Unravelling collaborative governance dynamics within healthcare networks: a scoping review

In many countries, healthcare systems suffer from fragmentation between hospitals and primary care. In response, many governments institutionalized healthcare networks (HN) to facilitate integration and efficient healthcare delivery. Despite potential benefits, the implementation of HN is often challenged by inefficient collaborative dynamics that result in delayed decision-making, lack of strategic alignment and lack of reciprocal trust between network members. Yet, limited attention has been paid to the collective dynamics, challenges and enablers for effective inter-organizational collaborations. To consider these issues, we carried out a scoping review to identify the underlying processes for effective inter-organizational collaboration and the contextual conditions within which these processes are triggered. Following appropriate methodological guidance for scoping reviews, we searched four databases [PubMed (n = 114), Web of Science (n = 171), Google Scholar (n = 153) and Scopus (n = 52)] and used snowballing (n = 22). A total of 37 papers addressing HN including hospitals were included. We used a framework synthesis informed by the collaborative governance framework to guide data extraction and analysis, while being sensitive to emergent themes. Our review showed the prominence of balancing between top-down and bottom-up decision-making (e.g. strategic vs steering committees), formal procedural arrangements and strategic governing bodies in stimulating participative decision-making, collaboration and sense of ownership. In a highly institutionalized context, the inter-organizational partnership is facilitated by pre-existing legal frameworks. HN are suitable for tackling wicked healthcare issues by mutualizing resources, staff pooling and improved coordination. Overall performance depends on the capacity of partners for joint action, principled engagement and a closeness culture, trust relationships, shared commitment, distributed leadership, power sharing and interoperability of information systems To promote the effectiveness of HN, more bottom-up participative decision-making, formalization of governance arrangement and building trust relationships are needed. Yet, there is still inconsistent evidence on the effectiveness of HN in improving health outcomes and quality of care.

UHC in Morocco: a bottom-up estimation of public hospitals' financing size based on a costing database

BACKGROUND

Morocco is engaged in a health system reform aimed at generalizing health insurance across the whole population by 2025. This study aims to build a national database of costs at all levels of public hospitals in Morocco and craft this database as a resource for further use in a strategic purchasing system. It also aims at estimating the funding gap and the budget that should be secured for public hospitals in Morocco to fully play their roles in the current ambitious reform.

METHOD

A costing study was implemented in 39 hospitals in 12 regions of Morocco (10 provincial hospitals, 11 regional hospitals, and 18 teaching hospitals). Using the hospital costing approach, we adapted and validated nationally our methodology to generate a database of unit costs based on data from 2019. All perspectives on cost were considered. Data collection was performed by cadres from MoH and facilitated by the WHO country office in Morocco. The production of the cost database allowed the development of a bottom-up estimation of the financing size for public health hospitals.

RESULTS

The study showed the feasibility of large-scale costing in the context of Morocco. The ownership of MoH and adherence to the process ensured the high quality of the collected data. There are many differences in unit costs for the same services moving from one hospital to another, which indicates existing inefficiencies. The database will contribute to shaping the strategic purchasing mechanism within the generalized health insurance schemes. The studied hospitals could be used as references to systematically update the billing system for health insurance.

Decision-making and health system strengthening: bringing time frames into perspective

In many low-and middle-income countries, health systems decision-makers are facing a host of new challenges and competing priorities. They must not only plan and implement as they used to do but also deal with discontented citizens and health staff, be responsive and accountable. This contributes to create new political hazards susceptible to disrupt the whole execution of health plans. The starting point of this article is the observation by the first author of the limitations of the building-blocks framework to structure decision-making as for strengthening of the Moroccan health system. The management of a health system is affected by different temporalities, the recognition of which allows a more realistic analysis of the obstacles and successes of health system strengthening approaches. Inspired by practice and enriched thanks a consultation of the literature, our analytical framework revolves around five dynamics: the services dynamic, the programming dynamic, the political dynamic, the reform dynamic and the capacity-building dynamic. These five dynamics are differentiated by their temporalities, their profile, the role of their actors and the nature of their activities. The Moroccan experience suggests that it is possible to strengthen health systems by opening up the analysis of temporalities, which affects both decision-making processes and the dynamics of functioning of health systems.

Comparison of appropriateness of Nutri-Score and other front-of-pack nutrition labels across a group of Moroccan consumers: awareness, understanding and food choices

Background

The front of pack nutrition label Nutri-Score, intended to help consumers orient their choices towards foods that are more favorable to health, was developed in France and applied in several European countries. Consideration is underway for its use in Morocco. This study aims to assess Moroccan consumers’ perception and objective understanding of Nutri-Score and 4 other nutritional information labels (Health Star Rating, Health warning, Reference Intakes and Multiple Trafic Light) and their impact on purchase intentions.

Methods

814 participants were asked to choose among 3 food classes (yoghurts, biscuits and cold cuts), which ones they would prefer to buy among three products with different nutritional profiles and then to rank them according to their nutritional quality. Participants first performed these tasks without a visible nutritional label, and then, after being randomized to one of five labels tested, with the nutritional label visible on front of packs. Next, the full set of tested labels was presented to the participants who were asked a series of questions regarding their preferences, the attractiveness of the labels, their perceptions, intention to use and the trustworthiness placed in the labels.

Results

Compared to the Reference Intake, the Nutri-Score (OR = 2.48 [1.53–4.05], p < 0.0001), was associated with the highest improvement in the ability to correctly classify foods based on their nutritional quality. The percentage of participants who improved their food choice was higher than those who worsened it for all the labels. For yogurts and cookies, the most significant improvements were observed for the Nutri-Score and the Reference Intakes: Concerning the perception of labels, the Nutri-Score is the label that received the highest number of positive responses, whether concerning the ease of being spotted (82.2%), of being understood (74%), and to provide rapid information (68.8%). The Nutri-Score was ranked as the preferred label by 64.9% of the participants.

