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Chaves ACC, Scherer MDDA, Conill EM. What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020. CIENCIA & SAUDE COLETIVA 2023; 28:2537-2551. [PMID: 37672445 DOI: 10.1590/1413-81232023289.15342022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/11/2023] [Indexed: 09/08/2023] Open
Abstract
Primary Health Care (PHC) intends to rearrange services to make it more effective. Nevertheless, effectiveness in PHC is quite a challenge. This study reviews several articles regarding the effectiveness improvements in PHC between 2010 and 2020. Ninety out of 8,369 articles found in PubMed and the Virtual Health Library databases search were selected for thematic analysis using the Atlas.ti® 9.0 software. There were four categories identified: strategies for monitoring and evaluating health services, organizational arrangements, models and technologies applied to PHC. Studies concerning the sensitive conditions indicators were predominant. Institutional assessment programs, PHC as a structuring policy, appropriate workforce, measures to increase access and digital technologies showed positive effects. However, payment for performance is still controversial. The expressive number of Brazilian publications reveals the broad diffusion of PHC in the country and the concern on its performance. These findings reassure well-known aspects, but it also points to the need for a logical model to better define what is intended as effectiveness within primary health care as well as clarify the polysemy that surrounds the concept. We also suggest substituting the term "resolvability", commonly used in Brazil, for "effectiveness".
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Turner SL, Korevaar E, Cumpston MS, Kanukula R, Forbes AB, McKenzie JE. Effect estimates can be accurately calculated with data digitally extracted from interrupted time series graphs. Res Synth Methods 2023; 14:622-638. [PMID: 37293884 PMCID: PMC10946754 DOI: 10.1002/jrsm.1646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 03/12/2023] [Accepted: 05/10/2023] [Indexed: 06/10/2023]
Abstract
Interrupted time series (ITS) studies are frequently used to examine the impact of population-level interventions or exposures. Systematic reviews with meta-analyses including ITS designs may inform public health and policy decision-making. Re-analysis of ITS may be required for inclusion in meta-analysis. While publications of ITS rarely provide raw data for re-analysis, graphs are often included, from which time series data can be digitally extracted. However, the accuracy of effect estimates calculated from data digitally extracted from ITS graphs is currently unknown. Forty-three ITS with available datasets and time series graphs were included. Time series data from each graph was extracted by four researchers using digital data extraction software. Data extraction errors were analysed. Segmented linear regression models were fitted to the extracted and provided datasets, from which estimates of immediate level and slope change (and associated statistics) were calculated and compared across the datasets. Although there were some data extraction errors of time points, primarily due to complications in the original graphs, they did not translate into important differences in estimates of interruption effects (and associated statistics). Using digital data extraction to obtain data from ITS graphs should be considered in reviews including ITS. Including these studies in meta-analyses, even with slight inaccuracy, is likely to outweigh the loss of information from non-inclusion.
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Affiliation(s)
- Simon Lee Turner
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Elizabeth Korevaar
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Miranda S. Cumpston
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Raju Kanukula
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Andrew B. Forbes
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
| | - Joanne E. McKenzie
- School of Public Health and Preventive MedicineMonash UniversityMelbourneAustralia
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Wisniewski J, Worges M, Lusamba-Dikassa PS. Impact of a free care policy on routine health service volumes during a protracted Ebola virus disease outbreak in the Democratic Republic of Congo. Soc Sci Med 2023; 322:115815. [PMID: 36889222 DOI: 10.1016/j.socscimed.2023.115815] [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: 03/08/2022] [Revised: 02/02/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND In response to the DRC's 10th Ebola Virus Disease (EVD) outbreak, the government subsidized routine health services in select health zones with the goal of maintaining routine service volumes. We assess the impact of the initial and revised Free Care Policies (FCP) on total clinic visits, uncomplicated malaria, simple pneumonia, fourth antenatal care clinic visits, and measles vaccinations, testing the hypothesis that routine services would not significantly decrease during the FCP. METHODS AND FINDINGS We used data from the DRC's national health information system spanning January 2017 to November 2020. Intervention facilities were those that were initially and secondarily enrolled in the FCP, which occurred in August 2018 and November 2018, respectively. Comparison facilities were limited to the North Kivu Province and were from health zones that recorded at least one case of Ebola. A controlled interrupted time series analysis was conducted. The FCP appeared to have a positive effect in increasing overall clinic attendance rates, uncomplicated malaria case rates, and simple pneumonia case rates in those health zones where the policy was enacted relative to comparison sites. The longer-term effects of the FCP were mostly non-significant or, if significant, relatively modest in nature. Rates for measles vaccinations and fourth ANC clinic visits appeared to be unaffected or minimally affected, respectively, by the implementation of the FCP and relative to comparison sites. We did not observe the decrease in measles vaccinations that has been observed elsewhere. The study is limited in that we were unable to account for health facility bypassing and service volumes at private health facilities. CONCLUSIONS Our findings provide evidence that FCPs can be used to maintain routine service provision during outbreaks. Additionally, the study design demonstrates that routinely reported health information from the DRC are sensitive enough to detect changes in health policy.
