Sector-wide or disease-specific? Implications of trends in development assistance for health for the SDG era

Surveillance system integration: reporting the results of a global multicountry survey

OBJECTIVES

Currently, there is no comprehensive picture of the global surveillance landscape. This survey examines the current state of surveillance systems, levels of integration, barriers and opportunities for the integration of surveillance systems at the country level, and the role of national public health institutes (NPHIs).

STUDY DESIGN

This was a cross-sectional survey of NPHIs.

METHODS

A web-based survey questionnaire was disseminated to 110 NPHIs in 95 countries between July and August 2022. Data were descriptively analysed, stratified by World Health Organization region, World Bank Income Group, and self-reported Integrated Disease Surveillance (IDS) maturity status.

RESULTS

Sixty-five NPHIs responded. Systems exist to monitor notifiable diseases and vaccination coverage, but less so for private, pharmaceutical, and food safety sectors. While Ministries of Health usually lead surveillance, in many countries, NPHIs are also involved. Most countries report having partially developed IDS. Surveillance data are frequently inaccessible to the lead public health agency and seldomly integrated into a national public health surveillance system. Common challenges to establishing IDS include information technology system issues, financial constraints, data sharing and ownership limitations, workforce capacity gaps, and data availability.

CONCLUSIONS

Public health surveillance systems across the globe, although built on similar principles, are at different levels of maturity but face similar developmental challenges. Leadership, ownership and governance, supporting legal mandates and regulations, as well as adherence to mandates, and enforcement of regulations are critical components of effective surveillance. In many countries, NPHIs play a significant role in integrated disease surveillance.

In with the good, out with the bad - Investment standards for external funding of health?

In recent decades, external financing of health systems in low- and middle-income countries has helped achieve remarkable improvements across the world. However, these successes have not come without problems. There are a growing number of areas where external assistance can cause harm and even undermine the development of national health systems. Recent decades have seen a surge of knowledge on investing in health systems. We propose the setting up of investment standards for external assistance that aim to incentivize a more efficient evidence-based investment in a country's health system, led by decision-makers in country. Using a more standardized process would lead to a better use of precious external assistance resources. The long-term goal would be fully functioning health systems with all the necessary essential public health functions in all countries.

Efficiency and management factors: finding the balance in Thalassaemia care centres

BACKGROUND

Optimizing efficiency has become increasingly critical with the growing demand for finite healthcare resources driven by population growth and an ageing society. Hence, policymakers are urgently finding more efficient ways to deliver health services. Thalassemia is a complex inherited blood disorder with significant prevalence in Malaysia. The high number of patients put substantial strain on the healthcare system. This study aims to evaluate the technical efficiency of thalassaemia care centres throughout Malaysia and the determinants that affect the efficiency.

METHOD

Data from 30 public hospitals with thalassaemia care centres were collected. A double bootstrap data envelopment analysis (DEA) approach is used with the assumption of input-oriented and variable-to-scale DEA models to generate technical efficiency scores. Bootstrap truncated regression was later conducted to identify the factors affecting the efficiency scores.

RESULTS

The mean bias-corrected technical efficiency score has improved to 0.75 in 2017 from 0.71 in 2016. In both years, more than 50% of thalassaemia care centres showed good efficiency scores (0.8-1.0). Management factors that affect the efficiency scores include separation of patient management (β = 0.0653) and budget (β = 0.0843), where they are found to positively affect the efficiency scores. In contrast, having longer operating hours is found to inversely influence the performance levels (β = - 0.4023).

CONCLUSIONS

The study provides a pioneering framework to evaluate the technical efficiency of thalassaemia treatment centres in public healthcare settings and could provide a useful guide for policymaker and thalassaemia care centre managers to improve efficiency in service delivery to thalassaemia patients and their caregivers without compromising quality of care.

