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Brunet Johansson A, Hurtig AK, Nkulu Kalengayi FK. Sexual and Reproductive Health and Rights for Young Migrants in Sweden: An Ideal-Type Analysis Exploring Regional Variations of Accessible Documents. Int J Public Health 2024; 69:1606568. [PMID: 38698911 PMCID: PMC11063276 DOI: 10.3389/ijph.2024.1606568] [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: 08/31/2023] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
Objectives: This study aims to map sexual and reproductive health and rights (SRHR) policies, strategies, and interventions targeting young migrants and describe the patterns of organisation, resources, and services across Sweden's 21 regions. Methods: We conducted a document analysis of accessible online documents on SRHR policies, strategies, and interventions targeting young migrants in Sweden's 21 regions. We used ideal-type analysis of the documents to create a typology, which formed the basis of a ratings system illustrating variations in organisation, resources, and services across regions. Results: Findings suggest that efforts aimed at addressing young migrants' SRHR are fragmented and unequal across regions. While SRHR policies and strategies are commonplace, they routinely lack specificity. Available resources vary depending on region and resource type. Additionally, information and interventions, although common, do not consistently meet the specific needs of migrant youths. Conclusion: This study suggests that fragmented efforts are fuelling geographic inequalities in fulfilling SRHR among young migrants. There is an urgent need to improve national coordination and collaboration between national and local actors in SRHR efforts targeting young migrants to ensure equity.
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Affiliation(s)
- Albert Brunet Johansson
- Department of Epidemiology and Global Health, Faculty of Medicine, Umeå University, Umeå, Sweden
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2
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Sinnott C, Vedanthan R, van Olmen J. Elusive but hopefully not illusive: coordinating care for patients with heart failure with preserved ejection fraction. BMJ Qual Saf 2024; 33:212-215. [PMID: 38195252 DOI: 10.1136/bmjqs-2023-016754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 01/11/2024]
Affiliation(s)
- Carol Sinnott
- THIS Institute, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Rajesh Vedanthan
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Josefien van Olmen
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
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Chiu K, Pandya S, Sharma M, Hooimeyer A, de Souza A, Sud A. An international comparative policy analysis of opioid use disorder treatment in primary care across nine high-income jurisdictions. Health Policy 2024; 141:104993. [PMID: 38237202 DOI: 10.1016/j.healthpol.2024.104993] [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: 08/03/2023] [Revised: 11/09/2023] [Accepted: 01/09/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Opioid use disorder (OUD) and opioid-related harms are current health priorities in many high-income countries such as Canada. Opioid agonist therapy (OAT) is an effective evidence-based treatment for OUD, but access is often limited. AIMS To describe and compare OUD treatment policies across nine international jurisdictions, and to understand how they are situated within their primary care and health systems. METHODS Using policy documents, we collected data on health systems, drug use epidemiology, drug policies, and OUD treatment from Australia, Canada, France, Germany, Ireland, Portugal, Sweden, Switzerland, and Taiwan. We used the health system dynamics framework and adapted definitions of low- and high-threshold treatment to describe and compare OUD treatment policies, and to understand how they may be shaped by their health systems context. RESULTS Broad similarities across jurisdictions included the OAT pharmacological agents used and the need for supervised dosing; however, preferred OAT, treatment settings, primary care and specialist physicians' roles, and funding varied. Most jurisdictions had elements of lower-threshold treatment access, such as the availability of treatment through primary care and multiple OAT options, but the higher-threshold criteria of supervised dosing. CONCLUSIONS From the Canadian perspective, there are opportunities to improve accessibility of OUD care by drawing on how different jurisdictions incorporate multidisciplinary care, regulate OAT medications, remunerate healthcare professionals, and provide funding for services.
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Affiliation(s)
- Kellia Chiu
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Saloni Pandya
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Manu Sharma
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Alexandra de Souza
- Menzies Centre for Health Policy and Economics, The University of Sydney, Sydney, NSW, Australia
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Humber River Hospital, Toronto, ON, Canada.
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Weisz G, Harper J. Investigating the citing communities around three leading health-system frameworks. Health Res Policy Syst 2024; 22:16. [PMID: 38279103 PMCID: PMC10811803 DOI: 10.1186/s12961-023-01075-6] [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: 06/07/2023] [Accepted: 11/14/2023] [Indexed: 01/28/2024] Open
Abstract
Of numerous proposed frameworks for analyzing and impacting health systems, three stand out for the large number of publications that cite them and for their links to influential international institutions: Murray and Frenk (Bull World Health Organ 78:717-31, 2000) connected initially to the World Health Organization (WHO) and then to the Global Burden of Disease Project; Roberts et al. (Getting health reform right: a guide to improving performance and equity, Oxford University Press, Oxford, 2004) sponsored by the World Bank/Harvard Flagship Program; and de Savigny and Adam (Systems thinking for health systems strengthening, WHO, 2009) linked to the WHO and the Alliance for Health Policy and Systems Research. In this paper, we examine the citation communities that form around these works to better understand the underlying logic of these citation grouping as well as the dynamics of Global Health research on health systems. We conclude that these groupings are largely independent of one another, reflecting a range of factors including the goals of each framework and the problems that it was meant to explore, the prestige and authority of institutions and individuals associated with these frameworks, and the intellectual and geographic proximity of the citing researchers to each other and to the framework authors.
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Affiliation(s)
- George Weisz
- Dept. Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada.
| | - Jonathan Harper
- Dept. Social Studies of Medicine, McGill University, 3647 Peel Street, Montreal, QC, H3A 1X1, Canada
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Blumenberg C, Costa JC, Ricardo LI, Jacobs C, Ferreira LZ, Vidaletti LP, Wehrmeister FC, Barros AJD, Faye C, Boerma T. Coverage, Trends, and Inequalities of Maternal, Newborn, and Child Health Indicators among the Poor and Non-Poor in the Most Populous Cities from 38 Sub-Saharan African Countries. J Urban Health 2023:10.1007/s11524-023-00806-y. [PMID: 38110773 DOI: 10.1007/s11524-023-00806-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 12/20/2023]
Abstract
Rapid urbanization is likely to be associated with suboptimal access to essential health services. This is especially true in cities from sub-Saharan Africa (SSA), where urbanization is outpacing improvements in infrastructure. We assessed the current situation in regard to several markers of maternal, newborn, and child health, including indicators of coverage of health interventions (demand for family planning satisfied with modern methods, at least four antenatal care visits (ANC4+), institutional birth, and three doses of DPT vaccine[diphtheria, pertussis and tetanus]) and health status (stunting in children under 5 years, neonatal and under-5 mortality rates) among the poor and non-poor in the most populous cities from 38 SSA countries. We analyzed 136 population-based surveys (year range 2000-2019), contrasting the poorest 40% of households (referred to as poor) with the richest 60% (non-poor). Coverage in the most recent survey was higher for the city non-poor compared to the poor for all interventions in virtually all cities, with the largest median gap observed for ANC4+ (13.5 percentage points higher for the non-poor). Stunting, neonatal, and under-5 mortality rates were higher among the poor (7.6 percentage points, 21.2 and 10.3 deaths per 1000 live births, respectively). The gaps in coverage between the two groups were reducing, except for ANC4, with similar median average annual rate of change in both groups. Similar rates of change were also observed for stunting and the mortality indicators. Continuation of these positive trends is needed to eliminate inequalities in essential health services and child survival in SSA cities.
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Affiliation(s)
- Cauane Blumenberg
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil.
- Post-Graduate Program in Epidemiology, Federal University of Pelotas, 1160 Marechal Deodoro St., 3rd floor, CEP 96020-220, Center, Pelotas, RS, Brazil.
- Causale consultoria, Pelotas, Brazil.
| | - Janaina Calu Costa
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Harvard University, Boston, MA, USA
| | - Luiza I Ricardo
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Choolwe Jacobs
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Leonardo Z Ferreira
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Luis Paulo Vidaletti
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Fernando C Wehrmeister
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Post-Graduate Program in Epidemiology, Federal University of Pelotas, 1160 Marechal Deodoro St., 3rd floor, CEP 96020-220, Center, Pelotas, RS, Brazil
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Aluisio J D Barros
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
- Post-Graduate Program in Epidemiology, Federal University of Pelotas, 1160 Marechal Deodoro St., 3rd floor, CEP 96020-220, Center, Pelotas, RS, Brazil
| | - Cheikh Faye
- African Population and Health Research Center, Dakar, Senegal
| | - Ties Boerma
- Institute for Global Public Health, University of Manitoba, Winnipeg, Canada
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Solomon-Rakiep T, Olivier J, Amponsah-Dacosta E. Weak Adoption and Performance of Hepatitis B Birth-Dose Vaccination Programs in Africa: Time to Consider Systems Complexity?-A Scoping Review. Trop Med Infect Dis 2023; 8:474. [PMID: 37888602 PMCID: PMC10611266 DOI: 10.3390/tropicalmed8100474] [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: 08/19/2023] [Revised: 10/01/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023] Open
Abstract
The persistent burden of chronic hepatitis B among ≤5-year-old children in Africa suggests missed opportunities for controlling mother-to-child transmission (MTCT) of the hepatitis B virus (HBV). This scoping review maps the evidence base on the risk of HBV MTCT, the status of HBV MTCT mitigation strategies including hepatitis B birth-dose vaccination, and the role of systems complexity on the suboptimal adoption and performance of hepatitis B birth-dose vaccination programs in Africa. Overall, 88 peer-reviewed and grey literature sources published between 2000-2022 were included in this review. The growing evidence base consistently argues for a heightened risk of HBV MTCT amidst the HIV co-epidemic in the region. Without universal HBV screening programs integrated within broader antenatal care services, current selective hepatitis B birth-dose vaccination is unlikely to effectively interrupt HBV MTCT. We underscore critical health systems-related barriers to universal adoption and optimal performance of hepatitis B birth-dose vaccination programs in the region. To better conceptualize the role of complexity and system-wide effects on the observed performance of the program, we propose an adapted systems-based logic model. Ultimately, exploring contextualized complex systems approaches to scaling-up universal hepatitis B birth-dose vaccination programs should form an integral part of the regional research agenda.
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Affiliation(s)
- Tasneem Solomon-Rakiep
- Health Policy and Systems Division, School of Public Health, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
- Vaccines for Africa Initiative, School of Public Health, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
| | - Jill Olivier
- Health Policy and Systems Division, School of Public Health, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
| | - Edina Amponsah-Dacosta
- Vaccines for Africa Initiative, School of Public Health, Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town 7925, South Africa
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Sud A, Chiu K, Friedman J, Dupouy J. Buprenorphine deregulation as an opioid crisis policy response - A comparative analysis between France and the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104161. [PMID: 37619440 DOI: 10.1016/j.drugpo.2023.104161] [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: 02/16/2023] [Revised: 07/22/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND In passing the Maintstreaming Addiction Treatment Act, the United States has abolished its federal X waiver, considered a major barrier to the wider buprenorphine prescribing needed to respond to opioid-related harms. Advocates for this policy have drawn on the French response of deregulating buprenorphine prescribing to address increasing overdose mortality around the turn of the millennium. So far, such policy advocacy has incompletely accounted for contextual and health system differences between the two countries. METHODS Using the health system dynamics framework, this analysis compares France from 1995 to 2003 (the relevant period of buprenorphine reform) to the US from 2018 until today (the comparison period to explore potential impacts of reform). We used it to guide examination of a) contextual issues relating to opioid use epidemiology and b) health system factors including prescriber supply, sector organization, and insurance coverage for primary care to draw relevant policy learning for the contemporary US. RESULTS We identified that the US had a 22.5-fold higher mortality rate and a 2.3-fold higher opioid use disorder (OUD) rate compared to France, despite having rates of prescribed buprenorphine per-capita higher than, and per-person with OUD comparable to, than that of France. These wide gulfs between the scales and nature of the problems between France and the US suggest that relaxing restrictions on buprenorphine prescribing through abolishing the X waiver will be insufficient for achieving hoped-for reductions in overdose mortality. CONCLUSION Health system strengthening with a focus on improvements in primary care prescriber supply, coverage, and coordination are likely higher yield policy complements to relaxing buprenorphine regulation. Such an approach would better prepare the US to adapt to ongoing dynamics and uncertainties in the opioid crisis and to optimize the already relatively high levels of buprenorphine prescribing.