Conclusion

The Nutri-Score appears to be the most effective nutritional information system to inform consumers about the nutritional quality of foods in Morocco, where it could constitute a useful tool to help consumers in their food choices in situations of purchase.

Governance Roles and Capacities of Ministries of Health: A Multidimensional Framework

The lack of capacity for governance of Ministries of Health (MoHs) is frequently advanced as an explanation for health systems failures in low- and middle-income countries (LMICs). But do we understand what governance capacities MoHs should have? Existing frameworks have not fully captured the dynamic and contextually determined role of MoHs, and there are few frameworks that specifically define capacities for governance. We propose a multidimensional framework of capacities for governance by MoHs that encompasses both the "hard" (de jure , explicit and functional) and "soft" (de facto , tacit, and relational) dimensions of governance, and reflects the diversification of their mandates in the context of the Sustainable Development Goals (SDGs). Four case studies illustrate different aspects of the framework. We hope that the framework will have multiple potential benefits including benchmarking MoH governance capacities, identifying and helping analyze capacity gaps, and guiding strategies to strengthen capacity.

Spatial sensitivity analysis of COVID-19 infections concerning the satellite-based four air pollutants levels

The novel coronavirus (COVID-19), first reported in late December 2019, has affected the lives of many people throughout the world. Significant studies have been conducted on this pandemic, some of which have addressed understanding the relationship between different air pollutants and confirmed cases. In this study, the effects of four air pollutants (carbon monoxide, nitrogen dioxide, ozone, and sulfur dioxide) were assessed from February 19 to March 22, 2020 to explore how they can affect COVID-19 contagion in Iran. The mean concentrations of air pollutants were extracted from Sentinel 5P data. The COVID-19 confirmed case densities of two provinces, Semnan and Qom, were more than all other provinces. The effect of pollutants on the confirmed case densities was analyzed using multiple linear regression in order to estimate the impact coefficients for individual provinces. The impact coefficients determine the level of each pollutant's contribution to the density of total confirmed cases. Carbon monoxide, nitrogen dioxide, sulfur dioxide, and ozone had both considerable negative and positive correlations with the density of confirmed COVID-19 cases, although sulfur dioxide was correlated more negatively than positively. In Semnan, a high hot spot province, nitrogen dioxide had the most significant effect on the density of confirmed cases among all pollutants, while the effect of carbon monoxide was greater in Qom. The results indicated that even short-term exposure to higher concentrations of the pollutants could lead to an increased risk of COVID-19 outbreaks, which should be considered in adopting adequate and appropriate control policies to manage the disease.

Policy dialogue and participation: a new way of crafting a national health financing strategy in Morocco

BACKGROUND

Policy dialogue for health policies has started to gain importance in recent years, especially for complex issues such as health financing. Moroccan health financing has faced several challenges during the last years. This study aims to document the Moroccan experience in developing a consolidated health financing strategy according to the policy dialogue approach. It especially considers the importance of conceptualising this process in the Moroccan context.

METHOD

We documented the process of developing a health financing strategy in Morocco. It concerned four steps, as follows: (1) summarising health financing evidence in preparation of the policy dialogue; (2) organising the health policy dialogue process with 250 participants (government, private sector, NGOs, civil society, parliamentarians, technical and financial partners); (3) a technical workshop to formulate the strategy actions; and (4) an ultimate workshop for validation with decision-makers. The process lasted 1 year from March 2019 to February 2020. We have reviewed all documents related to the four steps of the process through our active participation in the policy debate and the documentation of two technical workshops to produce the strategy document.

RESULTS

The policy dialogue approach showed its usefulness in creating convergence among all health actors to define a national shared vision on health financing in Morocco. There was a high political commitment in the process and all actors officially adopted recommendations on health financing actions. A strategy document produced within a collaborative approach was the final output. This experience also marked a shift from previous top-down approaches in designing health policies for more participation and inclusion. The evidence synthesis played a crucial role in facilitating the debate. The collaborative approach seems to work in favouring national consensus on practical health financing actions.

CONCLUSION

The policy dialogue process adopted for health financing in Morocco helped to create collective ownership of health financing actions. Despite the positive results in terms of national mobilisation around the health financing vision in Morocco, there is a need to institutionalise the policy dialogue with a more decentralised approach to consider subnational specificities.

A scoping review of the uses and institutionalisation of knowledge for health policy in low- and middle-income countries

There is growing interest in how different forms of knowledge can strengthen policy-making in low- and middle-income country (LMIC) health systems. Additionally, health policy and systems researchers are increasingly aware of the need to design effective institutions for supporting knowledge utilisation in LMICs. To address these interwoven agendas, this scoping review uses the Arskey and O’Malley framework to review the literature on knowledge utilisation in LMIC health systems, using eight public health and social science databases. Articles that described the process for how knowledge was used in policy-making, specified the type of knowledge used, identified actors involved (individual, organisation or professional), and were set in specific LMICs were included. A total of 53 articles, from 1999 to 2016 and representing 56 countries, were identified. The majority of articles in this review presented knowledge utilisation as utilisation of research findings, and to a lesser extent routine health system data, survey data and technical advice. Most of the articles centered on domestic public sector employees and their interactions with civil society representatives, international stakeholders or academics in utilising epistemic knowledge for policy-making in LMICs. Furthermore, nearly all of the articles identified normative dimensions of institutionalisation. While there is some evidence of how different uses and institutionalisation of knowledge can strengthen health systems, the evidence on how these processes can ultimately improve health outcomes remains unclear. Further research on the ways in which knowledge can be effectively utilised and institutionalised is needed to advance the collective understanding of health systems strengthening and enhance evidence-informed policy formulation.

The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence

One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: 'Voting with feet' (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); 'Close to ground' (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and 'Watching the watchers' (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.

Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan

Decentralisation is widely practised but its scrutiny tends to focus on structural and authority changes or outcomes. Politics and process of devolution implementation needs to be better understood to evaluate how national governments use the enhanced decision space for bringing improvements in the health system and the underlying challenges faced. We use the example of Pakistan’s radical, politically driven provincial devolution to analyse how national structures use decentralisation opportunities for improved health planning, spending and carrying out transformations to the health system. Our narrative draws on secondary data sources from the PRIMASYS study, supplemented with policy roundtable notes from Pakistan.

Our analysis shows that in decentralised Pakistan, health became prioritised for increased government resources and achieved good budgetary use, major strides were made contextualised sector-wide health planning and legislations, and a proliferation seen in governance measures to improve and regulate healthcare delivery. Despite a disadvantaged and abrupt start to devolution, high ownership by politicians and bureaucracy in provincial governments led to resourcing, planning and innovations. However, effective translation remained impeded by weak institutional capacity, feeble federal–provincial coordination and vulnerability to interference by local elites.

Building on this illustrative example, we propose (1) political management of decentralisation for effective national coordination, sustaining stable leadership and protecting from political interfere by local elites; (2) investment in stewardship capacity in the devolved structures as well as the central ministry to deliver on new roles.

Applying a health system perspective to the evolving Farmácia Popular medicines access programme in Brazil

The Farmácia Popular Program (FPP) launched a subsidy system in Brazil, but in coexistence with the ongoing regular governmental access to medicines (Unified Health System (SUS) dispensings) mechanisms, causing overlaps in terms of financing and target population. This characteristic is quite different from most countries with medicines cost-sharing schemes. This paper aims to analyse the FPP under a health systems perspective considering the different health system levels. We analysed the findings from the study ‘Impact of consecutive subsidies policies on access to and use of medicines in Brazil – ISAUM-Br’, designed with the objective of describing and evaluating the impact of the government medicines subsidy policies implemented between 2004 and 2011. Patient share of copayment increased with the implementation of the intervention, which decreased the reference price and decreased with SNP (Saúde Não Tem Preço; zero copayment for patients). There was an increased number of FPP dispensations over time, but SUS dispensings remained the most important source for medicines, especially for hypertension and diabetes. FPP allowed the establishment of a well-designed pharmaceutical information system in the country. Despite the improvement on control mechanism, fraud remained a problem. There were important effects on the pharmaceutical market and sales of generic medicines. FPP has proven to be a very important policy for promoting access to medicines for hypertension and diabetes in Brazil. Examining this policy with a health system perspective has allowed us to highlight many of its important consequences, including for the first time a broad and consistent information system on access to medicines in the country.

Preparedness for delivering non-communicable disease services in primary care: access to medicines for diabetes and hypertension in a district in south India

Introduction

Non-communicable diseases (NCDs) have become a major public health challenge worldwide; they account for 28 million deaths per year in low-and-middle-income countries (LMICs). Like many other LMICs, India is struggling to organise quality care for a large NCD-affected population especially at the primary healthcare level. The aim of this study was to assess local health system preparedness in a south Indian primary healthcare setting for addressing diabetes and hypertension.

Methods

This paper draws on a mixed-methods research study on access to medicines conducted in Tumkur, Karnataka, India. We used quantitative data from household and health facility surveys, and qualitative data from focus group discussions and in-depth interviews with health workers and patients. We identified systemic drivers that influence utilisation of services at government primary health centres (PHCs) using thematic analysis of qualitative data and a systems framework on access to medicines to assess supply and demand side factors.

Results

Majority of households depend on private facilities for diabetes and hypertension care because of the lack of laboratory facilities and frequent medicine stockouts at PHCs. Financial and managerial resource allocation for NCDs and prioritisation of care and processes related to NCDs was suboptimal compared to the prominence of this agenda at global and national levels. Primary healthcare has a limited role even in the activities under the national programme that addresses diabetes and hypertension.

Discussion

The study finds critical gaps in the preparedness of PHCs and district health systems in organising and managing care for diabetes and hypertension. Due to the lack of continuous care organised through PHCs, patients depend on expensive and often episodic care in the private sector. There is a need to improve managerial and financial resource allocation towards diabetes and hypertension (and other NCDs) at the district level.

Trial registration number

CTRI/2015/03/005640; Pre-results.

Health system effects of implementing integrated community case management (iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative study

Background

Intervening in private drug shops to improve quality of care and enhance regulatory oversight may have health system effects that need to be understood before scaling up any such interventions. We examine the processes through which a drug shop intervention culminated in positive unintended effects and other dynamic interactions within the underlying health system.

Methods

A multifaceted intervention consisting of drug seller training, supply of diagnostics and subsidised medicines, use of treatment algorithms, monthly supervision and community sensitisation was implemented in drug shops in South Western Uganda, to improve paediatric fever management. Focus group discussions and in-depth interviews were conducted with stakeholders (drug sellers, government officials and community health workers) at baseline, midpoint and end-line between September 2013 and September 2015. Using a health market and systems lens, transcripts from the interviews were analysed to identify health system effects associated with the apparent success of the intervention.

Findings

Stakeholders initially expressed caution and fears about the intervention's implications for quality, equity and interface with the regulatory framework. Over time, these stakeholders embraced the intervention. Most respondents noted that the intervention had improved drug shop standards, enabled drug shops to embrace patient record keeping, parasite-based treatment of malaria and appropriate medicine use. There was also improved supportive supervision, and better compliance to licensing and other regulatory requirements. Drug seller legitimacy was enhanced from the community and client perspective, leading to improved trust in drug shops.

Conclusion

The study showed how effectively using health technologies and the perceived efficacy of medicines contributed to improved legitimacy and trust in drug shops among stakeholders. The study also demonstrated that using a combination of appropriate incentives and consumer empowerment strategies can help harmonise common practices with medicine regulations and safeguard public health, especially in mixed health market contexts.

Limited understanding, limited services, limited resources: patients' experiences with managing hypertension and diabetes in Cambodia

INTRODUCTION

Health system responses to the emergence of non-communicable diseases (NCDs) in many Southeast Asian nations, Cambodia included, have been insufficient. Little is known about how people suffering from such conditions behave in constrained contexts. We examined the experience of patients with NCDs as they seek care for their conditions and manage them.