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Affiliation(s)
- Janna Wisniewski
- Department of International Health and Sustainable Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St. Suite 2200, New Orleans, Louisiana, USA.
| | - Matt Worges
- Department of International Health and Sustainable Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St. Suite 2200, New Orleans, Louisiana, USA.
| | - Paul-Samson Lusamba-Dikassa
- Department of International Health and Sustainable Development, Tulane University School of Public Health and Tropical Medicine, 1440 Canal St. Suite 2200, New Orleans, Louisiana, USA; University of Kinshasa School of Public Health, Faculty of Medicine, Kinshasa, Congo.
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Bapolisi WA, Karemere H, Ndogozi F, Cikomola A, Kasongo G, Ntambwe A, Bisimwa G. First recourse for care-seeking and associated factors among rural populations in the eastern Democratic Republic of the Congo. BMC Public Health 2021; 21:1367. [PMID: 34246245 PMCID: PMC8272345 DOI: 10.1186/s12889-021-11313-7] [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: 04/17/2020] [Accepted: 06/18/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Access to quality healthcare is a global fundamental human right. However, in the Democratic Republic of the Congo, several parameters affect the choices of health service users in fragile, rural contexts (zones). The overarching aim of this study was to identify the first recourse of healthcare-seeking and the determinants of utilization of health centers (primary health care structures) in the rural health zones of Katana and Walungu. METHODS A cross-sectional survey was conducted from June to September 2017. Consenting respondents comprised 1751 adults. Continuous data were summarized using means (standard deviation) and medians (interquartile range). We used Pearson's chi-square test and Fisher exact test to compare proportions. Logistic regression was run to assess socio-determinants of health center utilization. RESULTS The morbidity rate of the sample population for the previous month was 86.4% (n = 1501) of which 60% used health centers for their last morbid episode and 20% did not. 5.3% of the respondents patronized prayer rooms and 7.9% resorted to self-medication principally because the cost was low, or the services were fast. Being female (OR: 1.51; p = 0.005) and a higher level of education (OR: 1.79; p = 0.032) were determinants of the use of health centers in Walungu. Only the level of education was associated with the use of health centers in Katana (OR: 2.78; p = 0.045). CONCLUSION Our findings suggest that health centers are the first recourse for the majority of the population during an illness. However, a significant percentage of patients are still using traditional healers or prayer rooms because the cost is low. Our results suggest that future interventions to encourage integrated health service use should target those with lower levels of education.
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Affiliation(s)
- Wyvine Ansima Bapolisi
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo.