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Affiliation(s)
- Abhimanyu Sud
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada; Humber River Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Kellia Chiu
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Joseph Friedman
- Center for Social Medicine and Humanities, University of California, Los Angeles, United States
| | - Julie Dupouy
- University Department of General Medicine, University of Toulouse, Faculty of Medicine, Toulouse, France; Inserm UMR1295, University of Toulouse III, Faculty of Medicine, Toulouse, France
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Zakumumpa H, Kwiringira J, Katureebe C, Spicer N. Understanding Uganda's early adoption of novel differentiated HIV treatment services: a qualitative exploration of drivers of policy uptake. BMC Health Serv Res 2023; 23:343. [PMID: 37020290 PMCID: PMC10075495 DOI: 10.1186/s12913-023-09313-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 03/20/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Although differentiated service delivery (DSD) for HIV treatment was endorsed by the WHO in its landmark 2016 guidelines to lessen patients' need to frequently visit clinics and hence to reduce unnecessary burdens on health systems, uptake has been uneven globally. This paper is prompted by the HIV Policy Lab's annual report of 2022 which reveals substantial variations in programmatic uptake of differentiated HIV treatment services across the globe. We use Uganda as a case study of an 'early adopter' to explore the drivers of programmatic uptake of novel differentiated HIV treatment services. METHODS We conducted a qualitative case-study in Uganda. In-depth interviews were held with national-level HIV program managers (n = 18), district health team members (n = 24), HIV clinic managers (n = 36) and five focus groups with recipients of HIV care (60 participants) supplemented with documentary reviews. Our thematic analysis of the qualitative data was guided by the Consolidated Framework for Implementation Research (CFIR)'s five domains (inner context, outer setting, individuals, process of implementation). RESULTS Our analysis reveals that drivers of Uganda's 'early adoption' of DSD include: having a decades-old HIV treatment intervention implementation history; receiving substantial external donor support in policy uptake; the imperatives of having a high HIV burden; accelerated uptake of select DSD models owing to Covid-19 'lockdown' restrictions; and Uganda's participation in clinical trials underpinning WHO guidance on DSD. The identified processes of implementation entailed policy adoption of DSD (such as the role of local Technical Working Groups in domesticating global guidelines, disseminating national DSD implementation guidelines) and implementation strategies (high-level health ministry buy-in, protracted patient engagement to enhance model uptake, devising metrics for measuring DSD uptake progress) for promoting programmatic adoption. CONCLUSION Our analysis suggests early adoption derives from Uganda's decades-old HIV intervention implementation experience, the imperative of having a high HIV burden which prompted innovations in HIV treatment delivery as well as outer context factors such as receiving substantial external assistance in policy uptake. Our case study of Uganda offers implementation research lessons on pragmatic strategies for promoting programmatic uptake of differentiated treatment HIV services in other countries with a high HIV burden.
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Affiliation(s)
- Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
| | | | - Cordelia Katureebe
- Ministry of Health, AIDS Control Program, Kampala, Uganda
- London School of Hygiene and Tropical Medicine, London, UK
| | - Neil Spicer
- London School of Hygiene and Tropical Medicine, London, UK
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Aqil A, Saldana K, Mian NU, Ndu M. Reliability and validity of an innovative high performing healthcare system assessment tool. BMC Health Serv Res 2023; 23:242. [PMID: 36915091 PMCID: PMC10009863 DOI: 10.1186/s12913-022-08852-z] [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: 03/01/2021] [Accepted: 11/17/2022] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Universal Health coverage (UHC) is the mantra of the twenty-first century yet knowing when it has been achieved or how to best influence its progression remains elusive. An innovative framework for High Performing Healthcare (HPHC) attempts to address these issues. It focuses on measuring four constructs of Accountable, Affordable, Accessible, and Reliable (AAAR) healthcare that contribute to better health outcomes and impact. The HPHC tool collects information on the perceived functionality of health system processes and provides real-time data analysis on the AAAR constructs, and on processes for health system resilience, responsiveness, and quality, that include roles of community, private sector, as well as both demand, and supply factors affecting health system performance. The tool attempts to capture the multidimensionality of UHC measurement and evidence that links health system strengthening activities to outcomes. This paper provides evidence on the reliability and validity of the tool. METHODS Internet survey with non-probability sampling was used for testing reliability and validity of the HPHC tool. The volunteers were recruited using international networks and listservs. Two hundred and thirteen people from public, private, civil society and international organizations volunteered from 35 low-and-middle-income countries. Analyses involved testing reliability and validity and validation from other international sources of information as well as applicability in different setting and contexts. RESULTS The HPHC tool's AAAR constructs, and their sub-domains showed high internal consistency (Cronbach alpha >.80) and construct validity. The tool scores normal distribution displayed variations among respondents. In addition, the tool demonstrated its precision and relevance in different contexts/countries. The triangulation of HPHC findings with other international data sources further confirmed the tool's validity. CONCLUSIONS Besides being reliable and valid, the HPHC tool adds value to the state of health system measurement by focusing on linkages between AAAR processes and health outcomes. It ensures that health system stakeholders take responsibility and are accountable for better system performance, and the community is empowered to participate in decision-making process. The HPHC tool collects and analyzes data in real time with minimum costs, supports monitoring, and promotes adaptive management, policy, and program development for better health outcomes.
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Affiliation(s)
- Anwer Aqil
- Credence Management Solution, LLC, GHTASC, Institutional contractor USAID, Senior HSS MEL Advisor, Office of Health System, USAID, Washington, D.C., USA.
| | - Kelly Saldana
- Systems Strengthening and Resilience, Abt Associates, Rockville, USA
| | | | - Mary Ndu
- Health and Rehabilitation Sciences, University of Western Ontario, London, Canada
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Mwanza J, Kawonga M, Kumwenda A, Gray GE, Mutale W, Doherty T. Health system response to preventing mother-to-child transmission of HIV policy changes in Zambia: a health system dynamics analysis of primary health care facilities. Glob Health Action 2022; 15:2126269. [PMID: 36239946 PMCID: PMC9578454 DOI: 10.1080/16549716.2022.2126269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Zambia is focusing on attaining HIV epidemic control by 2021, including eliminating Mother to Child Transmission (eMTCT) of HIV. However, there is little evidence to understand frontline healthcare workers’ experience with the policy changes and the readiness of different health system elements to contribute to this goal. Objective To understand frontline healthcare workers’ experience of preventing mother-to-child transmission (PMTCT) of human immunodeficiency (HIV) policy changes and to explore the health system readiness to respond to rapid changes in PMTCT policy by using the health system dynamic framework. Method We conducted a qualitative study in which 35 frontline healthcare workers were selected and interviewed using a snowball sampling technique. All transcripts were analysed through thematic content analysis and deductive coding. Themes were derived and presented according to the health system dynamics framework. Results Among the ten elements of the health system dynamics framework, service delivery, context, and resources (i.e. infrastructure and supplies, knowledge and information, human resource, and finance) were critical in implementing the continuously evolving PMTCT policies. Furthermore, due to the fragmented primary health care platform in Zambia, non-governmental organisations (NGOs) were instrumental in ensuring that the PMTCT programme met the demand and requirements of the general population. Frontline healthcare workers who participated in the study described inequity in access to ART services due to the service delivery model employed in the selected study sites. Conclusion The study highlights challenges when policies are implemented without consideration for the readiness, context, and capacity in which the policy is implemented. We offer lessons that can inform implementation of universal health coverage of antiretroviral therapy (ART), a strategy many countries have adopted, despite weak health systems.
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Affiliation(s)
- Jonathan Mwanza
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mary Kawonga
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Department of Community Health, Charlotte Maxeke Johannesburg Academic Hospital Johannesburg, Johannesburg, South Africa
| | - Andrew Kumwenda
- Department of Obstetrics and Gynaecology, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Glenda E Gray
- Office of the President, South Africa Medical Research Council, Cape Town, South Africa
| | - Wilbroad Mutale
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Tanya Doherty
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Health Systems Research Unit, South Africa Medical Research Council, Cape Town, South Africa
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Kabir A, Karim MN, Billah B. Health system challenges and opportunities in organizing non-communicable diseases services delivery at primary healthcare level in Bangladesh: A qualitative study. Front Public Health 2022; 10:1015245. [PMID: 36438215 PMCID: PMC9682236 DOI: 10.3389/fpubh.2022.1015245] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The weak health system is viewed as a major systematic obstacle to address the rising burden of non-communicable diseases (NCDs) in resource-poor settings. There is little information about the health system challenges and opportunities in organizing NCD services. This study examined the health system challenges and opportunities in organizing NCD services for four major NCDs (cervical cancer, diabetes mellitus, cardiovascular diseases, and chronic respiratory illnesses) at the primary healthcare (PHC) level in Bangladesh. Methods Using a qualitative method, data were collected from May to October 2021 by conducting 15 in-depth interviews with local healthcare providers, 14 key informant interviews with facility-based providers and managers, and 16 focus group discussions with community members. Based on a health system dynamics framework, data were analyzed thematically. Information gathered through the methods and sources was triangulated to validate the data. Results Organization of NCD services at the PHC level was influenced by a wide range of health system factors, including the lack of using standard treatment guidelines and protocols, under-regulated informal and profit-based private healthcare sectors, poor health information system and record-keeping, and poor coordination across healthcare providers and platforms. Furthermore, the lack of functional referral services; inadequate medicine, diagnostic facilities, and logistics supply; and a large number of untrained human resources emerged as key weaknesses that affected the organization of NCD services. The availability of NCD-related policy documents, the vast network of healthcare infrastructure and frontline staff, and increased demand for NCD services were identified as the major opportunities. Conclusion Despite the substantial potential, the health system challenge impeded the organization of NCD services delivery at the PHC level. This weakness needs be to addressed to organize quality NCD services to better respond to the rising burden of NCDs at the PHC level.
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Kabwama SN, Wanyenze RK, Kiwanuka SN, Namale A, Ndejjo R, Monje F, Wang W, Lazenby S, Kizito S, Troeger C, Liu A, Lindgren H, Razaz N, Ssenkusu J, Sambisa W, Bartlein R, Alfvén T. Interventions for Maintenance of Essential Health Service Delivery during the COVID-19 Response in Uganda, between March 2020 and April 2021. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191912522. [PMID: 36231823 PMCID: PMC9566395 DOI: 10.3390/ijerph191912522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/19/2022] [Accepted: 09/27/2022] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The COVID-19 pandemic overwhelmed health systems globally and affected the delivery of health services. We conducted a study in Uganda to describe the interventions adopted to maintain the delivery of other health services. METHODS We reviewed documents and interviewed 21 key informants. Thematic analysis was conducted to identify themes using the World Health Organization health system building blocks as a guiding framework. RESULTS Governance strategies included the establishment of coordination committees and the development and dissemination of guidelines. Infrastructure and commodity strategies included the review of drug supply plans and allowing emergency orders. Workforce strategies included the provision of infection prevention and control equipment, recruitment and provision of incentives. Service delivery modifications included the designation of facilities for COVID-19 management, patient self-management, dispensing drugs for longer periods and the leveraging community patient networks to distribute medicines. However, multi-month drug dispensing led to drug stock-outs while community drug distribution was associated with stigma. CONCLUSIONS Health service maintenance during emergencies requires coordination to harness existing health system investments. The essential services continuity committee coordinated efforts to maintain services and should remain a critical element of emergency response. Self-management and leveraging patient networks should address stigma to support service continuity in similar settings and strengthen service delivery beyond the pandemic.
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Affiliation(s)
- Steven Ndugwa Kabwama
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University, Kampala P.O. Box 7062, Uganda
- Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Suzanne N. Kiwanuka
- Department of Health Policy Planning and Management, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Alice Namale
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Rawlance Ndejjo
- Department of Disease Control and Environmental Health, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | - Fred Monje
- School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | | | | | - Susan Kizito
- School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | | | - Anne Liu
- Gates Ventures, Kirkland, WA 98033, USA
| | - Helena Lindgren
- Department of Women’s and Children’s Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Neda Razaz
- Department of Medicine, Karolinska Institutet, 17177 Stockholm, Sweden
| | - John Ssenkusu
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala P.O. Box 7072, Uganda
| | | | | | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, 17177 Stockholm, Sweden
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Abejirinde IOO, Gwacham-Anisiobi U, Affun-Adegbulu C, Vanhamel J, Van Belle S, Marchal B. A perspective on urban health systems and research for equitable healthcare in Africa. BMJ Glob Health 2022; 7:bmjgh-2022-010333. [PMID: 36162869 PMCID: PMC9516074 DOI: 10.1136/bmjgh-2022-010333] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ibukun-Oluwa Omolade Abejirinde
- Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada .,Division of Social & Behavioural Health Sciences, University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | | | - Jef Vanhamel
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Sara Van Belle
- Fund for Belgian Scientific Research, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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14
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Nguyen Thu H, Nguyen Quynh A, Khuat Hai O, Le Thi Thanh H, Nguyen Thanh H. Impact of the COVID-19 pandemic on provision of HIV/AIDS services for key populations. Int J Health Plann Manage 2022; 37:2852-2868. [PMID: 35607717 PMCID: PMC9348422 DOI: 10.1002/hpm.3508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 04/14/2022] [Accepted: 05/10/2022] [Indexed: 11/06/2022] Open
Abstract
The COVID-19 pandemic has aggravated the obstacles for HIV/AIDS programs in limited-resource countries like Vietnam to achieve the HIV/AIDS-related Sustainable Development target. The paper aims to evaluate the impact of the COVID-19 pandemic on the provision of HIV/AIDS services-a pathway to achieving universal health coverage for key populations (KPs). Employing mix-methods, we conducted a desk study, one focus group discussion, and ten in-depth interviews with participants from the Ministry of Health, Provincial Centres for Disease Control, and HIV/AIDS-related facilities. The results showed the reduced coverage of KPs with access to prevention (i.e., harm-reduction services, counselling), testing, and treatment services (i.e., antiretroviral therapy, isoniazid preventive therapy). It also showed the reduced coverage of quality essential services, mainly in skipping consultation and testing, delaying un-emergency services, and redirecting KPs to non-HIV-specialised facilities. There was a gap in providing support for mental health, violence/abuse, and reproductive health. Financial risk protection for KPs was reduced due to uncertain local budget allocation; decreasing their ability to pay for HIV/AIDS-related services and social health insurance premiums; and increased out-of-pocket payments to comply with the COVID-19 control measures. This paper provides recommendations for strategic planning to ensure universal health coverage for KPs in the post COVID-19 era, especially for limited-resource countries like Vietnam.