METHODS

In-depth interviews with 28 purposively selected patients with hypertension and/or diabetes using an interview guide to capture the trajectory followed by interviewees from the development and recognition of symptoms to adherence to treatment. A general outline of major topics to be discussed was used instead of a predetermined list of specific questions.

RESULTS

All interviewees had experienced symptoms for a substantial period of time, sometimes many years, before being diagnosed. Initial treatment focused on symptoms instead of underlying conditions, often at considerable financial cost. Following diagnosis, many struggled to take medicines daily for their condition and adhering to the required behaviour changes. Many resorted to complementary medicine. Lack of financial resources was a common reason to discontinue treatment. Many reported loss of income and assets such as livestock and productive land and increasingly relied on others.

CONCLUSION

In order to assist people with NCDs in Cambodia, there is a need for a multipronged approach focusing on communities and healthcare providers. Information campaigns could focus on the timely recognition by communities of symptoms indicative of the conditions, together with instigating demand for routine screening at qualified health providers. Peer support is considerable, and locally adjusted approaches based on this principle should be considered.

Governing the mixed health workforce: learning from Asian experiences

Examination of the composition of the health workforce in many low and middle-income countries (LMICs) reveals deep-seated heterogeneity that manifests in multiple ways: varying levels of official legitimacy and informality of practice; wide gradation in type of employment and behaviour (public to private) and diverse, sometimes overlapping, systems of knowledge and variably specialised cadres of providers. Coordinating this mixed workforce necessitates an approach to governance that is responsive to the opportunities and challenges presented by this diversity. This article discusses some of these opportunities and challenges for LMICs in general, and illustrates them through three case studies from different Asian country settings.

From Scheme to System (Part 1): Notes on Conceptual and Methodological Innovations in the Multicountry Research Program on Scaling Up Results-Based Financing in Health Systems

Abstract-This article presents conceptual and methodological developments made in analyzing the scale up of results-based financing (RBF) as part of a multicountry research program supported by the Alliance for Health Policy and Systems Research. Following a brief overview of the research process, the article proposes a new five-dimensional conceptualization of scale-up (population coverage, service coverage, health system integration, cross-sectoral diffusion, and knowledge expansion) to capture various facets of RBF scale-up. It also presents how Walt and Gilson's health policy triangle framework was modified to identify the enablers and barriers to scale-up in the country case studies included in this research program. The article then puts forth a four-phase model of scale-up, including phases of generation, adoption, institutionalization, and expansion, developed for the purpose of this research program. The article concludes by providing some lessons learned on the use of the methods and theoretical frameworks developed for this multicountry research program.

From Scheme to System (Part 2): Findings from Ten Countries on the Policy Evolution of Results-Based Financing in Health Systems

Abstract- This article presents the enablers and barriers to the scaling-up of results-based financing (RBF) programs. It draws on the Alliance for Health Policy and Systems Research's multicountry program of research Taking Results Based Financing From Scheme to System, which compared the scale-up of RBF interventions over four phases-generation, adoption, institutionalization, and expansion-across ten countries. Comparing country experiences reveals broad lessons on scale up of RBF for each of the scale-up phases. Though the coming together of global, national, and regional contextual factors was key to the development of pilot projects, national factors were important to scale up these pilots to national programs, including a political context favoring results and transparency, the presence of enabling policies and institutions, and the presence of policy entrepreneurs at the national level. The third transition, from program to policy, was enabled by the availability of domestic financial resources, legislative and financing arrangements to enhance health facility autonomy, and technical and political leadership within and beyond the Ministry of Health. The article provides lessons learned on RBF policy evolution, emphasizing the importance of phase-specific groups of actors, the need to tailor advocacy messages to enable scale-up, the influence of political feasibility on policy content, and policy processes to build national ownership and enable health system strengthening.

Improving access to medicines for non-communicable diseases in rural India: a mixed methods study protocol using quasi-experimental design

Background

India has the distinction of financing its healthcare mainly through out-of-pocket expenses by individual families contributing to catastrophic health expenditure and impoverishment. Nearly 70 % of the expenditure is on medicines purchased at private pharmacies. Patients with chronic ailments are especially affected, as they often need lifelong medicines. Over the past years in India, there have been several efforts to improve drug availability at government primary health centres. In this study, we aim to understand health system factors that affect utilisation and access to generic medicines for people with non-communicable diseases.

Methods

This study aims to understand if (and how) a package of interventions targeting primary health centres and community participation platforms affect utilisation and access to generic medicines for people with non-communicable diseases in the current district context in India. This study will employ a quasi-experimental design and a qualitative theory-driven approach. PHCs will be randomly assigned to one of three arms of the intervention. In one arm, PHCs will receive inputs to optimise service delivery for non-communicable diseases, while the second arm will receive an additional package of interventions to strengthen community participation platforms for improving non-communicable disease care. The third arm will be the control. We will conduct household and facility surveys, before and after the intervention and will estimate the effect of the intervention by difference-in-difference analysis. Sample size for measuring effects was calculated based on obtaining at least 30 households for each primary health centre spread across three distance-based clusters. Primary outcomes include availability and utilisation of medicines at primary health centres and out-of-pocket expenditure for medicines by non-communicable disease households. Focus group discussions with patients and in-depth interviews with health workers will also be conducted. Qualitative and process documentation data will be used to explain how the intervention could have worked.

Discussion

By taking into consideration several health system building blocks and trying to understand how they interact, our study aims to generate evidence for health planners on how to optimise health services to improve access to medicines.

Trial registration

Protocol registered on Clinical Trials Registry of India with registration identifier number CTRI/2015/03/005640 on 17^th March 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1680-3) contains supplementary material, which is available to authorized users.

