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Sapkota S, Dhakal A, Rushton S, van Teijlingen E, Marahatta SB, Balen J, Lee AC. The impact of decentralisation on health systems: a systematic review of reviews. BMJ Glob Health 2023; 8:e013317. [PMID: 38135299 DOI: 10.1136/bmjgh-2023-013317] [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: 07/04/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Decentralisation is a common mechanism for health system reform; yet, evidence of how it impacts health systems remains fragmented. Despite published findings from primary and secondary research illustrating range of impacts, a comprehensive and clear understanding is currently lacking. This review synthesised the existing evidence to assess how decentralisation (by devolution) impacts each of the six WHO building blocks, and the health system. METHOD We systematically searched five electronic databases for reviews exploring impact of decentralisation on health systems, globally. Reviews, both systematic and non-systematic, published in the English language from January 1990 to February 2022 were included. Data were synthesised across each of six building blocks. Quality assessment of the reviews was conducted using Critical Appraisal Skills Program for systematic and Scale for Assessment of Narrative Review Articles for non-systematic reviews. RESULTS Nine reviews, each addressing somewhat different questions, contexts and issues, were included. A range of positive and negative impacts of decentralisation on health system building blocks were identified; yet, overall, the impacts were more negative. Although inconclusive, evidence suggested that the impacts on leadership and governance and financing components in particular shape the impact on overall health system. Assessment of how the impact on building blocks translates to the broader impact on health systems is challenged by the dynamic complexities related to contexts, process and the health system itself. CONCLUSIONS Decentralisation, even if well intentioned, can have unintended consequences. Despite the difficulty of reaching universally applicable conclusions about the pros and cons of decentralisation, this review highlights some of the common potential issues to consider in advance. PROSPERO REGISTRATION NUMBER CRD42022302013.
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Affiliation(s)
- Sujata Sapkota
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Amshu Dhakal
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Simon Rushton
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- The University of Sheffield, Sheffield, UK
| | - Edwin van Teijlingen
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- Bournemouth University, Poole, UK
| | - Sujan B Marahatta
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- Nepal Open University, Lalitpur, Nepal
| | - Julie Balen
- Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
- The University of Sheffield, Sheffield, UK
- Canterbury Christ Church University, Canterbury, UK
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Allorant A, Fullman N, Leslie HH, Sarr M, Gueye D, Eliakimu E, Wakefield J, Dieleman JL, Pigott D, Puttkammer N, Reiner RC. A small area model to assess temporal trends and sub-national disparities in healthcare quality. Nat Commun 2023; 14:4555. [PMID: 37507373 PMCID: PMC10382513 DOI: 10.1038/s41467-023-40234-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
Monitoring subnational healthcare quality is important for identifying and addressing geographic inequities. Yet, health facility surveys are rarely powered to support the generation of estimates at more local levels. With this study, we propose an analytical approach for estimating both temporal and subnational patterns of healthcare quality indicators from health facility survey data. This method uses random effects to account for differences between survey instruments; space-time processes to leverage correlations in space and time; and covariates to incorporate auxiliary information. We applied this method for three countries in which at least four health facility surveys had been conducted since 1999 - Kenya, Senegal, and Tanzania - and estimated measures of sick-child care quality per WHO Service Availability and Readiness Assessment (SARA) guidelines at programmatic subnational level, between 1999 and 2020. Model performance metrics indicated good out-of-sample predictive validity, illustrating the potential utility of geospatial statistical models for health facility data. This method offers a way to jointly estimate indicators of healthcare quality over space and time, which could then provide insights to decision-makers and health service program managers.
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Affiliation(s)
- Adrien Allorant
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada.
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA.
| | - Nancy Fullman
- Department of Global Health, University of Washington, Seattle, WA, USA
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Hannah H Leslie
- Division of Prevention Science, University of California San Francisco, San Francisco, CA, USA
| | - Moussa Sarr
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formation, Dakar, Senegal
| | - Daouda Gueye
- Institut de Recherche en Santé de Surveillance Epidémiologique et de Formation, Dakar, Senegal
| | - Eliudi Eliakimu
- Health Quality Assurance Unit, Ministry of Health, Dodoma, Tanzania
| | - Jon Wakefield
- Department of Statistics and Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Joseph L Dieleman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - David Pigott
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Nancy Puttkammer
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, Seattle, WA, USA
| | - Robert C Reiner
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
- Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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Moucheraud C, McBride K, Heuveline P, Shah M. Preventing, but Not Caring for, Adolescent Pregnancies? Disparities in the Quality of Reproductive Health Care in Sub-Saharan Africa. J Adolesc Health 2022; 71:210-216. [PMID: 35437221 PMCID: PMC9995166 DOI: 10.1016/j.jadohealth.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE There is concern that adolescents experience worse quality of health care than older women. We compare quality of reproductive health services (family planning and antenatal care) for adolescents (<20 years) versus adult women (≥25 years), in four sub-Saharan African countries. METHODS In total, 2,342 family planning visits and 8,600 antenatal care visits were analyzed from Democratic Republic of the Congo, Malawi, Senegal, and Tanzania. Service Provision Assessment surveys include observation of care and client exit interviews. We compare visit content and care satisfaction for adolescents versus adult women aged ≥25. All models are multilevel, weighted to reflect survey design, and include client, provider, and facility covariates (pooled models also include survey fixed effects). RESULTS Adolescents receive more overall family planning care activities compared to adult women (2.31 activities in adjusted generalized linear models, standard error [SE] 1.29, p < .1), and 3.76 more discussion activities (e.g., counseling) on average (SE 1.94, p < .1), but significantly fewer discussion activities during antenatal care (-3.10 activities, SE .97, p < .01). However, adolescents' satisfaction with both care types was not significantly different than adult women. These relationships largely persist in country-stratified models, using different model specifications, and when comparing adolescents to women aged ≥20. CONCLUSIONS Adolescents' family planning visits are similar to, or even slightly more comprehensive than, adult women-but their antenatal visits include fewer recommended care components, with particular gaps for activities requiring provider-client dialog. This suggests opportunities for strengthening communication between providers and young women, and improving care across the reproductive health continuum.