| | - Hermès Karemere
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo
| | - Freddy Ndogozi
- Division provincial de la Santé du Sud-Kivu, Bukavu, Democratic Republic of the Congo
| | - Aimé Cikomola
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo.,Division provincial de la Santé du Sud-Kivu, Bukavu, Democratic Republic of the Congo.,Programme RIPSEC (Renforcement Institutionnel des Institutions pour les Politiques de santé basées sur l'évidence en République Démocratique du Congo), Lubumbashi, Democratic Republic of the Congo
| | - Ghislain Kasongo
- Bureau central de la zone de santé de Walungu, Walungu, Democratic Republic of the Congo
| | - Albert Ntambwe
- Programme RIPSEC (Renforcement Institutionnel des Institutions pour les Politiques de santé basées sur l'évidence en République Démocratique du Congo), Lubumbashi, Democratic Republic of the Congo.,Ecole de santé Publique de l'Université de Lubumbashi, Lubumbashi, Democratic Republic of the Congo
| | - Ghislain Bisimwa
- Ecole Régionale de Santé Publique de Bukavu, Université Catholique de Bukavu, Bukavu, Democratic Republic of the Congo.,Programme RIPSEC (Renforcement Institutionnel des Institutions pour les Politiques de santé basées sur l'évidence en République Démocratique du Congo), Lubumbashi, Democratic Republic of the Congo
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Hung YW, Law MR, Cheng L, Abramowitz S, Alcayna-Stevens L, Lurton G, Mayaka SM, Olekhnovitch R, Kyomba G, Ruton H, Ramazani SY, Grépin KA. Impact of a free care policy on the utilisation of health services during an Ebola outbreak in the Democratic Republic of Congo: an interrupted time-series analysis. BMJ Glob Health 2021; 5:bmjgh-2019-002119. [PMID: 32718948 PMCID: PMC7389747 DOI: 10.1136/bmjgh-2019-002119] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 05/08/2020] [Accepted: 05/09/2020] [Indexed: 12/04/2022] Open
Abstract
Background During past outbreaks of Ebola virus disease (EVD) and other infectious diseases, health service utilisation declined among the general public, delaying health seeking behaviour and affecting population health. From May to July 2018, the Democratic Republic of Congo experienced an outbreak of EVD in Equateur province. The Ministry of Public Health introduced a free care policy (FCP) in both affected and neighbouring health zones. We evaluated the impact of this policy on health service utilisation. Methods Using monthly data from the national Health Management Information System from January 2017 to January 2019, we examined rates of the use of nine health services at primary health facilities: total visits; first and fourth antenatal care visits; institutional deliveries; postnatal care visits; diphtheria, pertussis and tetanus (DTP) vaccinations and visits for uncomplicated malaria, pneumonia and diarrhoea. We used controlled interrupted time series analysis with a mixed effects model to estimate changes in the rates of services use during the policy (June–September 2018) and afterwards. Findings Overall, use of most services increased compared to control health zones, including EVD affected areas. Total visits and visits for pneumonia and diarrhoea initially increased more than two-fold relative to the control areas (p<0.001), while institutional deliveries and first antenatal care increased between 20% and 50% (p<0.01). Visits for DTP, fourth antenatal care visits and postnatal care visits were not significantly affected. During the FCP period, visit rates followed a downward trend. Most increases did not persist after the policy ended. Interpretation The FCP was effective at rapidly increasing the use of some health services both EVD affected and not affected health zones, but this effect was not sustained post FCP. Such policies may mitigate the adverse impact of infectious disease outbreaks on population health.