Using health markets to improve access to medicines: three case studies

This editorial introduces a series of case studies that together highlight the use of health market interventions to improve access to medicines in low-and-middle income countries (LMICs). It underscores the added value of using a systems approach for a holistic understanding of how these interventions interact with the rest of the health system and the intended and unintended consequences that result. It goes on to summarize key findings from each of the studies and concludes with lessons for decision-makers on the design and implementation of market based interventions in LMIC health systems

Managing non-communicable diseases at health district level in Cambodia: a systems analysis and suggestions for improvement

Background

Cambodia developed its public health system along the principles of the district model and geared its services towards managing communicable diseases and maternal and child health issues. In line with other countries in the region, non-communicable diseases have emerged as a leading cause of adult mortality. We assessed the current capacity of the Cambodian district health system to manage hypertension and diabetes, with a focus on access to medicine for these chronic conditions.

Methods

A case study whereby in three purposely selected districts in an equal number of provinces a total of 74 informants were interviewed: 27 health care providers and administrators, 30 community representatives and 17 managers of specific non-communicable diseases interventions and social health protection schemes. Questions related to the World Health Organization’s health system building blocks. Data analysis involved coding, indexing, charting and mapping the data. Following these exercises all information was analysed by kind of respondent and their respective answer to the question concerned. Responses by respondents of three groups of interviewees were compared when appropriate. At 14 health centres and 3 district hospitals the availability of key medicines for hypertension and diabetes in accordance with the National Essential Drug List was assessed. This was also done for essential tools and equipment to diagnose these two conditions.

Results

Although there was agreement amongst nearly all interviewees that non-communicable diseases were prevalent, the district health system, including all health systems building blocks and the referral system, was inadequately developed to effectively deal with these conditions. Medicines supply was erratic and the quantity provided allowed for few patients to be treated, for a short period only, mainly at secondary or tertiary level.

Conclusions

Because of the public health, social and economic importance of non-communicable diseases, a rapid response is required. Given the current Cambodian situation, such response may initially be a diagonal approach, with non-communicable diseases services integrated in the National HIV/AIDS Programme. This should happen together with a reorientation of the health system to enable a horizontal approach to non-communicable diseases management in the long term.

Access to Treatment for Diabetes and Hypertension in Rural Cambodia: Performance of Existing Social Health Protection Schemes

Background

Non-communicable diseases (NCD) pose challenges to Cambodia’s health system. Medicines for NCD are on the National Essential Medicines List but no clinical guidelines support their utilization. Two social health protection schemes aimed at the informal sector population exist (Health Equity Funds and Insurance) together with two disease-specific interventions (a Peer Educator Network and Chronic Diseases Clinics) targeted at NCD patients. This study examines performance of these various schemes in relation to NCD.

Methods

Cross-sectional household survey among 709 individuals self-reporting diabetes and/or hypertension in three geographical locations in rural Cambodia using a structured questionnaire investigating diagnostic and treatment pathways, health seeking behaviour, health expenditures, and financial coping mechanisms.

Results

Two third of respondents with NCD were female and 55% did not belong to any scheme. The majority (59%) were diagnosed in the private sector and only 56% were on allopathic treatment that was mainly sought in the private sector (49%). Outpatient treatment cost was higher in the private sector and when using multiple providers of care. The majority were indebted, 11% due to health-related expenses. Contrary to social health protection schemes, disease-specific interventions offered better access to allopathic treatment and provided medicines in accordance with NEML.

Conclusion

The benefit packages of existing social health protection schemes and services in the public health sector should be adjusted to cater for the needs of people living with NCD in rural Cambodia. Initiatives that offer active disease management strategies and promote patients and community participation appear more successful in increasing treatment adherence and decreasing the risk of financial hardship.

Patient-centred innovation to ensure access to diabetes care in Cambodia: the case of MoPoTsyo

BACKGROUND

The increasing prevalence of chronic diseases puts a high burden on the health care systems of Low and Middle Income Countries which are often not adapted to provide the care needed. Peer support programmes are promoted to address health system constraints. This case study analyses a peer educator diabetes programme in Cambodia, MoPoTsyo, from a health system's perspective. Which strategies were used and how did these strategies change? How is the programme perceived?

METHODS

Data were collected through semi-structured interviews with patients, MoPoTsyo staff and peer educators, contracted pharmacy staff and health workers, health care workers and non-contracted pharmacists and managers and policy makers at district, provincial and national level. Four areas were purposively selected to do the interviews. An inductive content analysis was done independently by two researchers.

RESULTS

MoPoTsyo developed into three stages: a focus on diabetes self-management; a widening scope to ensure affordable medicines and access to other health care services; and aiming for sustainability through more integration with the Cambodian public system and further upscaling. All respondents acknowledged the peer educators' role and competence in patient education, but their ideas about additional tasks and their place in the system differed. Indirectly involved stakeholders and district managers emphasized the particular roles and responsibilities of all actors in the system and the particular role of the peer educator in the community. MoPoTsyo's diagnostics and laboratory services were perceived as useful, especially by patients and project staff. Respondents were positive about the revolving drug fund, but expressed concerns about its integration into the government system. The degree of collaboration between health care staff and peer educators varied.

CONCLUSION

MoPoTsyo responds to the needs of people with diabetes in Cambodia. Key success factors were: consistent focus on and involvement of the target group, backed up by a strong organisation; simultaneous reduction of other barriers to care; and the ongoing maintenance of relations at all levels within the health system. Despite resistance, MoPoTsyo has established a more balanced relationship between patients and health service providers, empowering patients to self-manage and access services that meet their needs.

A news media analysis of economic sanction effects on access to medicine in Iran

OBJECTIVE

In the past decades economic sanctions have been used by different countries or international organizations in order to deprive target countries of some transactions. While the sanctions do not target health care systems or public health structures, they may, in fact, affect the availability of health care in target countries. In this study, we used media analysis to assess the impacts of recent sanctions imposed by the Central Bank of Iran in 2012 on access to medicines in Iran.