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Affiliation(s)
- Ha Nguyen Thu
- Department of Health Policy and Health Economics, Hanoi University of Public Health, Hanoi, Vietnam
| | - Anh Nguyen Quynh
- Department of Health Policy and Health Economics, Hanoi University of Public Health, Hanoi, Vietnam
| | - Oanh Khuat Hai
- Centre for Supporting Community Development Initiatives, Hanoi, Vietnam
| | - Ha Le Thi Thanh
- Centre for Supporting Community Development Initiatives, Hanoi, Vietnam
| | - Huong Nguyen Thanh
- Department of Health Promotion, Faculty of Social and Behavioural Sciences, Hanoi University of Public Health, Hanoi, Vietnam
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Lall D, Balachandra SS, Prabhu P, Kumar D, Mokashi T, Devadasan N. Lessons for the Design of Comprehensive Primary Healthcare in India: A Qualitative Study. JOURNAL OF HEALTH MANAGEMENT 2022. [DOI: 10.1177/09720634221076238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Health systems with strong comprehensive primary health care (CPHC) are known to result in better health outcomes for people. In India, there is a recent push to strengthen CPHC through Ayushman Bharat. This study aimed to document lessons from successful CPHC initiatives in rural and urban India using a qualitative case study approach. A total of 72 CPHC initiatives were identified through desk review and 12 of these were studied as cases. The following two main models of CPHC delivery were seen in India: (a) a hospital or health centre with outreach and (b) social franchising model, prevalent in rural and urban contexts, respectively. Themes identified were related to organisation of services, workforce, financing and challenges in practice. Services being comprehensive, dialoguing with the community, addressing social determinants were themes under organisation of services. There is need for more generalists and training health professionals towards CPHC. Financing of CPHC especially in the rural context remains a major challenge and cannot be sustained with user fees. Leadership, values, team-based care and organisational culture play a vital role in the delivery of good quality CPHC. These findings contribute to the literature on what works and why, which could be used to design CPHC in India.
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Affiliation(s)
- Dorothy Lall
- Department of Community Health, Christian Medical College Vellore, Chittoor, Andhra Pradesh, India
- Institute of Public Health, Bengaluru, Karnataka, India
| | | | - Priya Prabhu
- Institute of Public Health, Bengaluru, Karnataka, India
| | | | | | - N Devadasan
- Institute of Public Health, Bengaluru, Karnataka, India
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16
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Operationalising resilience: A methodological framework for assessing urban resilience through System Dynamics Model. Ecol Modell 2022. [DOI: 10.1016/j.ecolmodel.2021.109851] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kabir A, Karim MN, Islam RM, Romero L, Billah B. Health system readiness for non-communicable diseases at the primary care level: a systematic review. BMJ Open 2022; 12:e060387. [PMID: 35140165 PMCID: PMC8830230 DOI: 10.1136/bmjopen-2021-060387] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To synthesise evidence on the primary healthcare system's readiness for preventing and managing non-communicable diseases (NCDs). DESIGN Systematic review. DATA SOURCES Ovid MEDLINE, EMBASE, CINAHL, PsycINFO and Scopus were searched from 1 January 1984 to 30 July 2021, with hand-searching references and expert advice. ELIGIBILITY CRITERIA Any English-language health research with evidence of readiness/preparedness of the health system at the primary healthcare level in the context of four major NCDs: diabetes mellitus, cancer, chronic respiratory diseases (CRDs) and cardiovascular diseases (CVDs). DATA EXTRACTION AND SYNTHESIS Two authors independently extracted data and assessed the bias. The full-text selected articles were then assessed using the Mixed Methods Appraisal Tool. Health system readiness was descriptively and thematically synthesised in line with the health system dynamics framework. RESULTS Out of 7843 records, 23 papers were included in this review (15 quantitative, 3 qualitative and 5 mixed-method studies). The findings showed that existing literature predominantly examined health system readiness from the supply-side perspective as embedded in the WHO's health system framework. However, at the primary healthcare level, these components are insufficiently prepared for NCDs. Among NCDs, higher levels of readiness were reported for diabetes mellitus and hypertension in comparison to CRDs (asthma, chronic obstructive pulmonary disease), CVDs and cancer. There has been a dearth of research on the demand-side perspective, which is an essential component of a health system and must be addressed in the future research. CONCLUSION The supply-side components at the primary healthcare level are inadequately ready to address the growing NCD burden. Improving supply-side factors, with a particular focus on CRDs, CVDs and cancer, and improving understanding of the demand-side components of the health system's readiness, may help to prevent and manage NCDs at the primary healthcare level.
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Affiliation(s)
- Ashraful Kabir
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Md Nazmul Karim
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rakibul M Islam
- Women's Health Research Program, Monash University, Melbourne, Victoria, Australia
| | - Lorena Romero
- The Ian Potter Library, Ground Floor, AMREP Building, The Alfred, Melbourne, Victoria, Australia
| | - Baki Billah
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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18
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van Niekerk SM, Kamalakannan S, Inglis-Jassiem G, Charumbira MY, Fernandes S, Webster J, English R, Louw QA, Smythe T. Towards universal health coverage for people with stroke in South Africa: a scoping review. BMJ Open 2021; 11:e049988. [PMID: 34824111 PMCID: PMC8627414 DOI: 10.1136/bmjopen-2021-049988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore the opportunities and challenges within the health system to facilitate the achievement of universal health coverage (UHC) for people with stroke (PWS) in South Africa (SA). SETTING SA. DESIGN Scoping review. SEARCH METHODS We conducted a scoping review of opportunities and challenges to achieve UHC for PWS in SA. Global and Africa-specific databases and grey literature were searched in July 2020. We included studies of all designs that described the healthcare system for PWS. Two frameworks, the Health Systems Dynamics Framework and WHO Framework, were used to map data on governance and regulation, resources, service delivery, context, reorientation of care and community engagement. A narrative approach was used to synthesise results. RESULTS Fifty-nine articles were included in the review. Over half (n=31, 52.5%) were conducted in Western Cape province and most (n=41, 69.4%) were conducted in urban areas. Studies evaluated a diverse range of health system categories and various outcomes. The most common reported component was service delivery (n=46, 77.9%), and only four studies (6.7%) evaluated governance and regulation. Service delivery factors for stroke care were frequently reported as poor and compounded by context-related limiting factors. Governance and regulations for stroke care in terms of government support, investment in policy, treatment guidelines, resource distribution and commitment to evidence-based solutions were limited. Promising supporting factors included adequately equipped and staffed urban tertiary facilities, the emergence of Stroke units, prompt assessment by health professionals, positive staff attitudes and care, two clinical care guidelines and educational and information resources being available. CONCLUSION This review fills a gap in the literature by providing the range of opportunities and challenges to achieve health for all PWS in SA. It highlights some health system areas that show encouraging trends to improve service delivery including comprehensiveness, quality and perceptions of care.
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Affiliation(s)
- Sjan-Mari van Niekerk
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Sureshkumar Kamalakannan
- SACDIR Indian Institute of Public Health Hyderabad, Public Health Foundation of India, New Delhi, India
- International Center for Evidence in Disability, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Gakeemah Inglis-Jassiem
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Maria Yvonne Charumbira
- Rehabilitation Sciences, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Silke Fernandes
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Tropical Health and Medicine, London, UK
| | - Rene English
- Global Health, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Quinette A Louw
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Tracey Smythe
- Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Das V, Daniels B, Kwan A, Saria V, Das R, Pai M, Das J. Simulated patients and their reality: An inquiry into theory and method. Soc Sci Med 2021; 300:114571. [PMID: 34865913 PMCID: PMC9077327 DOI: 10.1016/j.socscimed.2021.114571] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 11/02/2021] [Accepted: 11/15/2021] [Indexed: 11/25/2022]
Abstract
Simulated standardized patients (SSP) have emerged as close to a ‘gold standard’ for measuring the quality of clinical care. This method resolves problems of patient mix across healthcare providers and allows care to be benchmarked against preexisting standards. Nevertheless, SSPs are not real patients. How, then, should data from SSPs be considered relative to clinical observations with ‘real’ patients in a given health system? Here, we reject the proposition that SSPs are direct substitutes for real patients and that the validity of SSP studies therefore relies on their ability to imitate real patients. Instead, we argue that the success of the SSP methodology lies in its counterfactual manipulations of the possibilities available to real careseekers – especially those paths not taken up by them – through which real responses can be elicited from real providers. Using results from a unique pilot study where SSPs returned to providers for follow-ups when asked, we demonstrate that the SSP method works well to elicit responses from the provider through conditional manipulations of SSP behavior. At the same time, observational methods are better suited to understand what choices real people make, and how these can affect the direction of diagnosis and treatment. A combination of SSP and observational methods can thus help parse out how quality of care emerges for the “patient” as a shared history between care-seeking individuals and care providers. We assess how simulated standardized patients (SSPs) compare to ‘real’ patients. SSPs elicit real responses from providers for different counterfactual patients. However, SSPs are not informative of observed variation in patient behavior. SSPs illustrate how providers behave with different types of patients. Observation studies can complement SSPs by studying patient responses.
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Affiliation(s)
- Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA.
| | | | - Ada Kwan
- Department of Medicine, University of California at San Francisco, San Francisco, USA
| | - Vaibhav Saria
- Department of Gender, Sexuality, and Women's Studies, Simon Fraser University, Burnaby, Canada
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Canada; Manipal McGill Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, India
| | - Jishnu Das
- Georgetown University, Washington DC, USA; Center for Policy Research, New Delhi, India
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20
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Bello K, De Lepeleire J, Kabinda M. J, Bosongo S, Dossou JP, Waweru E, Apers L, Zannou M, Criel B. The expanding movement of primary care physicians operating at the first line of healthcare delivery systems in sub-Saharan Africa: A scoping review. PLoS One 2021; 16:e0258955. [PMID: 34679111 PMCID: PMC8535187 DOI: 10.1371/journal.pone.0258955] [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: 08/14/2020] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In sub-Saharan Africa (SSA), the physicians' ratio is increasing. There are clear indications that many of them have opted to work at the first-line of healthcare delivery systems, i.e. providing primary care. This constitutes an important change in African healthcare systems where the first line has been under the responsibility of nurse-practitioners for decades. Previous reviews on primary care physicians (PCPs) in SSA focused on the specific case of family physicians in English-speaking countries. This scoping review provides a broader mapping of the PCPs' practices in SSA, beyond family physicians and including francophone Africa. For this study, we defined PCPs as medical doctors who work at the first-line of healthcare delivery and provide generalist healthcare. METHODS We searched five databases and identified additional sources through purposively selected websites, expert recommendations, and citation tracking. Two reviewers independently selected studies and extracted and coded the data. The findings were presented to a range of stakeholders. FINDINGS We included 81 papers, mostly related to the Republic of South Africa. Three categories of PCPs are proposed: family physicians, "médecins généralistes communautaires", and general practitioners. We analysed the functioning of each along four dimensions that emerged from the data analysis: professional identity, governance, roles and activities, and output/outcome. Our analysis highlighted several challenges about the PCPs' governance that could threaten their effective contribution to primary care. More research is needed to investigate better the precise nature and performance of the PCPs' activities. Evidence is particularly needed for PCPs classified in the category of GPs and, more generally, PCPs in African countries other than the Republic of South Africa. CONCLUSIONS This review sheds more light on the institutional, organisational and operational realities of PCPs in SSA. It also highlighted persisting gaps that remain in our understanding of the functioning and the potential of African PCPs.
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Affiliation(s)
- Kéfilath Bello
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jan De Lepeleire
- Department of Public Health and Primary Care, General Practice, KU Leuven—University of Leuven, Leuven, Belgium
| | - Jeff Kabinda M.