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Affiliation(s)
- Yuen W Hung
- Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Lucy Cheng
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Lys Alcayna-Stevens
- Department of Anthropology, Harvard University, Cambridge, Massachusetts, USA
| | | | - Serge Manitu Mayaka
- Public Health School of Kinshasa, Université de Kinshasa, Kinshasa, The Democratic Republic of Congo
| | | | - Gabriel Kyomba
- Public Health School of Kinshasa, Université de Kinshasa, Kinshasa, The Democratic Republic of Congo
| | - Hinda Ruton
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, British Columbia, Canada.,School of Public Health, University of Rwanda, Kigali, Rwanda
| | | | - Karen A Grépin
- Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada .,School of Public Health, University of Hong Kong, Pokfulam, Hong Kong SAR
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Jordan K, Lewis TP, Roberts B. Quality in crisis: a systematic review of the quality of health systems in humanitarian settings. Confl Health 2021; 15:7. [PMID: 33531065 PMCID: PMC7851932 DOI: 10.1186/s13031-021-00342-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 01/22/2021] [Indexed: 12/03/2022] Open
Abstract
Background There is a growing concern that the quality of health systems in humanitarian crises and the care they provide has received little attention. To help better understand current practice and research on health system quality, this paper aimed to examine the evidence on the quality of health systems in humanitarian settings. Methods This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. The context of interest was populations affected by humanitarian crisis in low- and middle- income countries (LMICs). We included studies where the intervention of interest, health services for populations affected by crisis, was provided by the formal health system. Our outcome of interest was the quality of the health system. We included primary research studies, from a combination of information sources, published in English between January 2000 and January 2019 using quantitative and qualitative methods. We used the High Quality Health Systems Framework to analyze the included studies by quality domain and sub-domain. Results We identified 2285 articles through our search, of which 163 were eligible for full-text review, and 55 articles were eligible for inclusion in our systematic review. Poor diagnosis, inadequate patient referrals, and inappropriate treatment of illness were commonly cited barriers to quality care. There was a strong focus placed on the foundations of a health system with emphasis on the workforce and tools, but a limited focus on the health impacts of health systems. The review also suggests some barriers to high quality health systems that are specific to humanitarian settings such as language barriers for refugees in their host country, discontinued care for migrant populations with chronic conditions, and fears around provider safety. Conclusion The review highlights a large gap in the measurement of quality both at the point of care and at the health system level. There is a need for further work particularly on health system measurement strategies, accountability mechanisms, and patient-centered approaches in humanitarian settings. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-021-00342-z.
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Affiliation(s)
- Keely Jordan
- Department of Health Policy, New York University School of Global Public Health, 665 Broadway, New York, NY, 10012, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bayard Roberts
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Jia L, Meng Q, Scott A, Yuan B, Zhang L. Payment methods for healthcare providers working in outpatient healthcare settings. Cochrane Database Syst Rev 2021; 1:CD011865. [PMID: 33469932 PMCID: PMC8094987 DOI: 10.1002/14651858.cd011865.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.
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Affiliation(s)
- Liying Jia
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
- NHC Key Lab for Health Economics and Policy Research, Shandong University, Jinan, China
| | - Qingyue Meng
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Carlton, Melbourne, Australia
| | - Beibei Yuan
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Lu Zhang
- Weihai Health Care Security Administration, Weihai, China
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Altare C, Malembaka EB, Tosha M, Hook C, Ba H, Bikoro SM, Scognamiglio T, Tappis H, Pfaffmann J, Balaluka GB, Boerma T, Spiegel P. Health services for women, children and adolescents in conflict affected settings: experience from North and South Kivu, Democratic Republic of Congo. Confl Health 2020; 14:31. [PMID: 32514296 PMCID: PMC7254646 DOI: 10.1186/s13031-020-00265-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/02/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Insecurity has characterized the Eastern regions of the Democratic Republic of Congo for decades. Providing health services to sustain women's and children's health during protracted conflict is challenging. This mixed-methods case study aimed to describe how reproductive, maternal, newborn, child, adolescent health and nutrition (RMNCAH+N) services have been offered in North and South Kivu since 2000 and how successful they were. METHODS We conducted a case study using a desk review of publicly available literature, secondary analysis of survey and health information system data, and primary qualitative interviews. The qualitative component provides insights on factors shaping RMNCAH+N design and implementation. We conducted 49 interviews with government officials, humanitarian agency staff and facility-based healthcare providers, and focus group discussions with community health workers in four health zones (Minova, Walungu, Ruanguba, Mweso). We applied framework analysis to investigate key themes across informants.The quantitative component used secondary data from nationwide surveys and the national health facility information system to estimate coverage of RMNCAH+N interventions at provincial and sub-provincial level. The association between insecurity on service provision was examined with random effects generalized least square models using health facility data from South Kivu. RESULTS Coverage of selected preventive RMNCAH+N interventions seems high in North and South Kivu, often higher than the national level. Health facility data show a small negative association of insecurity and preventive service coverage within provinces. However, health outcomes are poorer in conflict-affected territories than in stable ones. The main challenges to service provisions identified by study respondents are the availability and retention of skilled personnel, the lack of basic materials and equipment as well as the insufficient financial resources to ensure health workers' regular payment, medicaments' availability and facilities' running costs. Insecurity exacerbates pre-existing challenges, but do not seem to represent the main barrier to service provision in North and South Kivu. CONCLUSIONS Provision of preventive schedulable RMNCAH+N services has continued during intermittent conflict in North and South Kivu. The prolonged effort by non-governmental organizations and UN agencies to respond to humanitarian needs was likely key in maintaining intervention coverage despite conflict. Health actors and communities appear to have adapted to changing levels and nature of insecurity and developed strategies to ensure preventive services are provided and accessed. However, emergency non-schedulable RMNCAH+N interventions do not appear to be readily accessible. Achieving the Sustainable Development Goals will require increased access to life-saving interventions, especially for newborn and pregnant women.