METHODS

We searched different sources of written news media including a database of nonspecialized weeklies and magazines, online news sources, web pages of daily newspapers and healthcare oriented weeklies from 2011 to 2013. We searched the sources using the general term "medicine" to reduce the chances of missing relevant items. The identified news media were read, and categorized under three groups of items announcing "shortage of medicines," "medicines related issues" and "no shortage." We conducted trend analyzes to see whether the news media related to access to medicines were affected by the economic sanctions.

FINDINGS

A total number of 371 relevant news media were collected. The number of news media related to medicines substantially increased in the study period: 30 (8%), 161 (43%) and 180 (49%) were published in 2011, 2012 and 2013, respectively. While 145 (39%) of media items referred to the shortage of medicines, 97 (26%) reported no shortage or alleviating of concerns.

CONCLUSION

Media analysis suggests a clear increase in the number of news media reporting a shortage in Iran after the sanctions. In 2013, there were accompanying increases in the number of news media reporting alleviation of the shortages of medicines. Our analysis provides evidence of negative effects of the sanctions on access to medicines in Iran.

Stakeholders' perspectives on access-to-medicines policy and research priorities in Latin America and the Caribbean: face-to-face and web-based interviews

Background

This study aims to rank policy concerns and policy-related research issues in order to identify policy and research gaps on access to medicines (ATM) in low- and middle-income countries in Latin America and the Caribbean (LAC), as perceived by policy makers, researchers, NGO and international organization representatives, as part of a global prioritization exercise.

Methods

Data collection, conducted between January and May 2011, involved face-to-face interviews in El Salvador, Colombia, Dominican Republic, and Suriname, and an e-mail survey with key-stakeholders. Respondents were asked to choose the five most relevant criteria for research prioritization and to score policy/research items according to the degree to which they represented current policies, desired policies, current research topics, and/or desired research topics. Mean scores and summary rankings were obtained. Linear regressions were performed to contrast rankings concerning current and desired policies (policy gaps), and current and desired research (research gaps).

Results

Relevance, feasibility, and research utilization were the top ranked criteria for prioritizing research. Technical capacity, research and development for new drugs, and responsiveness, were the main policy gaps. Quality assurance, staff technical capacity, price regulation, out-of-pocket payments, and cost containment policies, were the main research gaps. There was high level of coherence between current and desired policies: coefficients of determination (R²) varied from 0.46 (Health system structure; r = 0.68, P <0.01) to 0.86 (Sustainable financing; r = 0.93, P <0.01). There was also high coherence between current and desired research on Rational selection and use of medicines (r = 0.71, P <0.05, R² = 0.51), Pricing/affordability (r = 0.82, P <0.01, R² = 0.67), and Sustainable financing (r = 0.76, P <0.01, R² = 0.58). Coherence was less for Health system structure (r = 0.61, P <0.01, R² = 0.38).

Conclusions

This study combines metrics approaches, contributing to priority setting methodology development, with country and regional level stakeholder participation. Stakeholders received feedback with the results, and we hope to have contributed to the discussion and implementation of ATM research and policy priorities in LAC.

Kinetic energy management in road traffic injury prevention: a call for action

By virtue of their variability, mass and speed have important roles in transferring energies during a crash incidence (kinetic energy). The sum of kinetic energy is important in determining an injury severity and that is equal to one half of the vehicle mass multiplied by the square of the vehicle speed. To meet the Vision Zero policy (a traffic safety policy) prevention activities should be focused on vehicle speed management. Understanding the role of kinetic energy will help to develop measures to reduce the generation, distribution, and effects of this energy during a road traffic crash. Road traffic injury preventive activities necessitate Kinetic energy management to improve road user safety.

Antibiotic resistance-the need for global solutions

The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. Here, we describe the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed.

Health policy and systems research in access to medicines: a prioritized agenda for low- and middle-income countries

OBJECTIVES

To identify priority policy issues in access to medicines (ATM) relevant for low- and middle-income countries, to identify research questions that would help address these policy issues, and to prioritize these research questions in a health policy and systems research (HPSR) agenda.

METHODS

The study involved i) country- and regional-level priority-setting exercises performed in 17 countries across five regions, with a desk review of relevant grey and published literature combined with mapping and interviews of national and regional stakeholders; ii) interviews with global-level stakeholders; iii) a scoping of published literature; and iv) a consensus building exercise with global stakeholders which resulted in the formulation and ranking of HPSR questions in the field of ATM.

RESULTS

A list of 18 priority policy issues was established following analysis of country-, regional-, and global-level exercises. Eighteen research questions were formulated during the global stakeholders' meeting and ranked according to four ranking criteria (innovation, impact on health and health systems, equity, and lack of research). The top three research questions were: i) In risk protection schemes, which innovations and policies improve equitable access to and appropriate use of medicines, sustainability of the insurance system, and financial impact on the insured? ii) How can stakeholders use the information available in the system, e.g., price, availability, quality, utilization, registration, procurement, in a transparent way towards improving access and use of medicines? and iii) How do policies and other interventions into private markets, such as information, subsidies, price controls, donation, regulatory mechanisms, promotion practices, etc., impact on access to and appropriate use of medicines?

CONCLUSIONS

Our HPSR agenda adopts a health systems perspective and will guide relevant, innovative research, likely to bear an impact on health, health systems and equity.

Bibliographic review of research publications on access to and use of medicines in low-income and middle-income countries in the Eastern Mediterranean Region: identifying the research gaps

OBJECTIVES

We assessed the situation of academic publications on access to and use of medicines (ATM) in low-income and middle-income countries (LMICs) of the Eastern Mediterranean Region (EMR). We aimed to inform priority setting for research on ATM in the region.

DESIGN

Bibliographic review of published studies.

SETTING

LMICs in EMR.

INCLUSION CRITERIA

Publications on ATM issues originating from or focusing on EMR LMICs covering the period 2000-2011. Publications involving multinational studies were included if at least one eligible country had been included in the study.