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Democratic Republic of Congo
| | - Samuel Bosongo
- Centre de Connaissances en Santé en République Démocratique du Congo, Kinshasa, Democratic Republic of Congo
| | - Jean-Paul Dossou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Evelyn Waweru
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Ludwig Apers
- Department Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marcel Zannou
- Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Faculty of Health Sciences, University of Abomey-Calavi, Abomey-Calavi, Benin
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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21
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Edwards JG, Barry M, Essam D, Elsayed M, Abdulkarim M, Elhossein BMA, Mohammed ZHA, Elnogomi A, Elfaki ASE, Elsayed A, Chang AY. Health system and patient-level factors serving as facilitators and barriers to rheumatic heart disease care in Sudan. Glob Health Res Policy 2021; 6:35. [PMID: 34598719 PMCID: PMC8486630 DOI: 10.1186/s41256-021-00222-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/15/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Rheumatic heart disease (RHD) remains a leading cause of morbidity and mortality in Sub-Saharan Africa despite widely available preventive therapies such as prophylactic benzathine penicillin G (BPG). In this study, we sought to characterize facilitators and barriers to optimal RHD treatment with BPG in Sudan. METHODS We conducted a mixed-methods study, collecting survey data from 397 patients who were enrolled in a national RHD registry between July and November 2017. The cross-sectional surveys included information on demographics, healthcare access, and patient perspectives on treatment barriers and facilitators. Factors associated with increased likelihood of RHD treatment adherence to prophylactic BPG were assessed by using adjusted logistic regression. These data were enhanced by focus group discussions with 20 participants, to further explore health system factors impacting RHD care. RESULTS Our quantitative analysis revealed that only 32% of the study cohort reported optimal prophylaxis adherence. Younger age, reduced primary RHD healthcare facility wait time, perception of adequate health facility staffing, increased treatment costs, and high patient knowledge about RHD were significantly associated with increased odds of treatment adherence. Qualitative data revealed significant barriers to RHD treatment arising from health services factors at the health system level, including lack of access due to inadequate healthcare staffing, lack of faith in local healthcare systems, poor ancillary services, and patient lack of understanding of disease. Facilitators of RHD treatment included strong interpersonal support. CONCLUSIONS Multiple patient and system-level barriers to RHD prophylaxis adherence were identified in Khartoum, Sudan. These included patient self-efficacy and participant perception of healthcare facility quality. Strengthening local health system infrastructure, while enhancing RHD patient education, may help to improve treatment adherence in this vulnerable population.
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Affiliation(s)
- Jeffrey G. Edwards
- Stanford University School of Medicine, Stanford, CA USA
- Present Address: Boston Medical Center, Department of Pediatrics, Boston University School of Medicine, Residency Program Coordinator, c/o Jeffrey Edwards, 801 Albany, St Boston, MA 02119-2598 USA
- Boston Children’s Hospital, Harvard Medical School, Boston, MA USA
| | - Michele Barry
- Department of Medicine, Stanford University, Stanford, CA USA
- Center for Innovation in Global Health, Stanford University, Stanford, CA USA
| | - Dary Essam
- Alazhari Health Research Center, Alzaeim Alazhari University, Khartoum, Sudan
| | - Mohammed Elsayed
- Alazhari Health Research Center, Alzaeim Alazhari University, Khartoum, Sudan
| | | | | | - Zahia H. A. Mohammed
- Faculty of Medicine, Alzaeim Alazhari University, Khartoum, Sudan
- Department of Psychiatry, Alzaeim Alazhari University Khartoum, Khartoum, Sudan
| | | | - Amna S. E. Elfaki
- Alazhari Health Research Center, Alzaeim Alazhari University, Khartoum, Sudan
| | - Ahmed Elsayed
- Alazhari Health Research Center, Alzaeim Alazhari University, Khartoum, Sudan
| | - Andrew Y. Chang
- Department of Medicine, Stanford University, Stanford, CA USA
- Center for Innovation in Global Health, Stanford University, Stanford, CA USA
- Cardiovascular Institute, Stanford University, Stanford, CA USA
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22
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Kabir A, Karim MN, Billah B. Primary healthcare system readiness to prevent and manage non-communicable diseases in Bangladesh: a mixed-method study protocol. BMJ Open 2021; 11:e051961. [PMID: 34493524 PMCID: PMC8424828 DOI: 10.1136/bmjopen-2021-051961] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION The burden of non-communicable diseases (NCDs) is rapidly increasing in Bangladesh. Currently, it contributes to 67% of annual deaths, and accounts for approximately 64% of the disease burden. Since 70% of the Bangladeshi population residing in the rural area rely on the primary healthcare system, assessment of its capacity is crucial for guiding public health decisions to prevent and manage NCDs. This protocol is designed to recognise and assess the Bangladeshi health system's readiness for NCDs at the primary level. METHODS AND ANALYSIS The study will use a mixed-method design. Numerical data will be collected using households and health facilities surveys, while qualitative data will be collected by interviewing healthcare providers, policy planners, health administrators and community members. The WHO's Service Availability and Readiness Assessment (SARA) methodology and Package of Essential Non-communicable (PEN) Disease Interventions for Primary Healthcare reference manuals will be used to assess the readiness of the primary healthcare facilities for NCD services. Furthermore, Health System Dynamics Framework will be used to examine health system factors. Using the supportive items outlined in the WHO PEN package, and indicators proposed in WHO SARA methodology, a composite score will be created to analyse facility-level data. Two independent samples t-test, analysis of variance and χ2 test methods will be used for bivariate analysis, and multiple regression analysis will be used for multivariable analysis. Complementarily, the thematic analysis approach will be used to analyse qualitative data. ETHICS AND DISSEMINATION The project has been approved by the Monash University Human Research Ethics Committee (Project ID: 27112), and Bangladesh Medical Research Council (Ref: BMRC/NREC/2019-2022/270). The research findings will be shared through research articles, conference proceedings or in other scientific media. The reports or publications will not have any information that can be used to identify any of the study participants.
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Affiliation(s)
- Ashraful Kabir
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Md Nazmul Karim
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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23
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Whyle EB, Olivier J. Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis. Int J Health Policy Manag 2021; 10:414-429. [PMID: 32861236 PMCID: PMC9056134 DOI: 10.34172/ijhpm.2020.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/15/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the 'social value of health systems.' METHODS We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between 'health systems' and 'social values.' We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory. RESULTS We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen's understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups. CONCLUSION We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.
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Affiliation(s)
- Eleanor Beth Whyle
- Health Policy and Systems Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Raman V, Seshadri T, Joice SV, N Srinivas P. Sickle cell disease in India: a scoping review from a health systems perspective to identify an agenda for research and action. BMJ Glob Health 2021; 6:bmjgh-2020-004322. [PMID: 33602689 PMCID: PMC7896595 DOI: 10.1136/bmjgh-2020-004322] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/07/2021] [Accepted: 01/26/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Sickle cell disease (SCD) disproportionately impacts Adivasi (tribal) communities in India. Current research has focused on epidemiological and biomedical aspects but there has been scarce research on social determinants and health systems aspects. Given its fragmented distribution, resources and programmes have emerged in west and central India. This scoping review seeks to identify geographical and evidence gaps for action on SCD from a health systems lens. METHODS We followed a scoping review protocol, using Google Scholar and PubMed for published literature. Keywords used included sickle cell anaemia/disease, health systems, tribal and India. We used Google search for grey literature. We compiled a list of 55 records (of which 35 were retained), with about half pertaining directly to India and others relevant to similar settings. Results were organised and analysed using the WHO health systems framework to identify geographical and evidence gaps. RESULTS We found substantial literature on biomedical and clinical aspects of SCD but little on the design and implementation of programmes in community and Adivasi-specific contexts as well as on social determinants of SCD. There were regional gaps in knowledge in southern and northeast India. Wherever community-based programmes exist, they have originated in civil society initiatives and relatively limited state-led primary healthcare-based efforts pointing to weak agenda setting. CONCLUSION Both research and action on SCD especially among tribal populations need immediate attention. While geospatial epidemiology has been well understood, gaps remain in context-specific knowledge for action in several parts, as well as evidence gaps across several health system building blocks, including governance and financing of care. Despite publication of a draft policy, delayed adoption and lapses in implementation have limited the response largely to local communities and non-governmental organisations.
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Affiliation(s)
- Vineet Raman
- Health equity cluster, Institute of Public Health, Bangalore, India
| | - Tanya Seshadri
- Health equity cluster, Institute of Public Health, Bangalore, India.,Tribal Health Resource Centre, Vivekananda Tribal Welfare Center, BR Hills, Karnataka, India
| | - Sangeetha V Joice
- Department of Biochemistry, Malabar Medical College and Research Centre, Modakkallur, India
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van Niekerk SM, Inglis-Jassiem G, Kamalakannan S, Fernandes S, Webster J, English R, Smythe T, Louw QA. Achieving universal health coverage for people with stroke in South Africa: protocol for a scoping review. BMJ Open 2020; 10:e041221. [PMID: 33046479 PMCID: PMC7552861 DOI: 10.1136/bmjopen-2020-041221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Stroke is the second most common cause of death after HIV/AIDS and a significant health burden in South Africa. The extent to which universal health coverage (UHC) is achieved for people with stroke in South Africa is unknown. Therefore, a scoping review to explore the opportunities and challenges within the South African health system to facilitate the achievement of UHC for people with stroke is warranted. METHODS AND ANALYSIS The scoping review will follow the approach recommended by Levac, Colquhoun and O'Brien, which includes five steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarising and reporting the results. Health Systems Dynamics Framework and WHO Framework on integrated people-centred health services will be used to map, synthesise and analyse data thematically. ETHICS AND DISSEMINATION Ethical approval is not required for this scoping review, as it will only include published and publicly available data. The findings of this review will be published in an open-access, peer-reviewed journal and we will develop an accessible summary of the results for website posting and stakeholder meetings.
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Affiliation(s)
- Sjan-Mari van Niekerk
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gakeemah Inglis-Jassiem
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sureshkumar Kamalakannan
- SACDIR, Public Health Foundation of India, Gurgaon, India
- International Center for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Silke Fernandes
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, Stellenbosch University, Cape Town, South Africa
| | - Rene English
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, London, UK
| | - Tracey Smythe
- International Center for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Q A Louw
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
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Babatunde GB, van Rensburg AJ, Bhana A, Petersen I. Stakeholders' perceptions of child and adolescent mental health services in a South African district: a qualitative study. Int J Ment Health Syst 2020; 14:73. [PMID: 33020703 PMCID: PMC7530880 DOI: 10.1186/s13033-020-00406-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background In order to develop a district child and adolescent mental health (CAMH) plan, it is vital to engage with a range of stakeholders involved in providing CAMH services, given the complexities associated with delivering such services. Hence this study sought to explore multisectoral dynamics in providing CAMH care in one resource-constrained South African district as a case study, towards informing the development of a model for district mental health plan and generating lessons for mental health systems strengthening to support CAMH services using the Health Systems Dynamics (HSD) framework. HSD provides a suitable structure for analysing interactions between different elements within the health system and other sectors. Methods Purposive sampling of 60 key informants was conducted to obtain an in-depth understanding of various stakeholders' experiences and perceptions of the available CAMH services in the district. The participants include stakeholders from the Departments of Health (DoH), Basic Education (DBE), community-based/non-governmental organizations and caregivers of children receiving CAMH care. The data was categorized according to the elements of the HSD framework. Results The HSD framework helped in identifying the components of the health systems that are necessary for CAMH service delivery. At a district level, the shortage of human resources, un-coordinated CAMH management system, lack of intersectoral collaboration and the low priority given to the CAMH system negatively impacts on the service providers' experiences of providing CAMH services. Services users' experiences of access to available CAMH services was negatively impacted by financial restrictions, low mental health literacy and stigmatization. Nevertheless, the study participants perceived the available CAMH specialists to be competent and dedicated to delivering quality services but will benefit from systems strengthening initiatives that can expand the workforce and equip non-specialists with the required skills, resources and adequate coordination. Conclusions The need to develop the capacity of all the involved stakeholders in relation to CAMH services was imperative in the district. The need to create a mental health outreach team and equip teachers and caregivers with skills required to promote mental wellbeing, promptly identify CAMH conditions, refer appropriately and adhere to a management regimen was emphasized.
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Affiliation(s)
- Gbotemi Bukola Babatunde
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - André Janse van Rensburg
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Inge Petersen
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
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Definitions, components and processes of data harmonisation in healthcare: a scoping review. BMC Med Inform Decis Mak 2020; 20:222. [PMID: 32928214 PMCID: PMC7488776 DOI: 10.1186/s12911-020-01218-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/12/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Data harmonisation (DH) has emerged amongst health managers, information technology specialists and researchers as an important intervention for routine health information systems (RHISs). It is important to understand what DH is, how it is defined and conceptualised, and how it can lead to better health management decision-making. This scoping review identifies a range of definitions for DH, its characteristics (in terms of key components and processes), and common explanations of the relationship between DH and health management decision-making. METHODS This scoping review identified relevant studies from 2000 onwards (date filter), written in English and published in PubMed, Web of Science and CINAHL. Two reviewers independently screened records for potential inclusion for the abstract and full-text screening stages. One reviewer did the data extraction, analysis and synthesis, with built-in reliability checks from the rest of the team. We developed a narrative synthesis of definitions and explanations of the relationship between DH and health management decision-making. RESULTS We sampled 61 of 181 included to synthesis definitions and concepts of DH in detail. We identified six common terms for data harmonisation: record linkage, data linkage, data warehousing, data sharing, data interoperability and health information exchange. We also identified nine key components of data harmonisation: DH involves (a) a process of multiple steps; (b) integrating, harmonising and bringing together different databases (c) two or more databases; (d) electronic data; (e) pooling data using unique patient identifiers; and (f) different types of data; (g) data found within and across different departments and institutions at facility, district, regional and national levels; (h) different types of technical activities; (i) has a specific scope. The relationship between DH and health management decision-making is not well-described in the literature. Several studies mentioned health providers' concerns about data completeness, data quality, terminology and coding of data elements as barriers to data utilisation for clinical decision-making. CONCLUSION To our knowledge, this scoping review was the first to synthesise definitions and concepts of DH and address the causal relationship between DH and health management decision-making. Future research is required to assess the effectiveness of data harmonisation on health management decision-making.