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Affiliation(s)
- Chiara Altare
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Espoir Bwenge Malembaka
- Ecole Régionale de Santé Publique, ERSP, Faculty of Medicine, Université catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Maphie Tosha
- Foundation RamaLevina, Bukavu, Democratic Republic of Congo
| | - Christopher Hook
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Hamady Ba
- United Nations Children’s Fund, Bukavu, Democratic Republic of Congo
| | | | - Thea Scognamiglio
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Hannah Tappis
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Ghislain Bisimwa Balaluka
- Ecole Régionale de Santé Publique, ERSP, Faculty of Medicine, Université catholique de Bukavu, Bukavu, Democratic Republic of Congo
| | - Ties Boerma
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - Paul Spiegel
- Centre for Humanitarian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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9
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Bertone MP, Jowett M, Dale E, Witter S. Health financing in fragile and conflict-affected settings: What do we know, seven years on? Soc Sci Med 2019; 232:209-219. [PMID: 31102931 DOI: 10.1016/j.socscimed.2019.04.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/20/2019] [Accepted: 04/14/2019] [Indexed: 12/21/2022]
Abstract
Over the last few years, there has been growing attention to health systems research in fragile and conflict-affected setting (FCAS) from both researchers and donors. In 2012, an exploratory literature review was conducted to analyse the main themes and findings of recent literature focusing on health financing in FCAS. Seven years later, this paper presents an update of that review, reflecting on what has changed in terms of the knowledge base, and what are the on-going gaps and new challenges in our understanding of health financing in FCAS. A total of 115 documents were reviewed following a purposeful, non-systematic search of grey and published literature. Data were analysed according to key health financing themes, ensuring comparability with the 2012 review. Bibliometric analysis suggests that the field has continued to grow, and is skewed towards countries with a large donor presence (such as Afghanistan). Aid coordination remains the largest single topic within the themes, likely reflecting the dominance of external players, not just substantively but also in relation to research. Many studies are commissioned by external agencies and in addition to concerns about independence of findings there is also likely a neglect of smaller, more home-grown reforms. In addition, we find that despite efforts to coordinate approaches across humanitarian and developmental settings, the literature remains distinct between them. We highlight research gaps, including empirical analysis of domestic and external financing trends across FCAS and non-FCAS over time, to understand better common health financing trajectories, what drives them and their implications. We highlight a dearth of evidence in relation to health financing goals and objectives for UHC (such as equity, efficiency, financial access), which is significant given the relevance of UHC, and the importance of the social and political values which different health financing arrangements can communicate, which also merit in-depth study.
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Affiliation(s)
- Maria Paola Bertone
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.
| | - Matthew Jowett
- Health Financing Unit, World Health Organisation, Geneva, Switzerland.
| | - Elina Dale
- Health Financing Unit, World Health Organisation, Geneva, Switzerland.
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK.
