martiniuk AL, Jan S. Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria. HEALTH ECONOMICS REVIEW 2016; 6:51. [PMID: 27844451 PMCID: PMC5108730 DOI: 10.1186/s13561-016-0131-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/26/2016] [Indexed: 05/06/2023]
Abstract
One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a "make-or-buy" decision. The "make" decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm-informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, Sydney Medical School, University of Sydney, Rm 128C, Edward Ford Building A27, Sydney, NSW, 2006, Australia.
- National Primary Health Care Development Agency, Abuja, FCT, Nigeria.
- The George Institute for Global Health, Sydney, NSW, Australia.
| | - Kemi Ogunsina
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Augustina N Charles-Okoli
- School of Public Health, Sydney Medical School, University of Sydney, Rm 128C, Edward Ford Building A27, Sydney, NSW, 2006, Australia
- Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Joel Negin
- School of Public Health, Sydney Medical School, University of Sydney, Rm 128C, Edward Ford Building A27, Sydney, NSW, 2006, Australia
| | - Alexandra L Martiniuk
- School of Public Health, Sydney Medical School, University of Sydney, Rm 128C, Edward Ford Building A27, Sydney, NSW, 2006, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Stephen Jan
- School of Public Health, Sydney Medical School, University of Sydney, Rm 128C, Edward Ford Building A27, Sydney, NSW, 2006, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
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Abimbola S, Molemodile SK, Okonkwo OA, Negin J, Jan S, Martiniuk AL. 'The government cannot do it all alone': realist analysis of the minutes of community health committee meetings in Nigeria. Health Policy Plan 2015. [PMID: 26210167 PMCID: PMC4779146 DOI: 10.1093/heapol/czv066] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Since the mid-1980s, the national health policy in Nigeria has sought to inspire community engagement in primary health care by bringing communities into partnership with service providers through community health committees. Using a realist approach to understand how and under what circumstances the committees function, we explored 581 meeting minutes from 129 committees across four states in Nigeria (Lagos, Benue, Nasarawa and Kaduna). We found that community health committees provide opportunities for improving the demand and supply of health care in their community. Committees demonstrate five modes of functioning: through meetings (as ‘village square’), reaching out within their community (as ‘community connectors’), lobbying governments for support (as ‘government botherers’), inducing and augmenting government support (as ‘back-up government’) and taking control of health care in their community (as ‘general overseers’). In performing these functions, community health committees operate within and through the existing social, cultural and religious structures of their community, thereby providing an opportunity for the health facility with which they are linked to be responsive to the needs and values of the community. But due to power asymmetries, committees have limited capacity to influence health facilities for improved performance, and governments for improved health service provision. This is perhaps because national guidelines are not clear on their accountability functions; they are not aware of the minimum standards of services to expect; and they have a limited sense of legitimacy in their relations with sub-national governments because they are established as the consequence of a national policy. Committees therefore tend to promote collective action for self-support more than collective action for demanding accountability. To function optimally, community health committees require national government or non-government organization mentoring and support; they need to be enshrined in law to bolster their sense of legitimacy; and they also require financial support to subsidise their operation costs especially in geographically large communities.
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Affiliation(s)
- Seye Abimbola
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia, National Primary Health Care Development Agency, Abuja, FCT 900247, Nigeria, The George Institute for Global Health, Sydney, NSW 2050, Australia,
| | - Shola K Molemodile
- Johns Hopkins University International Vaccine Access Centre, Abuja, FCT 900221, Nigeria and
| | - Ononuju A Okonkwo
- National Primary Health Care Development Agency, Abuja, FCT 900247, Nigeria
| | - Joel Negin
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia
| | - Stephen Jan
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia, The George Institute for Global Health, Sydney, NSW 2050, Australia
| | - Alexandra L Martiniuk
- School of Public Health, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia, The George Institute for Global Health, Sydney, NSW 2050, Australia, Dalla Lana School of Public Health, University of Toronto, ON M4N 3 M5, Canada
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