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Li Z, Hung P, He R, Zhang L. Association between direct government subsidies and service scope of primary care facilities: a cross-sectional study in China. Int J Equity Health 2020; 19:135. [PMID: 32778111 PMCID: PMC7418383 DOI: 10.1186/s12939-020-01248-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 07/29/2020] [Indexed: 12/01/2022] Open
Abstract
Background Comprehensive primary care practices, through preconception, preventive, curative, and rehabilitative care, have been a global priority in the promotion of health. However, the scope of primary care services has still been in decline in China. Studies on the factors for primary care service scope have centred on human resources and infrastructure; the role of direct government subsidies (DGS) on services scope of primary care facilities were left unanswered. This study aimed to explore the association between the DGS and services scope of primary care facilities in China. Methods A multi-stage, clustered cross-sectional survey using self-administrated questionnaire was conducted among primary care facilities of 36 districts/counties in China. A total of 770 primary care facilities were surveyed with 757 (98.3%) valid respondents. Of the 757 primary care facilities, 469 (62.0%) provided us detailed information of financial revenue and DGS from 2009 to 2016. Therefore, 469 primary care facilities from 31 counties/districts were included in this study. Sasabuchi-Lind-Mehlum tests and multivariate regression models were used to examine the inverted U-shaped relationship between the DGS and service scope. Results Of 469 PCFs, 332 (70.8%) were township health centres. Proportion of annul DGS to FR arose from 26.5% in 2009 to 50.5% in 2016. At the low proportion of DGS to financial revenue, an increase in DGS was associated with an increased service scope of primary care facilities, whereas the proportion of DGS to financial revenue over 42.5% might cause narrowed service scope (P = 0.023, 95% CI 11.59–51.74%); for the basic medical care dimension, the cut point is 42.6%. However, association between DGS and service scope of public health by primary care facilities is statistically insignificant. Conclusion While the DGS successfully achieved equalization of basic preventive and public health services, the disproportionate proportion of DGS to financial revenue is associated with narrowed service scope, which might cause underutilization of primary care and distorted incentive structure of primary care. Future improvements of DGS should focus on the incentive of broader basic medical services provision, such as clarifying service scope of primary care facilities and strategic procurement with a performance-based subsidies system to determine resource allocation.
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Affiliation(s)
- Zhong Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.,Research Center for Rural Health Services, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, Hubei, China.,Arnold School of Public Health, University of South Carolina, Columbia, 29205, SC, USA
| | - Peiyin Hung
- Arnold School of Public Health, University of South Carolina, Columbia, 29205, SC, USA
| | - Ruibo He
- School of Finance and Public Administration, Hubei University of Economics, Wuhan, 430205, Hubei, China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China. .,Research Center for Rural Health Services, Key Research Institute of Humanities & Social Sciences of Hubei Provincial Department of Education, Wuhan, 430030, Hubei, China.
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Whyle E, Olivier J. Social values and health systems in health policy and systems research: a mixed-method systematic review and evidence map. Health Policy Plan 2020; 35:735-751. [PMID: 32374881 PMCID: PMC7294246 DOI: 10.1093/heapol/czaa038] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2020] [Indexed: 12/17/2022] Open
Abstract
Because health systems are conceptualized as social systems, embedded in social contexts and shaped by human agency, values are a key factor in health system change. As such, health systems software-including values, norms, ideas and relationships-is considered a foundational focus of the field of health policy and systems research (HPSR). A substantive evidence-base exploring the influence of software factors on system functioning has developed but remains fragmented, with a lack of conceptual clarity and theoretical coherence. This is especially true for work on 'social values' within health systems-for which there is currently no substantive review available. This study reports on a systematic mixed-methods evidence mapping review on social values within HPSR. The study reaffirms the centrality of social values within HPSR and highlights significant evidence gaps. Research on social values in low- and middle-income country contexts is exceedingly rare (and mostly produced by authors in high-income countries), particularly within the limited body of empirical studies on the subject. In addition, few HPS researchers are drawing on available social science methodologies that would enable more in-depth empirical work on social values. This combination (over-representation of high-income country perspectives and little empirical work) suggests that the field of HPSR is at risk of developing theoretical foundations that are not supported by empirical evidence nor broadly generalizable. Strategies for future work on social values in HPSR are suggested, including: countering pervasive ideas about research hierarchies that prize positivist paradigms and systems hardware-focused studies as more rigorous and relevant to policy-makers; utilizing available social science theories and methodologies; conceptual development to build common framings of key concepts to guide future research, founded on quality empirical research from diverse contexts; and using empirical evidence to inform the development of operationalizable frameworks that will support rigorous future research on social values in health systems.
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Affiliation(s)
- Eleanor Whyle
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
| | - Jill Olivier
- Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
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Jacobs B, Sam Oeun S, Ir P, Rifkin S, Van Damme W. Can social accountability improve access to free public health care for the poor? Analysis of three Health Equity Fund configurations in Cambodia, 2015–17. Health Policy Plan 2020; 35:635-645. [DOI: 10.1093/heapol/czaa019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/31/2022] Open
Abstract
AbstractWithin the context of universal health coverage, community participation has been identified as instrumental to facilitate access to health services. Social accountability whereby citizens hold providers and policymakers accountable is one popular approach. This article describes one example, that of Community-Managed Health Equity Funds (CMHEFs), as an approach to community engagement in Cambodia to improve poor people’s use of their entitlement to fee-free health care at public health facilities. The objectives of this article are to describe the size of its operations and its ability to enable poor people continued access to health care. Using data collected routinely, we compare the uptake of curative health services by eligible poor people under three configurations of Health Equity Funds (HEFs) during a 24-month period (July 2015–June 2017): Standard HEF that operated without community engagement, Mature CMHEFs established years before the study period and New CMHEFs initiated just before the study period. One year within the study, non-governmental organizations (NGOs) stopped operating the HEF nationwide and only the community-participation aspects of New CMHEF continued receiving technical assistance from an NGO. Using utilization figures for curative services by non-poor people for comparison, following the cessation of HEF management by the NGOs, outpatient consultation figures declined for all three configurations in comparison with the year before but only significantly for Standard HEF. The three HEF configurations experienced a highly statistically significant reduction in monthly inpatient admissions following halting of NGO management of HEFs. This study shows that enhancing access to free health care through social accountability is optimized at health centres through engagement of a wide range of community representatives. Such effect at hospitals was only observed to a limited extent, suggesting the need for more engagement of hospital management authorities in social accountability mechanisms.
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Affiliation(s)
- Bart Jacobs
- Social Health Protection Project, Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Phnom Penh, Cambodia
- Social Health Protection Network P4H, Phnom Penh, Cambodia
| | - Sam Sam Oeun
- Buddhism for Health, National Road 1, Borey Peng Huoth, #64, St. P-10E Khan Chbar Ampov, Phnom Penh, Cambodia
| | - Por Ir
- Technical Bureau, National Institute of Public Health, lot no. 80, Samdach Penn Nouth Blvd (St. 289), Phnom Penh, Cambodia
| | - Susan Rifkin
- Distance Learning, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Wim Van Damme
- Public Health Department, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium
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Saulnier DD, Hean H, Thol D, Ir P, Hanson C, Von Schreeb J, Mölsted Alvesson H. Staying afloat: community perspectives on health system resilience in the management of pregnancy and childbirth care during floods in Cambodia. BMJ Glob Health 2020; 5:e002272. [PMID: 32332036 PMCID: PMC7204936 DOI: 10.1136/bmjgh-2019-002272] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/27/2020] [Accepted: 03/30/2020] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Resilient health systems have the capacity to continue providing health services to meet the community's diverse health needs following floods. This capacity is related to how the community manages its own health needs and the community and health system's joined capacities for resilience. Yet little is known about how community participation influences health systems resilience. The purpose of this study was to understand how community management of pregnancy and childbirth care during floods is contributing to the system's capacity to absorb, adapt or transform as viewed through a framework on health systems resilience. METHODS Eight focus group discussions and 17 semi-structured interviews were conducted with community members and leaders who experienced pregnancy or childbirth during recent flooding in rural Cambodia. The data were analysed by thematic analysis and discussed in relation to the resilience framework. RESULTS The theme 'Responsible for the status quo' reflected the community's responsibility to find ways to manage pregnancy and childbirth care, when neither the expectations of the health system nor the available benefits changed during floods. The theme was informed by notions on: i) developmental changes, the unpredictable nature of floods and limited support for managing care, ii) how information promoted by the public health system led to a limited decision-making space for pregnancy and childbirth care, iii) a desire for security during floods that outweighed mistrust in the public health system and iv) the limits to the coping strategies that the community prepared in case of flooding. CONCLUSIONS The community mainly employed absorptive strategies to manage their care during floods, relieving the burden on the health system, yet restricted support and decision-making may risk their capacity. Further involvement in decision-making for care could help improve the health system's resilience by creating room for the community to adapt and transform when experiencing floods.
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Affiliation(s)
- Dell D Saulnier
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Hom Hean
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
| | - Dawin Thol
- School of Public Health, National Institute of Public Health, Phnom Penh, Cambodia
- Department of Preventive Medicine, Phnom Penh, Cambodia
| | - Por Ir
- Technical Bureau, National Institute of Public Health, Phnom Penh, Cambodia
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Johan Von Schreeb
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Accoe K, Marchal B, Gnokane Y, Abdellahi D, Bossyns P, Criel B. Action research and health system strengthening: the case of the health sector support programme in Mauritania, West Africa. Health Res Policy Syst 2020; 18:25. [PMID: 32075648 PMCID: PMC7031916 DOI: 10.1186/s12961-020-0531-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 02/04/2020] [Indexed: 05/05/2023] Open
Abstract
Background Access to qualitative and equitable healthcare is a major challenge in Mauritania. In order to support the country’s efforts, a health sector strengthening programme was set up with participatory action research at its core. Reinforcing a health system requires a customised and comprehensive approach to face the complexity inherent to health systems. Yet, limited knowledge is available on how policies could enhance the performance of the system and how multi-stakeholder efforts could give rise to changes in health policy. We aimed to analyse the ongoing participatory action research and, more specifically, see in how far action research as an embedded research approach could contribute to strengthening health systems. Methods We adopted a single-case study design, based on two subunits of analysis, i.e., two selected districts. Qualitative data were collected by analysing country and programme documents, conducting 12 semi-structured interviews and performing participatory observations. Interviewees were selected based on their current position and participation in the programme. The data analysis was designed to address the objectives of the study, but evolved according to emerging insights and through triangulation and identification of emergent and/or recurrent themes along the process. Results An evaluation of the progress made in the two districts indicates that continuous capacity-building and empowerment efforts through a participative approach have been key elements to enhance dialogue between, and ownership of, the actors at the local health system level. However, the strong hierarchical structure of the Mauritanian health system and its low level of decentralisation constituted substantial barriers to innovation. Other constraints were sociocultural and organisational in nature. Poor work ethics due to a weak environmental support system played an important role. While aiming for an alignment between the flexible iterative approach of action research and the prevailing national linear planning process is quite challenging, effects on policy formulation and implementation were not observed. An adequate time frame, the engagement of proactive leaders, maintenance of a sustained dialogue and a pragmatic, flexible approach could further facilitate the process of change. Conclusion Our study showcases that the action research approach used in Mauritania can usher local and national actors towards change within the health system strengthening programme when certain conditions are met. An inclusive, participatory approach generates dynamics of engagement that can facilitate ownership and strengthen capacity. Continuous evaluation is needed to measure how these processes can further develop and presume a possible effect at policy level.
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Affiliation(s)
- Kirsten Accoe
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium
| | - Yahya Gnokane
- AI-PASS Programme (Institutional Support for Health Sector Strengthening), Enabel - Belgian Development Agency, Nouakchott, Mauritania
| | - Dieng Abdellahi
- AI-PASS Programme (Institutional Support for Health Sector Strengthening), Enabel - Belgian Development Agency, Nouakchott, Mauritania
| | - Paul Bossyns
- Department of Health, Enabel - Belgian Development Agency, Rue Haute 147, 1000, Brussels, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium
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Mugassa AM, Frumence G. Factors influencing the uptake of cervical cancer screening services in Tanzania: A health system perspective from national and district levels. Nurs Open 2020; 7:345-354. [PMID: 31871719 PMCID: PMC6917965 DOI: 10.1002/nop2.395] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/23/2019] [Accepted: 09/17/2019] [Indexed: 11/05/2022] Open
Abstract
Aim This study aimed at examining factors influencing uptake of cervical cancer screening services among women in Tanzania. Design Exploratory qualitative study. Methods In-depth interviews were used to obtain information from 10 key Informants. Of these, three were officials (policy makers) from the Reproductive Health-Cancer Unit of Ministry of Health and Community Development, Gender, Elderly and Children (MoHCDGEC), three were health managers working at Kinondoni Municipal health system reproductive and child health section and four were health workers from the Ocean Road Cancer Institute (ORCI). The study participants were purposively selected since they hold the responsibility of planning, coordinating and implementing the Tanzania cervical cancer prevention strategies at different levels of health system. The qualitative data analysis was done manually using thematic analysis. Results The national health system factors influencing the early uptake of cervical cancer screening services include poor flow of information from national to lower level and inadequate availability of tools and instruments and shortage of skilled and competent staff. The district level health systems factors influencing uptake of cervical cancer screening services include inadequate number of partners, poor flow of information, poor collaboration with the private sector, no adequate provision of cervical cancer screening services due to lack of prioritization, poor creation of awareness and failure to use the health information system effectively.