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Jacobs B, Bajracharya A, Saha J, Chhea C, Bellows B, Flessa S, Fernandes Antunes A. Making free public healthcare attractive: optimizing health equity funds in Cambodia. Int J Equity Health 2018; 17:88. [PMID: 29940970 PMCID: PMC6019830 DOI: 10.1186/s12939-018-0803-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 06/14/2018] [Indexed: 11/15/2022] Open
Abstract
Background Following the introduction of user fees in Cambodia, Health Equity Funds (HEF) were developed to enable poor people access to public health services by paying public health providers on their behalf, including non-medical costs for hospitalised beneficiaries (HEFB). The national scheme covers 3.1 million pre-identified HEFB. Uptake of benefits, however, has been mixed and a substantial proportion of poor people still initiate care at private facilities where they incur considerable out-of-pocket costs. We examine the benefits of additional interventions compared to existing stand-alone HEF scenarios in stimulating care seeking at public health facilities among eligible poor people. Methods We report on three configurations of HEF and their ability to attract HEFB to initiate care at public health facilities and their degree of financial risk protection: HEF covering only hospital services (HoHEF), HEF covering health centre and hospital services (CHEF), and Integrated Social Health Protection Scheme (iSHPS) that allowed non-HEFB community members to enrol in HEF. The iSHPS also used vouchers for selected health services, pay-for-performance for quantity and quality of care, and interventions aimed at increasing health providers’ degree of accountability. A cross sectional survey collected information from 1636 matched HEFB households in two health districts with iSHPS and two other health districts without iSHPS. Respondents were stratified according to the three HEF configurations for the descriptive analysis. Results The findings indicated that the proportion of HEFB who sought care first from public health providers in iSHPS areas was 55.7%, significantly higher than the 39.5% in the areas having HEF with health centres (CHEF) and 13.4% in the areas having HEF with hospital services only (HoHEF). The overall costs (out-of-pocket and transport) associated with the illness episode were lowest for cases residing within iSHPS sites, US$10.4, and highest in areas where health centres were not included in the package (HoHEF), US$20.7. Such costs were US$19.5 at HEF with health centres (CHEF). Conclusions The findings suggest that HEF encompassing health centre and hospital services and complemented by additional interventions are better than stand-alone HEF in attracting sick HEFB to public health facilities and lowering out-of-pocket expenses associated with healthcare seeking.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Programme, Deutsche Gesellschaft für Internationale Zusammenarbeit (GiZ), c/o NIPH, No.2, Street 289, Khan Toul Kork, P.O. Box 1238, Phnom Penh, Cambodia.
| | | | | | | | | | - Steffen Flessa
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany
| | - Adelio Fernandes Antunes
- Department of General Business Administration and Health Care Management, University of Greifswald, Greifswald, Germany.,SOCIEUX + Expertise on Social Protection, Labour and Employment, Brussels, Belgium
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Reeves BC, Wells GA, Waddington H. Quasi-experimental study designs series-paper 5: a checklist for classifying studies evaluating the effects on health interventions-a taxonomy without labels. J Clin Epidemiol 2017; 89:30-42. [PMID: 28351692 PMCID: PMC5669452 DOI: 10.1016/j.jclinepi.2017.02.016] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 10/02/2016] [Accepted: 02/06/2017] [Indexed: 11/29/2022]
Abstract
Objectives The aim of the study was to extend a previously published checklist of study design features to include study designs often used by health systems researchers and economists. Our intention is to help review authors in any field to set eligibility criteria for studies to include in a systematic review that relate directly to the intrinsic strength of the studies in inferring causality. We also seek to clarify key equivalences and differences in terminology used by different research communities. Study Design and Setting Expert consensus meeting. Results The checklist comprises seven questions, each with a list of response items, addressing: clustering of an intervention as an aspect of allocation or due to the intrinsic nature of the delivery of the intervention; for whom, and when, outcome data are available; how the intervention effect was estimated; the principle underlying control for confounding; how groups were formed; the features of a study carried out after it was designed; and the variables measured before intervention. Conclusion The checklist clarifies the basis of credible quasi-experimental studies, reconciling different terminology used in different fields of investigation and facilitating communications across research communities. By applying the checklist, review authors' attention is also directed to the assumptions underpinning the methods for inferring causality.
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Affiliation(s)
- Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7 Queen's Building, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
| | - George A Wells
- Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada K1Y 4W7
| | - Hugh Waddington
- International Initiative for Impact Evaluation (3ie), 202-203, Rectangle One, D-4, Saket District Centre, New Delhi, 110017, India
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