INFORMATION SOURCES AND DATA EXTRACTION

We conducted comprehensive searches of the PubMed, Social Science Citation Index and Science Citation Index. We used the WHO ATM framework for data extraction and synthesis. We analysed the data according to the ATM issues, health system levels, year of publication and the countries of origin or focus of the studies.

RESULTS

151 articles met the inclusion criteria. Most articles (77%) originated from LMICs in EMR, suggesting that the majority of evidence on ATM in the region is home-grown. Over 60% of articles were from Iran, Pakistan, Jordan and Lebanon (in order of volume), while we found no studies assessing ATM in Somalia, Djibouti and South Sudan, all low-income countries. Most studies focused on the rational use of medicines, while affordability and financing received limited attention. There was a steady growth over time in the number of ATM publications in the region (r=0.87).

CONCLUSIONS

There is a growing trend, over the years, of more studies from the region appearing in international journals. There is a need for further research on the financing and affordability aspects of ATM in the region. Cross-border issues and the roles of non-health sectors in access to medicines in the region have not been explored widely.

Access to medicines from a health system perspective

Most health system strengthening interventions ignore interconnections between systems components. In particular, complex relationships between medicines and health financing, human resources, health information and service delivery are not given sufficient consideration. As a consequence, populations' access to medicines (ATM) is addressed mainly through fragmented, often vertical approaches usually focusing on supply, unrelated to the wider issue of access to health services and interventions. The objective of this article is to embed ATM in a health system perspective. For this purpose, we perform a structured literature review: we examine existing ATM frameworks, review determinants of ATM and define at which level of the health system they are likely to occur; we analyse to which extent existing ATM frameworks take into account access constraints at different levels of the health system. Our findings suggest that ATM barriers are complex and interconnected as they occur at multiple levels of the health system. Existing ATM frameworks only partially address the full range of ATM barriers. We propose three essential paradigm shifts that take into account complex and dynamic relationships between medicines and other components of the health system. A holistic view of demand-side constraints in tandem with consideration of multiple and dynamic relationships between medicines and other health system resources should be applied; it should be recognized that determinants of ATM are rooted in national, regional and international contexts. These are schematized in a new framework proposing a health system perspective on ATM.

Access to essential medicines in Pakistan: policy and health systems research concerns

INTRODUCTION

Inadequate access to essential medicines is a common issue within developing countries. Policy response is constrained, amongst other factors, by a dearth of in-depth country level evidence. We share here i) gaps related to access to essential medicine in Pakistan; and ii) prioritization of emerging policy and research concerns.

METHODS

An exploratory research was carried out using a health systems perspective and applying the WHO Framework for Equitable Access to Essential Medicine. Methods involved key informant interviews with policy makers, providers, industry, NGOs, experts and development partners, review of published and grey literature, and consultative prioritization in stakeholder's Roundtable.

FINDINGS

A synthesis of evidence found major gaps in essential medicine access in Pakistan driven by weaknesses in the health care system as well as weak pharmaceutical regulation. 7 major policy concerns and 11 emerging research concerns were identified through consultative Roundtable. These related to weaknesses in medicine registration and quality assurance systems, unclear and counterproductive pricing policies, irrational prescribing and sub-optimal drug availability. Available research, both locally and globally, fails to target most of the identified policy concerns, tending to concentrate on irrational prescriptions. It overlooks trans-disciplinary areas of policy effectiveness surveillance, consumer behavior, operational pilots and pricing interventions review.

CONCLUSION

Experience from Pakistan shows that policy concerns related to essential medicine access need integrated responses across various components of the health systems, are poorly addressed by existing evidence, and require an expanded health systems research agenda.

Access to medicines in Latin America and the Caribbean (LAC): a scoping study

OBJECTIVE

To assess scientific publication and map research gaps on access to medicines (ATM) in Latin American and the Caribbean low-income and middle-income countries (LMIC).

DESIGN

Scoping review. Two independent reviewers assessed studies for inclusion and extracted data from each study.

INFORMATION SOURCES

Search strategies were developed and the following databases were searched: MEDLINE, ISI, SCOPUS and Lilacs, from 2000 to 2010.

ELIGIBILITY CRITERIA

Research articles and reviews published in English, Spanish and Portuguese were included. Studies including only high-income countries were excluded, as well as those carried out in very limited settings and discussion papers.

RESULTS

The 77 articles retained were categorised through consensus among the research team according to the level of the health system addressed, ATM domain and research issues covered. Publications on ATM have increased over time during the study period (r 0.93, p=0.00; R(2) 0.85). The top five countries covered were Brazil (68.8%), Mexico (15.6%), Colombia (11.7%), Argentina (10.4%) and Peru (10.4%). 'Health services delivery' and 'patients, household and communities' were the health system levels most frequently covered. The ATM domains 'leadership and governance', 'sustainable financing, affordability and price of medicines', 'medicines selection and use' and 'availability of medicines' were the top four explored. There are research gaps in important areas such as 'human resources for health', 'global policies and human rights', 'production of medicines' and 'traditional medicine'.

CONCLUSIONS

The upward trend on scientific publication reflects a growing research capacity in the region, which is concentrated on research teams in selected countries. The gaps on research capacity could be overcome through research collaboration among countries. It is important to strengthen these collaborations, assuring that interests and needs from the LMIC are addressed and local capacity building is promoted.

Health system barriers to access and use of magnesium sulfate for women with severe pre-eclampsia and eclampsia in Pakistan: evidence for policy and practice

Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified.

Trends in health policy and systems research over the past decade: still too little capacity in low-income countries

BACKGROUND

The past decade has seen several high-level events and documents committing to strengthening the field of health policy and systems research (HPSR) as a critical input to strengthening health systems. Specifically, they called for increased production, capacity to undertake and funding for HPSR. The objective of this paper is to assess the extent to which progress has been achieved, an important feedback for stakeholders in this field.