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Affiliation(s)
- Anitha M. Mugassa
- Department of Development StudiesSchool of Public Health and Social SciencesMuhimbili University of Health and Allied SciencesDar‐es SalaamTanzania
| | - Gasto Frumence
- Department of Development StudiesSchool of Public Health and Social SciencesMuhimbili University of Health and Allied SciencesDar‐es SalaamTanzania
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Fridell M, Edwin S, von Schreeb J, Saulnier DD. Health System Resilience: What Are We Talking About? A Scoping Review Mapping Characteristics and Keywords. Int J Health Policy Manag 2020; 9:6-16. [PMID: 31902190 PMCID: PMC6943300 DOI: 10.15171/ijhpm.2019.71] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 09/02/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Health systems are based on 6 functions that need to work together at all times to effectively deliver safe and quality health services. These functions are vulnerable to shocks and changes; if a health system is unable to withstand the pressure from a shock, it may cease to function or collapse. The concept of resilience has been introduced with the goal of strengthening health systems to avoid disruption or collapse. The concept is new within health systems research, and no common description exists to describe its meaning. The aim of this study is to summarize and characterize the existing descriptions of health system resilience to improve understanding of the concept. Methods and Analysis: A scoping review was undertaken to identify the descriptions and characteristics of health system resilience. Four databases and gray literature were searched using the keywords "health system" and "resilience" for published documents that included descriptions, frameworks or characteristics of health system resilience. Additional documents were identified from reference lists. Four expert consultations were conducted to gain a broader perspective. Descriptions were analysed by studying the frequency of key terms and were characterized by using the World Health Organization (WHO) health system framework. The scoping review identified eleven sources with descriptions and 24 sources that presented characteristics of health system resilience. Frequently used terms that were identified in the literature were shock, adapt, maintain, absorb and respond. Change and learning were also identified when combining the findings from the descriptions, characteristics and expert consultations. Leadership and governance were recognized as the most important building block for creating health system resilience. DISCUSSION No single description of health system resilience was used consistently. A variation was observed on how resilience is described and to what depth it was explained in the existing literature. The descriptions of health system resilience primarily focus on major shocks. Adjustments to long-term changes and the element of learning should be considered for a better understating of health system resilience.
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Affiliation(s)
- My Fridell
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Safreed-Harmon K, Anderson J, Azzopardi-Muscat N, Behrens GMN, d'Arminio Monforte A, Davidovich U, Del Amo J, Kall M, Noori T, Porter K, Lazarus JV. Reorienting health systems to care for people with HIV beyond viral suppression. Lancet HIV 2019; 6:e869-e877. [PMID: 31776099 DOI: 10.1016/s2352-3018(19)30334-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 07/18/2019] [Accepted: 08/20/2019] [Indexed: 02/08/2023]
Abstract
The effectiveness of antiretroviral therapy and its increasing availability globally means that millions of people living with HIV now have a much longer life expectancy. However, people living with HIV have disproportionately high incidence of major comorbidities and reduced health-related quality of life. Health systems must respond to this situation by pioneering care and service delivery models that promote wellness rather than mere survival. In this Series paper, we review evidence about the emerging challenges of the care of people with HIV beyond viral suppression and identify four priority areas for action: integrating HIV services and non-HIV services, reducing HIV-related discrimination in health-care settings, identifying indicators to monitor health systems' progress toward new goals, and catalysing new forms of civil society engagement in the more broadly focused HIV response that is now needed worldwide. Furthermore, in the context of an increasing burden of chronic diseases, we must consider the shift that is underway in the HIV field in relation to burgeoning policy and programmatic efforts to promote healthy ageing.
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Affiliation(s)
- Kelly Safreed-Harmon
- Barcelona Institute for Global Health, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Jane Anderson
- Centre for the Study of Sexual Health and HIV, Homerton University Hospital National Health Service Foundation Trust, London, UK
| | - Natasha Azzopardi-Muscat
- Department of Health Services Management, WHO Collaborating Centre on Health Systems and Policies in Small States, Faculty of Health Sciences, University of Malta, Msida, Malta
| | - Georg M N Behrens
- Department for Clinical Immunology and Rheumatology, Hannover Medical School, Hannover, Germany; German Centre for Infection Research, Hannover, Germany, Partner-site Hannover-Braunschweig, Germany
| | - Antonella d'Arminio Monforte
- Clinic of Infectious and Tropical Diseases, Department of Health Sciences, L'Azienda Socio-Sanitaria Territoriale Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Udi Davidovich
- Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, Amsterdam, Netherlands; Department of Infectious Diseases, Amsterdam Infection and Immunity Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Julia Del Amo
- National Center for Epidemiology, Institute of Health Carlos III, Madrid, Spain; National Plan against HIV/AIDS/STIs, Ministry of Health, Consumer Affairs and Welfare, Madrid, Spain
| | - Meaghan Kall
- HIV/STI Department, Public Health England, London, UK
| | - Teymur Noori
- Surveillance and Response Unit, European Centre for Disease Prevention and Control, Solna, Sweden
| | - Kholoud Porter
- Surveillance and Response Unit University College London, London, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health, Hospital Clínic, University of Barcelona, Barcelona, Spain.
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Goga AE, Dinh TH, Essajee S, Chirinda W, Larsen A, Mogashoa M, Jackson D, Cheyip M, Ngandu N, Modi S, Bhardwaj S, Chirwa E, Pillay Y, Mahy M. What will it take for the Global Plan priority countries in Sub-Saharan Africa to eliminate mother-to-child transmission of HIV? BMC Infect Dis 2019; 19:783. [PMID: 31526371 PMCID: PMC6745780 DOI: 10.1186/s12879-019-4393-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The 2016 'Start Free, Stay Free, AIDS Free' global agenda, builds on the 2011-2015 'Global Plan'. It prioritises 22 countries where 90% of the world's HIV-positive pregnant women live and aims to eliminate vertical transmission of HIV (EMTCT) and to keep mothers alive. By 2019, no Global Plan priority country had achieved EMTCT; however, 11 non-priority countries had. This paper synthesises the characteristics of the first four countries validated for EMTCT, and of the 21 Global Plan priority countries located in Sub-Saharan Africa (SSA). We consider what drives vertical transmission of HIV (MTCT) in the 21 SSA Global Plan priority countries. METHODS A literature review, using PubMed, Science direct and the google search engine was conducted to obtain global and national-level information on current HIV-related context and health system characteristics of the first four EMTCT-validated countries and the 21 SSA Global Plan priority countries. Data representing only one clinic, hospital or region were excluded. Additionally, key global experts working on EMTCT were contacted to obtain clarification on published data. We applied three theories (the World Health Organisation's building blocks to strengthen health systems, van Olmen's Health System Dynamics framework and Baral's socio-ecological model for HIV risk) to understand and explain the differences between EMTCT-validated and non-validated countries. Additionally, structural equation modelling (SEM) and linear regression were used to explain associations between infant HIV exposure, access to antiretroviral therapy and two outcomes: (i) percent MTCT and (iii) number of new paediatric HIV infections per 100 000 live births (paediatric HIV case rate). RESULTS EMTCT-validated countries have lower HIV prevalence, less breastfeeding, fewer challenges around leadership, governance within the health sector or country, infrastructure and service delivery compared with Global Plan priority countries. Although by 2016 EMTCT-validated countries and Global Plan priority countries had adopted a public health approach to HIV prevention, recommending lifelong antiretroviral therapy (ART) for all HIV-positive pregnant and lactating women, EMCT-validated countries had also included contact tracing such as assisted partner notification, and had integrated maternal and child health (MCH) and sexual and reproductive health (SRH) services, with services for HIV infection, sexually transmitted infections, and viral hepatitis. Additionally, Global Plan priority countries have limited data on key SRH indicators such as unmet need for family planning, with variable coverage of antenatal care, HIV testing and triple antiretroviral therapy (ART) and very limited contact tracing. Structural equation modelling (SEM) and linear regression analysis demonstrated that ART access protects against percent MTCT (p<0.001); in simple linear regression it is 53% protective against percent MTCT. In contrast, SEM demonstrated that the case rate was driven by the number of HIV exposed infants (HEI) i.e. maternal HIV prevalence (p<0.001). In linear regression models, ART access alone explains only 17% of the case rate while HEI alone explains 81% of the case rate. In multiple regression, HEI and ART access accounts for 83% of the case rate, with HEI making the most contribution (coef. infant HIV exposure=82.8, 95% CI: 64.6, 101.1, p<0.001 vs coef. ART access=-3.0, 95% CI: -6.2, 0.3, p=0.074). CONCLUSION Reducing infant HIV exposure, is critical to reducing the paediatric HIV case rate; increasing ART access is critical to reduce percent MTCT. Additionally, our study of four validated countries underscores the importance of contact tracing, strengthening programme monitoring, leadership and governance, as these are potentially-modifiable factors.
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Affiliation(s)
- Ameena E. Goga
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
- HIV Prevention Research Unit, South African Medical Researh Council, Pretoria, South Africa
- Department of Paediatrics, University of Pretoria, Pretoria, 0001 South Africa
| | - Thu-Ha Dinh
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA 30329 USA
| | - Shaffiq Essajee
- Department of HIV/AIDS, World Health Organisation, 27, CH-1211 Geneva, Switzerland
| | - Witness Chirinda
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
| | - Anna Larsen
- Centers for Disease Control and Prevention, Pretoria, 0001 South Africa
| | - Mary Mogashoa
- Centers for Disease Control and Prevention, Pretoria, 0001 South Africa
| | - Debra Jackson
- Health section, United Nations Children’s Fund (UNICEF), New York, 10017 USA
- School of Public Health, University of the Western Cape, Cape Town, 7535 South Africa
| | - Mireille Cheyip
- Centers for Disease Control and Prevention, Pretoria, 0001 South Africa
| | - Nobubelo Ngandu
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
| | - Surbhi Modi
- Division of Global HIV and Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA 30329 USA
| | - Sanjana Bhardwaj
- Health section, UNICEF South Africa, Pretoria, 0001 South Africa
| | - Esnat Chirwa
- Gender and Health Research Unit, South African Medical Research Council, Pretoria, 0001 South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, 2193 South Africa
| | - Yogan Pillay
- Chief Director HIV/AIDS, TB, MCWHN, National Department of Health, Pretoria, 0001 South Africa
| | - Mary Mahy
- Strategic Information and Evaluation Department, UNAIDS, 1211 Geneva, Switzerland
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Kuhn L, Goga AE. Moving towards elimination: findings from the South Africa prevention of mother to child transmission evaluation (SAPMTCTE). BMC Infect Dis 2019; 19:782. [PMID: 31526365 PMCID: PMC6745774 DOI: 10.1186/s12879-019-4334-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Louise Kuhn
- Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University Medical Center, 630 W 168th Street, New York, NY, 10032, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, 630 W 168th Street, New York, NY, 10032, USA.
| | - Ameena E Goga
- Health Systems Research Unit, South African Medical Research Council, Pretoria, 0001, South Africa.,Department of Paediatrics, University of Pretoria, Pretoria, 0001, South Africa
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Moresky RT, Razzak J, Reynolds T, Wallis LA, Wachira BW, Nyirenda M, Carlo WA, Lin J, Patel S, Bhoi S, Risko N, Wendle LA, Calvello Hynes EJ. Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems. BMJ Glob Health 2019; 4:e001265. [PMID: 31406599 PMCID: PMC6666806 DOI: 10.1136/bmjgh-2018-001265] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 02/07/2023] Open
Abstract
Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.
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Affiliation(s)
- Rachel T Moresky
- sidHARTe-Strengthening Emergency Systems Program, Columbia University Heilbrunn Department of Population and Family Health, New York, New York, USA.,Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Junaid Razzak
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Teri Reynolds
- Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention, World Health Organization, Geneva, Switzerland
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mulinda Nyirenda
- Adult Emergency and Trauma Centre, Queen Elizabeth Central Hospital, Ministry of Health, Blantyre, Malawi.,Emergency Medicine Section, Internal Medicine Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Waldemar A Carlo
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Janet Lin
- Department of Emergency Medicine and Center for Global Health, University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
| | - Shama Patel
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nicholas Risko
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lily A Wendle
- sidHARTe-Strengthening Emergency Systems Program, Columbia University Heilbrunn Department of Population and Family Health, New York, New York, USA
| | - Emilie J Calvello Hynes
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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van Olmen J, Marchal B, Ricarte B, Van Damme W, Van Belle S. The Need for a Dynamic Approach to Health System-Centered Innovations Comment on "What Health System Challenges Should Responsible Innovation in Health Address? Insights From an International Scoping Review". Int J Health Policy Manag 2019; 8:444-446. [PMID: 31441280 PMCID: PMC6706970 DOI: 10.15171/ijhpm.2019.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 04/27/2019] [Indexed: 11/09/2022] Open
Abstract
Lehoux and colleagues plea for a health systems perspective to evaluate innovations. Since many innovations and their scale-up strategies emerge from processes that are not (centrally) steered, we plea for any assessment with a dynamic, instead of a sequential, approach. We provide further guidance on how to adopt such dynamic approach, in order to better un-derstand and steer innovations for better health systems. A systems-level challenge is constituted by interactions and feedback loops between different actors and components of the health system. It is therefore essential to explore both the entry-point of innovation and the interactions with other components. If innovation is regarded as an injection of resources and opportunities into a health system, this system needs to have the capacity to transform these into desired outputs, the 'absorption capacity.' The highly organic diffusion of innovation in complex adapative systems cannot be easily controlled, but the system behaviours can be analysed, with occurance of phenomena such as path dependence, feedback loops, scale-free networks, emergent behaviour and phase transitions. This helps to anticipate unintended consequences, and to engage key actors in ongoing problem-solving and adaptation. By adopting a prospective approach, responsible innovation could set in motion prospective policy evaluations, which on the basis of iterative learning would allow decisionmakers to continuously adapt their policies and programmes. Priority-setting for innovation is an essentially political process that is geared towards consensus-building and grounded in values.