Noncommunicable disease outcomes and the effects of vertical and horizontal health aid

Foreign health aid forms a substantial portion of health spending in many low- and middle-income countries (LMICs). It can be either vertical (funds earmarked for specific diseases) or horizontal (funds used for broad health sector strengthening). Historically, most health aid has been disbursed vertically toward key infectious diseases, with minimal allocations to noncommunicable diseases (NCDs). High NCD burden in LMICs underscores a need for increased assistance toward NCD objectives, but evidence on the outcomes of health aid for NCDs is sparse. We obtained annual data on cause-specific deaths and disability-adjusted life years (DALYs) for four leading NCDs across 116 countries, 2000-2016, and evaluated the relationship between these indicators and vertical and horizontal health aid using country fixed-effects models with 1-to-5-year lagged effects. After adjusting for fixed and time-variant country heterogeneity, vertical assistance for NCDs was significantly associated with subsequent reductions in NCD morbidity and mortality, particularly for persons under age 70 and for cardiovascular and chronic respiratory diseases. An additional dollar in per-capita NCD vertical assistance corresponded to reductions in the average annual NCD burden of 7,459 DALYs/281 deaths after one year, 7,728 DALYs/319 deaths after two years, and 8,957 DALYs/346 deaths after three years. The findings suggest that vertical assistance for NCD programs may be an appropriate mechanism for addressing short-term NCD needs in LMICs, where it may help to fill health sector gaps in NCD care, but longer-term evaluation is needed for assessing the role of horizontal assistance.

Questions for future evidence-informed policy initiatives: insights from the evolution and aspirations of National Immunization Technical Advisory Groups

BACKGROUND

Attention to evidence-informed policy has grown; however, efforts to strengthen the quality and use of evidence are not starting from a blank slate. Changes in health architectures and financing pose different considerations for investments in evidence-informed policy than in the past. We identify major trends that have shifted the environment in which health policies are made, and use the evolution and future aspirations of National Immunization Technical Advisory Groups (NITAGs) in low- and middle-income countries to identify questions the sector must confront when determining how best to structure and strengthen evidence-informed health policy.

DISCUSSION

Trends over the last two decades have resulted in a dense arena with many issue-specific groups, discrete initiatives to strengthen evidence-informed policy and increasing responsibility for subnational institutions. Many countries face a shifting resource base, which for some reduces the amount of resources for health. There is global momentum around universal health coverage, reflecting a broader systems approach, but few examples of how the vast array of stakeholders relate within it are available. NITAG aspirations reflect four interconnected themes related to their scope, their integration in national policy processes, health financing and relationships with ministries of finance, and NITAG positioning relative to other domestic and international entities, raising questions such as, What are the bounds of issue-specific groups and their relationship to allocation decision-making processes across health areas? How do technical advisory groups interface with what are inherently political processes? When are finances considered, by whom and how? What is the future of existing groups whose creation was intended to enhance national ownership but who need continued external support to function? When should new entities be created, in what form and with what mandate?

CONCLUSIONS

Countries must determine who makes decisions about resources, when, using what criteria, and how to do so in a robust yet efficient way given the existing and future landscape. While answers to these questions are necessarily country specific, they are collective matters that cannot be addressed by specialised groups alone and have implications for new investments in evidence-informed policy.

Has Gavi lived up to its promise? Quasi-experimental evidence on country immunisation rates and child mortality

Introduction

Gavi, the Vaccine Alliance, was set up in 2000 to improve access to vaccines for children living in the poorest countries. Funding has increased significantly over time, with Gavi disbursements reaching US $1.58 billion in 2015. We assess whether Gavi’s funding programmes have indeed increased immunisation coverage in 51 recipient countries for two key vaccines for 12–23 month olds: combined diphtheria, pertussis and tetanus (DPT) and measles. Additionally, we look at effects on infant and child mortality.

Methods

Taking a difference-in-differences quasi-experimental approach to observational data, we estimate the impact of Gavi eligibility on immunisation coverage and mortality rates over time, using WHO/UNICEF figures covering 1995–2016. We control for economy size and population of each country as well as running a suite of robustness checks and sensitivity tests.

Results

We find large and significant positive effects from Gavi’s funding programmes: on average a 12.02 percentage point increase in DPT immunisation coverage (95% CI 6.56 to 17.49) and an 8.81 percentage point increase in measles immunisation coverage (95% CI 3.58 to 14.04) over the period to 2016. Our estimates show Gavi support also induced 6.22 fewer infant deaths (95% CI −10.47 to −1.97) and 12.23 fewer under-five deaths (95% CI −19.66 to −4.79) per 1000 live births.

Conclusion

Our findings provide evidence that Gavi has had a substantial impact on the fight against communicable diseases for improved population and child health in lower-income countries. In this case, the health policy to verticalise aid—specifically development assistance for health—via a specialised global fund has had positive outcomes.