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Affiliation(s)
- Corrina Moucheraud
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California; UCLA Center for Health Policy Research, Los Angeles, California.
| | - Kaitlyn McBride
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Patrick Heuveline
- Department of Sociology and California Center for Population Research, University of California Los Angeles, Los Angeles, California
| | - Manisha Shah
- Department of Public Policy, Luskin School of Public Affairs, University of California Los Angeles, Los Angeles, California
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Carter ED, Leslie HH, Marchant T, Amouzou A, Munos MK. Methodological considerations for linking household and healthcare provider data for estimating effective coverage: a systematic review. BMJ Open 2021; 11:e045704. [PMID: 34446481 PMCID: PMC8395298 DOI: 10.1136/bmjopen-2020-045704] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To assess existing knowledge related to methodological considerations for linking population-based surveys and health facility data to generate effective coverage estimates. Effective coverage estimates the proportion of individuals in need of an intervention who receive it with sufficient quality to achieve health benefit. DESIGN Systematic review of available literature. DATA SOURCES Medline, Carolina Population Health Center and Demographic and Health Survey publications and handsearch of related or referenced works of all articles included in full text review. The search included publications from 1 January 2000 to 29 March 2021. ELIGIBILITY CRITERIA Publications explicitly evaluating (1) the suitability of data, (2) the implications of the design of existing data sources and (3) the impact of choice of method for combining datasets to obtain linked coverage estimates. RESULTS Of 3805 papers reviewed, 70 publications addressed relevant issues. Limited data suggest household surveys can be used to identify sources of care, but their validity in estimating intervention need was variable. Methods for collecting provider data and constructing quality indices were diverse and presented limitations. There was little empirical data supporting an association between structural, process and outcome quality. Few studies addressed the influence of the design of common data sources on linking analyses, including imprecise household geographical information system data, provider sampling design and estimate stability. The most consistent evidence suggested under certain conditions, combining data based on geographical proximity or administrative catchment (ecological linking) produced similar estimates to linking based on the specific provider utilised (exact match linking). CONCLUSIONS Linking household and healthcare provider data can leverage existing data sources to generate more informative estimates of intervention coverage and care. However, existing evidence on methods for linking data for effective coverage estimation are variable and numerous methodological questions remain. There is need for additional research to develop evidence-based, standardised best practices for these analyses.
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Affiliation(s)
- Emily D Carter
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Hannah H Leslie
- Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Tanya Marchant
- Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Agbessi Amouzou
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Brown KK, Boateng GO, Ossom-Williamson P, Haygood L. Defining, conceptualizing, and measuring perceived maternal care quality in low- to high-income countries: a scoping review protocol. Syst Rev 2021; 10:61. [PMID: 33627182 PMCID: PMC7903867 DOI: 10.1186/s13643-021-01608-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 02/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health practitioners and researchers must be able to measure and assess maternal care quality in facilities to monitor, intervene, and reduce global maternal mortality rates. On the global scale, there is a general lack of consensus on how maternal care quality is defined, conceptualized, and measured. Much of the literature addressing this problem has focused primarily on defining, conceptualizing, and measuring clinical indicators of maternal care quality. Less attention has been given in this regard to perceived maternal care quality among women which is known to influence care utilization and adherence. Therefore, there is a need to map the literature focused on defining, conceptualizing, and measuring perceived maternal care quality across low-, middle-, and high-income country contexts. METHODS This scoping review protocol will follow the Arksey and O'Malley methodological framework. A comprehensive search strategy will be used to search for articles published from inception to 2020 in Ovid MEDLINE, Embase, AMED, and WHO Global Index Medicus. Gray literature will be included. Two independent reviewers will screen articles by title and abstract, then by full-text based on pre-determined inclusion/exclusion criteria. A third reviewer will arbitrate any discrepancies. This protocol outlines a four-step analytic approach that includes numerical, graphical, tabular, and narrative summaries to provide a comprehensive description of the body of literature. DISCUSSION The findings from this scoping review will provide a comprehensive overview of the existing evidence on perceived maternal care quality. The findings are expected to inform future work on building consensus around the definition and conceptualization of perceived maternal care quality, and lay the groundwork for future research aimed at developing measures of perceived maternal care quality that can be applied across country contexts. Consequently, this review may aid in facilitating coordinated efforts to measure and improve maternal care quality across diverse country contexts (i.e., low-, middle-, and high-income country contexts). REVIEW REGISTRATION This scoping review has been registered in the Open Science Framework (osf.io/k8nqh).
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Affiliation(s)
- Kyrah K Brown
- Department of Kinesiology, University of Texas at Arlington, 500 W. Nedderman Drive, Box 19407, Arlington, TX, 76019-0407, USA.
| | - Godfred O Boateng
- Department of Kinesiology, University of Texas at Arlington, 500 W. Nedderman Drive, Box 19407, Arlington, TX, 76019-0407, USA
| | - Peace Ossom-Williamson
- Research Data Services, UTA Libraries, University of Texas at Arlington, 702 Planetarium Place, Arlington, TX, 76019, USA
| | - Laura Haygood
- Gibson D. Lewis Health Science Library, University of North Texas Health Science Center, 3500 Camp Bowie Blvd, Fort Worth, TX, 76107, USA
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