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Affiliation(s)
- Josefien van Olmen
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.,Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Bruno Marchal
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Button Ricarte
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Sara Van Belle
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Tang D, Li M, Ung COL, Tang C, Hu H. Exploratory study on development challenges of maternal and child healthcare institutions in China: a qualitative study combining interviews and focus groups. BMJ Open 2019; 9:e028789. [PMID: 31227539 PMCID: PMC6596970 DOI: 10.1136/bmjopen-2018-028789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To manage the development of the maternal and child healthcare institution (MCHI) in China, it is important to understand the key challenges and the influencing factors for sustainable development of MCHIs. However, these areas have not been fully investigated previously. This qualitative study aims to systematically explore the perceived development challenges for MCHIs from the perspectives of MCHI staff and government officials. DESIGN Qualitative approaches, including focus group, semistructured interview and documentary analysis, were employed to identify development challenges encountered by the MCHIs in Chengdu city, China. PARTICIPANTS Totally 16 medical staff of MCHIs and officials from local government. MEASURES Participants' opinions about the development challenges for MCHI. RESULTS The study revealed the main development challenges for MCHIs included: (1) incapability to provide differentiated medical service (including differentiated maternal and child health maintenance, integrative model of health maintenance and disease treatment, lack of innovation capability); (2) insufficient financial support; (3) shortage of gynaecologists and paediatricians; (4) insufficient facilities and medical equipment; (5) weakness in adopting information technology and (6) constraints of law and regulations. CONCLUSIONS The study recommends that MCHI should take governance reform to promote healthcare innovation to ensure the sustainable development of MCHI. Public-private partnership needs to be considered for the sustainable development of MCHIs.
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Affiliation(s)
- Daisheng Tang
- School of Economics and Management, Beijing Jiaotong University, Beijing, China
| | - Meng Li
- Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
| | | | - Chengxiang Tang
- School of Public Administration, Guangzhou University, Guangzhou, Guangdong, China
| | - Hao Hu
- Institute of Chinese Medical Sciences, University of Macau, Taipa, Macao
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Zakumumpa H, Dube N, Damian RS, Rutebemberwa E. Understanding the dynamic interactions driving the sustainability of ART scale-up implementation in Uganda. Glob Health Res Policy 2018; 3:23. [PMID: 30123838 PMCID: PMC6091155 DOI: 10.1186/s41256-018-0079-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/16/2018] [Indexed: 01/01/2023] Open
Abstract
Background Despite increasing recognition that health-systems constraints are the fundamental barrier to attaining anti-retroviral therapy (ART) scale-up targets in Sub-Saharan Africa, current discourses are dominated by a focus on financial sustainability. Utilizing the health system dynamics framework, this study aimed to explore the interactions in health system components and their influence on the sustainability of ART scale-up implementation in Uganda. Methods This study entailed qualitative organizational case-studies within a two-phased mixed-methods sequential explanatory research design. In Phase One, a survey of 195 health facilities across Uganda which commenced ART services between 2004 and 2009 was conducted. In Phase Two, six health facilities were purposively selected for in-depth examination involving i) In-depth interviews (n = 44) ii) and semi-structured interviews (n = 35). Qualitative data was analyzed by coding and thematic analysis. Descriptive statistics were managed in STATA (v 13). Results Five dynamic interactions in ART program sustainability drivers were identified; i) Failure to update basic ART program records contributed to chronic ART medicines stock-outs ii) Health workforce shortages and escalating patient volumes prompted adaptations in ART service delivery models iii) Broader governance issues manifested in poor road networks undermined ART medicines supply chains iv) Sustained financing for ART programs was influenced by external donors v) The values associated with the ownership-type of a health facility affected ART service delivery and coverage. Conclusion The sustainability of ART programs at the facility-level in Uganda is a function of a complex interaction in elements of the health system and must be understood beyond sustaining international funding for ART scale-up.
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Affiliation(s)
- Henry Zakumumpa
- 1School of Public Health, Makerere University, Kampala, Uganda
| | - Nkosiyazi Dube
- 2School of Health and Community Development, University of the Witwatersrand, Johannesburg, South Africa
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Rusoja E, Haynie D, Sievers J, Mustafee N, Nelson F, Reynolds M, Sarriot E, Swanson RC, Williams B. Thinking about complexity in health: A systematic review of the key systems thinking and complexity ideas in health. J Eval Clin Pract 2018; 24:600-606. [PMID: 29380477 DOI: 10.1111/jep.12856] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 09/21/2017] [Accepted: 10/23/2017] [Indexed: 01/18/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES As the Sustainable Development Goals are rolled out worldwide, development leaders will be looking to the experiences of the past to improve implementation in the future. Systems thinking and complexity science (ST/CS) propose that health and the health system are composed of dynamic actors constantly evolving in response to each other and their context. While offering practical guidance for steering the next development agenda, there is no consensus as to how these important ideas are discussed in relation to health. This systematic review sought to identify and describe some of the key terms, concepts, and methods in recent ST/CS literature. METHOD Using the search terms "systems thinkin * AND health OR complexity theor* AND health OR complex adaptive system* AND health," we identified 516 relevant full texts out of 3982 titles across the search period (2002-2015). RESULTS The peak number of articles were published in 2014 (83) with journals specifically focused on medicine/healthcare (265) and particularly the Journal of Evaluation in Clinical Practice (37) representing the largest number by volume. Dynamic/dynamical systems (n = 332), emergence (n = 294), complex adaptive system(s) (n = 270), and interdependent/interconnected (n = 263) were the most common terms with systems dynamic modelling (58) and agent-based modelling (43) as the most common methods. CONCLUSIONS The review offered several important conclusions. First, while there was no core ST/CS "canon," certain terms appeared frequently across the reviewed texts. Second, even as these ideas are gaining traction in academic and practitioner communities, most are concentrated in a few journals. Finally, articles on ST/CS remain largely theoretical illustrating the need for further study and practical application. Given the challenge posed by the next phase of development, gaining a better understanding of ST/CS ideas and their use may lead to improvements in the implementation and practice of the Sustainable Development Goals.
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Affiliation(s)
- Evan Rusoja
- Department of Emergency Medicine, Highland Hospital, Oakland, CA, USA
| | - Deson Haynie
- Department of Health Sciences, Brigham Young University, Provo, UT, USA
| | - Jessica Sievers
- Department of Health Sciences, Brigham Young University, Provo, UT, USA
| | | | - Fred Nelson
- F Edward Hébert SOM, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Martin Reynolds
- School of Engineering and Innovation, The Open University, Milton Keynes, UK
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Braithwaite T, Winford B, Bailey H, Bridgemohan P, Bartholomew D, Singh D, Sharma S, Sharma R, Silva JC, Gray A, Ramsewak SS, Bourne RRA. Health system dynamics analysis of eyecare services in Trinidad and Tobago and progress towards Vision 2020 Goals. Health Policy Plan 2018; 33:70-84. [PMID: 29092057 DOI: 10.1093/heapol/czx143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 12/24/2022] Open
Abstract
Avoidable blindness is an important global public health concern. This study aimed to assess Trinidad and Tobago's progress towards achieving the Pan American Health Organization, 'Strategic Framework for Vision 2020: The Right to Sight-Caribbean Region,' indicators through comprehensive review of the eyecare system, in order to facilitate health system priority setting. We administered structured surveys to six stakeholder groups, including eyecare providers, patients and older adult participants in the National Eye Survey of Trinidad and Tobago. We reviewed reports, registers and policy documents, and used a health system dynamics framework to synthesize data. In 2014, the population of 1.3 million were served by a pluralistic eyecare system, which had achieved 14 out of 27 Strategic Framework indicators. The Government provided free primary, secondary and emergency eyecare services, through 108 health centres and 5 hospitals (0.26 ophthalmologists and 1.32 ophthalmologists-in-training per 50 000 population). Private sector optometrists (4.37 per 50 000 population), and ophthalmologists (0.93 per 50 000 population) provided 80% of all eyecare. Only 19.3% of the adult population had private health insurance, revealing significant out-of-pocket expenditure. We identified potential weaknesses in the eyecare system where investment might reduce avoidable blindness. These included a need for more ophthalmic equipment and maintenance in the public sector, national screening programmes for diabetic retinopathy, retinopathy of prematurity and neonatal eye defects, and pathways to ensure timely and equitable access to subspecialized surgery. Eyecare for older adults was responsible for an estimated 9.5% (US$22.6 million) of annual health expenditure. This study used the health system dynamics framework and new data to identify priorities for eyecare system strengthening. We recommend this approach for exploring potential health system barriers to addressing avoidable blindness, and other important public health problems.
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Affiliation(s)
- Tasanee Braithwaite
- Vision and Eye Research Unit, Anglia Ruskin University, East Road, Cambridge CB1?1PT, UK
| | - Blaine Winford
- Department of Ophthalmology, Eric Williams Medical Centre, Mt Hope Hospital, St Augustine, Trinidad
| | - Henry Bailey
- Arthur Lok Jack Graduate School of Business, and HEU, Centre for Health Economics, The University of the West Indies, St Augustine, Trinidad
| | | | | | - Deo Singh
- Caribbean Eye Institute, Valsayn, Trinidad
| | - Subash Sharma
- Faculty of Medical Science, University of the West Indies, St Augustine, Trinidad
| | - Rishi Sharma
- Scarborough General Hospital, Scarborough, Tobago
| | | | - Alastair Gray
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Samuel S Ramsewak
- Faculty of Medical Science, University of the West Indies, St Augustine, Trinidad
| | - Rupert R A Bourne
- Vision and Eye Research Unit, Anglia Ruskin University, East Road, Cambridge CB1?1PT, UK
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Rwabukwisi FC, Bawah AA, Gimbel S, Phillips JF, Mutale W, Drobac P. Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries. BMC Health Serv Res 2017; 17:826. [PMID: 29297333 PMCID: PMC5763488 DOI: 10.1186/s12913-017-2662-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Achieving the United Nations Sustainable Development Goals in sub-Saharan Africa will require substantial improvements in the coverage and performance of primary health care delivery systems. Projects supported by the Doris Duke Charitable Foundation's (DDCF) African Health Initiative (AHI) created public-private-academic and community partnerships in five African countries to implement and evaluate district-level health system strengthening interventions. In this study, we captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions. METHODS We used qualitative data from key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through AHI in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. RESULTS Four major overarching lessons were highlighted. First, variety and inclusiveness of concerned key players (public, academic and private) are necessary to address complex health system issues at all levels. Second, a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Third, inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Fourth, five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects. CONCLUSION The AHI experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.