The integration of the global HIV/AIDS response into universal health coverage: desirable, perhaps possible, but far from easy

BACKGROUND

The international community's health focus is shifting from achieving disease-specific targets towards aiming for universal health coverage. Integrating the global HIV/AIDS response into universal health coverage may be inevitable to secure its achievements in the long run, and for expanding these achievements beyond addressing a single disease. However, this integration comes at a time when international financial support for the global HIV/AIDS response is declining, while political support for universal health coverage is not translated into financial support. To assess the risks, challenges and opportunities of the integration of the global HIV/AIDS response into national universal health coverage plans, we carried out assessments in Indonesia, Kenya, Uganda and Ukraine, based on key informant interviews with civil society, policy-makers and development partners, as well as on a review of grey and academic literature.

RESULTS

In the absence of international financial support, governments are turning towards national health insurance schemes to finance universal health coverage, making access to healthcare contingent on regular financial contributions. It is not clear how AIDS treatment will be fit in. While the global HIV/AIDS response accords special attention to exclusion due to sexual orientation and gender identity, sex work or drug use, efforts to achieve universal health coverage focus on exclusion due to poverty, gender and geographical inequalities. Policies aiming for universal health coverage try to include private healthcare providers in the health system, which could create a sustainable framework for civil society organisations providing HIV/AIDS-related services. While the global HIV/AIDS response insisted on the inclusion of civil society in decision-making policies, that is not (yet) the case for policies aiming for universal health coverage.

DISCUSSION

While there are many obstacles to successful integration of the global HIV/AIDS response into universal health coverage policies, integration seems inevitable and is happening. Successful integration will require expanding the principle of 'shared responsibility' which emerged with the global HIV/AIDS response to universal health coverage, rather than relying solely on domestic efforts for universal health coverage. The preference for national health insurance as the best way to achieve universal health coverage should be reconsidered. An alliance between HIV/AIDS advocates and proponents of universal health coverage requires mutual condemnation of discrimination based on sexual orientation and gender identity, sex work or drug use, as well as addressing of exclusion based on poverty and other factors. The fulfilment of the promise to include civil society in decision-making processes about universal health coverage is long overdue.

Understanding the persistence of vertical (stand-alone) HIV clinics in the health system in Uganda: a qualitative synthesis of patient and provider perspectives

Background

Although there is mounting evidence and policy guidance urging the integration of HIV services into general health systems in countries with a high HIV burden, vertical (stand-alone) HIV clinics are still common in Uganda. We sought to describe the specific contexts underpinning the endurance of vertical HIV clinics in Uganda.

Methods

A qualitative research design was adopted. Semi-structured interviews were conducted with the heads of HIV clinics, clinicians and facility in-charges (n = 78), coupled with eight focus group discussions (64 participants) with patients from 16 health facilities purposively selected, from a nationally-representative sample of 195 health facilities across Uganda, because they run stand-alone HIV clinics. Data were analyzed by thematic approach as guided by the theory proposed by Shediac-Rizkallah & Bone (1998) which identifies; Intervention characteristics, organizational context, and broader environment factors as potentially influential on health programme sustainability.

Results

Intervention characteristics: Provider stigma was reported to have been widespread in the integrated care experience of participating health facilities which necessitated the establishment of stand-alone HIV clinics. HIV disease management was described as highly specialized which necessitated a dedicated workforce and vertical HIV infrastructure such as counselling rooms. Organizational context: Participating health facilities reported health-system capacity constraints in implementing integrated systems of care due to a shortage of ART-proficient personnel and physical space, a lack of laboratory capacity to concurrently conduct HIV and non-HIV tests and increased workloads associated with implementing integrated care. Broader environment factors: Escalating HIV client loads and external HIV funding architectures were perceived to have perpetuated verticalized HIV programming over the past decade.

Conclusion

Our study offers in-depth, contextualized insights into the factors contributing to the endurance of vertical HIV clinics in Uganda. Our analysis suggests that there is a complex interaction in supply-side constraints (shortage of ART-proficient personnel, increased workloads, laboratory capacity deficiencies) and demand-side factors (escalating demand for HIV services, psychosocial barriers to HIV care) as well as the specialized nature of HIV disease management which pose challenges to the integrated-health services agenda.