METHODS AND FINDING

Two sources of data have been used. The first is a bibliometric analysis to assess growth in production of HPSR between 2003 and 2009. The six building blocks of the health system were used to define the scope of this search. The second is a survey of 96 research institutions undertaken in 2010 to assess the capacity and funding availability to undertake HPSR, compared with findings from the same survey undertaken in 2000 and 2008. Both analyses focus on HPSR relevant to low-income and middle-income countries (LMICs). Overall, we found an increasing trend of publications on HPSR in LMICs, although only 4% were led by authors from low-income countries (LICs). This is consistent with findings from the institutional survey, where despite improvements in infrastructure of research institutions, a minimal change has been seen in the level of experience of researchers within LIC institutions. Funding availability in LICs has increased notably to institutions in Sub-Saharan Africa; nonetheless, the overall increase has been modest in all regions.

CONCLUSION

Although progress has been made in both the production and funding availability for HPSR, capacity to undertake the research locally has grown at a much slower pace, particularly in LICs where there is most need for this research. A firm commitment to dedicate a proportion of all future funding for research to building capacity may be the only solution to turn the tide.

Composition of pluralistic health systems: how much can we learn from household surveys? An exploration in Cambodia

In spite of all efforts to build national health services, health systems of many low-income countries are today highly pluralistic. Households use a vast range of public and private health care providers, many of whom are not controlled by national health authorities. Experts have called on Ministries of Health to re-establish themselves as stewards of the entire health system. Modern stewardship will require national and decentralized health authorities to have an overall view of their pluralistic health system, especially of the components outside the public sector. Little guidance has been provided so far on how to develop such a view. In this paper, we explore whether household surveys could be a source of information. The study builds on secondary data analysis of a household survey carried out in three health districts in rural Cambodia and of two national surveys. Cambodia is indeed an interesting case, as massive efforts by donors in favour of the public sector go hand in hand with a dominant role of the private sector in the provision of health care services. The study confirms that the health care sector in Cambodia is now highly pluralistic, and that the great majority of health seeking behaviour takes place outside the public health system. Our analysis of the survey also shows that the disaffection of the population with public health facilities varies across places, socio-economic groups and health problems. We illustrate how such knowledge could allow stewards to better identify challenges for existing or future health policies. We argue that a whole research programme on the composition of pluralistic health systems still needs to be developed. We identify some challenges and opportunities.

Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries

While World Health Organization member countries embraced the concept of universal coverage as early as 2005, few low-income countries have yet achieved the objective. This is mainly due to numerous barriers that hamper access to needed health services. In this paper we provide an overview of the various dimensions of barriers to access to health care in low-income countries (geographical access, availability, affordability and acceptability) and outline existing interventions designed to overcome these barriers. These barriers and consequent interventions are arranged in an analytical framework, which is then applied to two case studies from Cambodia. The aim is to illustrate the use of the framework in identifying the dimensions of access barriers that have been tackled by the interventions. The findings suggest that a combination of interventions is required to tackle specific access barriers but that their effectiveness can be influenced by contextual factors. It is also necessary to address demand-side and supply-side barriers concurrently. The framework can be used both to identify interventions that effectively address particular access barriers and to analyse why certain interventions fail to tackle specific barriers.

A functional model for monitoring equity and effectiveness in purchasing health insurance premiums for the poor: evidence from Cambodia and the Lao PDR

OBJECTIVES

To assess the impact on equity and effectiveness of introducing targeted subsidies for the poor into existing voluntary health insurance schemes in Low Income Countries with special reference to cross-subsidisation.

METHODS

A functional model was constructed using routine collected financial data to analyse changes in financial flows and resulting shifts in cross-subsidization between poor and non-poor. Data were collected from two sites, in Cambodia at Kampot operational health district and in the Lao People's Democratic Republic at Nambak district.

RESULTS

Six key variables were identified as determining the financial flows between the subsidy and the insurance schemes and with health providers: population coverage, premium rate, facility contact rate, capitation rate, cost of treatment and changes in administration costs. Negative cross-subsidization was revealed where capitation was used as the payment mechanism and where utilisation rates of the poor were significantly below the non-poor. The same level of access for the poor could have been achieved with a lower Health Equity Fund subsidy if used as a direct reimbursement of user charges by the Health Equity Fund to the provider rather than through the Community Based Health Insurance scheme.

CONCLUSIONS

Purchasing premiums for the poor under these conditions is more costly than direct reimbursement to the provider for the same level of service delivery. Negative cross-subsidization is a serious risk that must be managed appropriately and the benefits of a larger risk pool (cross-subsidization of the poor) are not evident. Benefits from combined coverage may accrue in the longer term with an expanded base of voluntary payers or when those with subsidized premiums are lifted out of poverty.

Barriers to access and the purchasing function of health equity funds: lessons from Cambodia

PROBLEM

High out-of-pocket payments and user fees with unfunded exemptions limit access to health services for the poor. Health equity funds (HEF) emerged in Cambodia as a strategic purchasing mechanism used to fund exemptions and reduce the burden of health-care costs on people on very low incomes. Their impact on access to health services must be carefully examined.

APPROACH

Evidence from the field is examined to define barriers to access, analyse the role played by HEF and identify how HEF address these barriers.

LOCAL SETTING

Two-thirds of total health expenditure consists of patients' out-of-pocket spending at the time of care, mainly for self-medication and private services. While the private sector attracts most out-of-pocket spending, user fees remain a barrier to access to public services for people on very low incomes.

RELEVANT CHANGES

HEF brought new patients to public facilities, satisfying some unmet health-care needs. There was no perceived stigma for HEF patients but many of them still had to borrow money to access health care.

LESSONS LEARNED

HEF are a purchasing mechanism in the Cambodian health-care system. They exercise four essential roles: financing, community support, quality assurance and policy dialogue. These roles respond to the main barriers to access to health services. The impact is greatest where a third-party arrangement is in place. A strong and supportive policy environment is needed for the HEF to exercise their active purchasing role fully.