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Affiliation(s)
| | - Ayaga A. Bawah
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York City, NY USA
| | - Sarah Gimbel
- Department of Global Health, University of Washington, Seattle, WA USA
| | - James F. Phillips
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, New York City, NY USA
| | | | - Peter Drobac
- University of Global Health Equity, Kigali, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
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Roncarolo F, Boivin A, Denis JL, Hébert R, Lehoux P. What do we know about the needs and challenges of health systems? A scoping review of the international literature. BMC Health Serv Res 2017; 17:636. [PMID: 28886736 PMCID: PMC5591541 DOI: 10.1186/s12913-017-2585-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/30/2017] [Indexed: 11/12/2022] Open
Abstract
Background While there is an extensive literature on Health System (HS) strengthening and on the performance of specific HSs, there are few exhaustive syntheses of the challenges HSs are facing worldwide. This paper reports the findings of a scoping review aiming to classify the challenges of HSs investigated in the scientific literature. Specifically, it determines the kind of research conducted on HS challenges, where it was performed, in which health sectors and on which populations. It also identifies the types of challenge described the most and how they varied across countries. Methods We searched 8 databases to identify scientific papers published in English, French and Italian between January 2000 and April 2016 that addressed HS needs and challenges. The challenges reported in the articles were classified using van Olmen et al.’s dynamic HS framework. Countries were classified using the Human Development Index (HDI). Our analyses relied on descriptive statistics and qualitative content analysis. Results 292 articles were included in our scoping review. 33.6% of these articles were empirical studies and 60.1% were specific to countries falling within the very high HDI category, in particular the United States. The most frequently researched sectors were mental health (41%), infectious diseases (12%) and primary care (11%). The most frequently studied target populations included elderly people (23%), people living in remote or poor areas (21%), visible or ethnic minorities (15%), and children and adolescents (15%). The most frequently reported challenges related to human resources (22%), leadership and governance (21%) and health service delivery (24%). While health service delivery challenges were more often examined in countries within the very high HDI category, human resources challenges attracted more attention within the low HDI category. Conclusions This scoping review provides a quantitative description of the available evidence on HS challenges and a qualitative exploration of the dynamic relationships that HS components entertain. While health services research is increasingly concerned about the way HSs can adopt innovations, little is known about the system-level challenges that innovations should address in the first place. Within this perspective, four key lessons are drawn as well as three knowledge gaps. Electronic supplementary material The online version of this article (10.1186/s12913-017-2585-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Federico Roncarolo
- Institute of Public Health Research of Université de Montréal (IRSPUM), Montreal, Canada
| | - Antoine Boivin
- Institute of Public Health Research of Université de Montréal (IRSPUM), Montreal, Canada.,Department of Family Medicine, Faculty of Medicine, Université de Montréal, Montreal, Canada.,Research Center of the Université de Montréal Health Center (CRCHUM), Montreal, Canada.,Canada Research Chair in Patient and Public Partnership, Montreal, Canada
| | - Jean-Louis Denis
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, P.O. Box 6128, Branch Centre-ville, Montreal, QC, H3C 3J7, Canada.,Canada Research Chair in Governance and Transformation of Health Organizations and Systems, Montreal, Canada
| | - Rejean Hébert
- Institute of Public Health Research of Université de Montréal (IRSPUM), Montreal, Canada.,Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, P.O. Box 6128, Branch Centre-ville, Montreal, QC, H3C 3J7, Canada
| | - Pascale Lehoux
- Institute of Public Health Research of Université de Montréal (IRSPUM), Montreal, Canada. .,Research Center of the Université de Montréal Health Center (CRCHUM), Montreal, Canada. .,Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, P.O. Box 6128, Branch Centre-ville, Montreal, QC, H3C 3J7, Canada. .,Université de Montréal Chair on Responsible Innovation in Health, Montreal, Canada.
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Agyepong IA, Kwamie A, Frimpong E, Defor S, Ibrahim A, Aryeetey GC, Lokossou V, Sombie I. Spanning maternal, newborn and child health (MNCH) and health systems research boundaries: conducive and limiting health systems factors to improving MNCH outcomes in West Africa. Health Res Policy Syst 2017; 15:54. [PMID: 28722556 PMCID: PMC5516848 DOI: 10.1186/s12961-017-0212-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Despite improvements over time, West Africa lags behind global as well as sub-Saharan averages in its maternal, newborn and child health (MNCH) outcomes. This is despite the availability of an increasing body of knowledge on interventions that improve such outcomes. Beyond our knowledge of what interventions work, insights are needed on others factors that facilitate or inhibit MNCH outcome improvement. This study aimed to explore health system factors conducive or limiting to MNCH policy and programme implementation and outcomes in West Africa, and how and why they work in context. METHODS We conducted a mixed methods multi-country case study focusing predominantly, but not exclusively, on the six West African countries (Burkina Faso, Benin, Mali, Senegal, Nigeria and Ghana) of the Innovating for Maternal and Child Health in Africa initiative. Data collection involved non-exhaustive review of grey and published literature, and 48 key informant interviews. We validated our findings and conclusions at two separate multi-stakeholder meetings organised by the West African Health Organization. To guide our data collection and analysis, we developed a unique theoretical framework of the link between health systems and MNCH, in which we conceptualised health systems as the foundations, pillars and roofing of a shelter for MNCH, and context as the ground on which the foundation is laid. RESULTS A multitude of MNCH policies and interventions were being piloted, researched or implemented at scale in the sub-region, most of which faced multiple interacting conducive and limiting health system factors to effective implementation, as well as contextual challenges. Context acted through its effect on health system factors as well as on the social determinants of health. CONCLUSIONS To accelerate and sustain improvements in MNCH outcomes in West Africa, an integrated approach to research and practice of simultaneously addressing health systems and contextual factors alongside MNCH service delivery interventions is needed. This requires multi-level, multi-sectoral and multi-stakeholder engagement approaches that span current geographical, language, research and practice community boundaries in West Africa, and effectively link the efforts of actors interested in health systems strengthening with those of actors interested in MNCH outcome improvement.
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Affiliation(s)
- Irene Akua Agyepong
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Aku Kwamie
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Edith Frimpong
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Selina Defor
- Ghana Health Service, Research and Development Division, P.O. Box MB-190, Greater Accra region, Ghana
| | - Abdallah Ibrahim
- University of Ghana School of Public Health, P.O. Box LG13, Legon, Accra, Ghana
| | | | - Virgil Lokossou
- West African Health Organization, Bobo-Dioulasso, 01BP 153 Bobo-Dioulasso 01, Burkina Faso
| | - Issiaka Sombie
- West African Health Organization, Bobo-Dioulasso, 01BP 153 Bobo-Dioulasso 01, Burkina Faso
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Renmans D, Holvoet N, Criel B, Meessen B. Performance-based financing: the same is different. Health Policy Plan 2017; 32:860-868. [DOI: 10.1093/heapol/czx030] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 11/14/2022] Open
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Vargas-Peláez CM, Soares L, Rover MRM, Blatt CR, Mantel-Teeuwisse A, Rossi Buenaventura FA, Restrepo LG, Latorre MC, López JJ, Bürgin MT, Silva C, Leite SN, Mareni Rocha F. Towards a theoretical model on medicines as a health need. Soc Sci Med 2017; 178:167-174. [PMID: 28226302 DOI: 10.1016/j.socscimed.2017.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 10/31/2016] [Accepted: 02/10/2017] [Indexed: 01/29/2023]
Abstract
Medicines are considered one of the main tools of western medicine to resolve health problems. Currently, medicines represent an important share of the countries' healthcare budget. In the Latin America region, access to essential medicines is still a challenge, although countries have established some measures in the last years in order to guarantee equitable access to medicines. A theoretical model is proposed for analysing the social, political, and economic factors that modulate the role of medicines as a health need and their influence on the accessibility and access to medicines. The model was built based on a narrative review about health needs, and followed the conceptual modelling methodology for theory-building. The theoretical model considers elements (stakeholders, policies) that modulate the perception towards medicines as a health need from two perspectives - health and market - at three levels: international, national and local levels. The perception towards medicines as a health need is described according to Bradshaw's categories: felt need, normative need, comparative need and expressed need. When those different categories applied to medicines coincide, the patients get access to the medicines they perceive as a need, but when the categories do not coincide, barriers to access to medicines are created. Our theoretical model, which holds a broader view about the access to medicines, emphasises how power structures, interests, interdependencies, values and principles of the stakeholders could influence the perception towards medicines as a health need and the access to medicines in Latin American countries.
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Affiliation(s)
- Claudia Marcela Vargas-Peláez
- Programa de pós-graduação em Farmácia, Universidade Federal de Santa Catarina, Campus Universitário Trindade - Florianópolis, Santa Catarina, Brazil; WHO Collaborating Centre for Pharmaceutical Policy & Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), David de Wied Building, Universiteitsweg 99, Utrecht, The Netherlands.
| | - Luciano Soares
- Programa de Pós-Graduação em Saúde e Meio Ambiente, Universidade da Região de Joinville - Univille, Rua Paulo Malschitzki, 10 - Bom Retiro, Joinville, Santa Catarina, Brazil.
| | - Marina Raijche Mattozo Rover
- Programa de pós-graduação em Farmácia, Universidade Federal de Santa Catarina, Campus Universitário Trindade - Florianópolis, Santa Catarina, Brazil.
| | - Carine Raquel Blatt
- Departamento de Farmacociências, Universidade Federal de Ciências da Saúde de Porto Alegre, Rua Sarmento Leite, 245 - Cidade Baixa, Porto Alegre, Rio Grande do Sul, Brazil.
| | - Aukje Mantel-Teeuwisse
- WHO Collaborating Centre for Pharmaceutical Policy & Regulation, Utrecht Institute for Pharmaceutical Sciences (UIPS), David de Wied Building, Universiteitsweg 99, Utrecht, The Netherlands.
| | | | | | | | - José Julián López
- Departamento de Farmacia, Universidad Nacional de Colombia, Carrera 30 No. 45-03, Edificio 450, Oficina 214, Bogotá D.C., Colombia.
| | | | - Consuelo Silva
- Escuela Latinoamericana de Postgrados (ELAP) - Universidad de Artes y Ciencias Sociales (Arcis), Erasmo Escala 2728, Santiago, Chile.
| | - Silvana Nair Leite
- Programa de pós-graduação em Farmácia, Universidade Federal de Santa Catarina, Campus Universitário Trindade - Florianópolis, Santa Catarina, Brazil.
| | - Farias Mareni Rocha
- Programa de pós-graduação em Farmácia, Universidade Federal de Santa Catarina, Campus Universitário Trindade - Florianópolis, Santa Catarina, Brazil.
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Bailie J, Laycock A, Matthews V, Bailie R. System-Level Action Required for Wide-Scale Improvement in Quality of Primary Health Care: Synthesis of Feedback from an Interactive Process to Promote Dissemination and Use of Aggregated Quality of Care Data. Front Public Health 2016; 4:86. [PMID: 27200338 PMCID: PMC4854872 DOI: 10.3389/fpubh.2016.00086] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/20/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction There is an enduring gap between recommended practice and care that is actually delivered; and there is wide variation between primary health care (PHC) centers in delivery of care. Where aspects of care are not being done well across a range of PHC centers, this is likely due to inadequacies in the broader system. This paper aims to describe stakeholders’ perceptions of the barriers and enablers to addressing gaps in Australian Aboriginal and Torres Strait Islander chronic illness care and child health, and to identify key drivers for improvement. Methods This paper draws on data collected as part of a large-scale continuous quality improvement project in Australian Indigenous PHC settings. We undertook a qualitative assessment of stakeholder feedback on the main barriers and enablers to addressing gaps in care for Aboriginal and Torres Strait Islander children and in chronic illness care. Themes on barriers and enablers were further analyzed to develop a “driver diagram,” an improvement tool used to locate barriers and enablers within causal pathways (as primary and secondary drivers), enabling them to be targeted by tailored interventions. Results We identified 5 primary drivers and 11 secondary drivers of high-quality care, and associated strategies that have potential for wide-scale implementation to address barriers and enablers for improving care. Perceived barriers to addressing gaps in care included both health system and staff attributes. Primary drivers were: staff capability to deliver high-quality care; availability and use of clinical information systems and decision support tools; embedding of quality improvement processes and data-driven decision-making; appropriate and effective recruitment and retention of staff; and community capacity, engagement and mobilization for health. Suggested strategies included mechanisms for increasing clinical supervision and support, staff retention, reorientation of service delivery, use of information systems and community health literacy. Conclusion The findings identify areas of focus for development of barrier-driven, tailored interventions to improve health outcomes. They reinforce the importance of system-level action to improve health center performance and health outcomes, and of developing strategies to address system-wide challenges that can be adapted to local contexts.
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Affiliation(s)
- Jodie Bailie
- Menzies School of Health Research, Charles Darwin University , Casuarina, NT , Australia
| | - Alison Laycock
- Menzies School of Health Research, Charles Darwin University , Casuarina, NT , Australia
| | - Veronica Matthews
- Menzies School of Health Research, Charles Darwin University , Casuarina, NT , Australia
| | - Ross Bailie
- Menzies School of Health Research, Charles Darwin University , Casuarina, NT , Australia
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Marten MG. From emergency to sustainability: shifting objectives in the US Government's HIV response in Tanzania. Glob Public Health 2015; 12:988-1003. [PMID: 26609563 DOI: 10.1080/17441692.2015.1094707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The US President's Emergency Plan for AIDS Relief (PEPFAR) was originally designed as an emergency initiative, operating with considerable funds, immediate roll-out, fast scale-up, and top-down technocratic administration. In a more recent iteration, PEPFAR shifted its focus from an emergency response to more closely account for healthcare sustainability. This transition came on the heels of the 2008 financial crisis, which threatened to stall the 'marvellous momentum' of the 2000's boom in donor aid for global health overall. Now many programmes are having to do more with less as funding flattens or decreases. This paper examines how this transition took shape in Tanzania in 2011-2012, and the successes and challenges associated with it, using participant observation and interview data from 20 months of fieldwork in rural and urban healthcare settings. In particular, I discuss (1) efforts to increase sustainability and country ownership of HIV programmes in Tanzania, focusing on the shift from PEPFAR-funded American non-governmental organisations to Tanzanian partner organisations; (2) principal challenges stakeholders encountered during the transition, including fragmented systems of healthcare delivery and a weakened healthcare workforce; and (3) strategies informants identified to better integrate services in order to build a stronger, more equitable, and sustainable health system in Tanzania.
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Affiliation(s)
- Meredith G Marten
- a Department of Anthropology , University of West Florida , Pensacola , FL , USA
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