Deconstructing the patient pathway to (in)effective care for hypertension: an application to the Philippines

Patient pathways for hypertension care are clinically-determined and depicted as a linear process: from diagnosis and initiation of treatment, to subsequent follow-up. However, increasing evidence suggests that patient journeys are more complex, involving different points of diagnosis; starting, stopping and changing treatment-in the formal and informal sectors-and multiple re-entries into the system. This longitudinal qualitative study sought to obtain in depth knowledge of these pathways over time.

We thematically analysed data from 40 interviews with hypertensive Filipino patients of low socio-economic status, repeated after 12 months to capture health events and actions taken. Data was also collected using mobile phone-based digital diaries in the interim.

Low-income hypertensive patients in the Philippines navigate a complex terrain to manage their condition. Barriers facing patients and their coping strategies differ at each stage. The pluralistic health system affects pathway through conflicting and alternative information from outside the formal health sector, social networks and commercial bodies. Patients proactively make decisions on how to manage their condition in relation to these formal and informal systems. Barriers to adherence include factors beyond the health system, notably precarious work contexts which require patients to compromise their livelihoods to follow provider-proscribed treatment. Families act as enables of care, motivating patients to follow or modify their pathway.

The concept of an optimal ‘patient pathway' is normative and often ignores the complex reality of patients' lives as they manage multiple priorities. In reality, pathways are cyclical and iterative. Advocating rigid pathways that patients must follow for life is unrealistic, especially for the poor. Instead, health systems need to adapt to reflect patients' fluid life trajectories and expectations to enable them to effectively manage their condition alongside other demands.

Toward a new framing of corruption in health systems in LMICs: what questions should we be asking?

Understanding and addressing corruption is critical for equitable and socially just development, and is therefore central to the realisation of the SDGs including the creation of responsive and trusted heath systems. Some conventional definitions of corruption do not reflect the complex reality in LMICs. Corruption is often conflated with poor governance, weak accountability or inefficiency but each manifestation has different structural and institutional causes, triggers and so requires different strategies to address it. 'Survival corruption' can be an informal coping strategy, other forms are manifest as reciprocal social exchanges within networks which may benefit wider groups of people and mask or contain health system dysfunctions. A proposition is made that we ask new questions that move away from a focus on the individual transaction towards locating it within health system and societal contexts that ultimately consider power and individual actor motivation.

Possible involvement of glutathione S-transferases in imazamox detoxification in an imidazolinone-resistant sunflower hybrid

The resistance of crops to herbicides can be due to target site based resistance or non-target site based resistance mechanisms or a combination of both. In non-target site resistance, the detoxification efficiency plays a major role by involvement of enzymes such as P450s, GTs, GSTs and ABC transporters. The resistance of the first commercial Clearfield sunflower hybrids (Imisun trait) to herbicides of imidazolinone group is based on a combination of both types of resistance. The target site resistance consists of a mutation in Ahasl1 gene, encoding the synthesis of the AHAS enzyme. The non-target site resistance is supposed to be due to intensified herbicide disposal and is not fully understood. The objective of this study was to detect the fast response of the glutathione-mediated detoxification system in IMI-R and IMI-S sunflower hybrids to the herbicide imazamox and to study the possible participation of GSTs in the enhancement of the hybrids' tolerance. The obtained results allow to presume that GSTs are involved in imazamox detoxification in the sunflower Imisun trait and thus contributing to its non-target site resistance.

Impact of measles elimination activities on immunization services and health systems: findings from six countries

BACKGROUND

One of the key concerns in determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam.

METHODS

Primary data were collected from key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches.

RESULTS

This study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia.

CONCLUSIONS

We conclude that while weaker health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.

Health service providers' perceptions of barriers to tuberculosis care in Russia

The Russian Federation has witnessed a marked rise in rates of tuberculosis (TB) over the past decade. Public health TB control institutions remain broadly modelled along pre-1990 lines despite substantial programmes of investment and advocacy in implementing the World Health Organization's 'Directly Observed Treatment--short course' (DOTS) strategy. In 2002, we undertook a qualitative study to explore health care providers' perceptions of existing barriers to access to TB services in Samara Oblast in Russia. Six focus group discussions were conducted with physicians and nurses from facilities in urban and rural areas. Data were analyzed using a framework approach for applied policy research. Barriers to access to care were identified in interconnected areas: barriers associated with the health care system, care process barriers, barriers related to wider contextual issues, and barriers associated with patients' personal characteristics and behaviour. In the health care system, insufficient funding was identified as an underlying problem resulting in a decrease in screening coverage, low salaries, staff shortages, irregularities in drug supplies and outdated infrastructure. Suboptimal collaboration with general health services and social services limits opportunities for care and social support to patients. Worsening socioeconomic conditions were seen both as a cause of TB and a major obstacle to access to care. Behavioural characteristics were identified as an important barrier to effective care and treatment, and health staff favoured compulsory treatment for 'noncompliant' patients and involvement of the police in defaulter tracing. TB was profoundly associated with stigma and this resulted in delays in accessing care and barriers to ensuring treatment success.

Access to water in the countries of the former Soviet Union

BACKGROUND

During the Soviet period, authorities in the USSR invested heavily in collective farming and modernization of living conditions in rural areas. However, many problems remained, including poor access to many basic amenities such as water. Since then, the situation is likely to have changed; economic decline has coincided with migration and widening social inequalities, potentially increasing disparities within and between countries.

AIM

To examine access to water and sanitation and its determinants in urban and rural areas of eight former Soviet countries.

METHODS

A series of nationally representative surveys in Armenia, Belarus, Georgia, Moldova, Kazakhstan, Kyrgyzstan, Russia and Ukraine was undertaken in 2001, covering 18,428 individuals (aged 18+ years).

RESULTS

The percentage of respondents living in rural areas varied between 27 and 59% among countries. There are wide urban-rural differences in access to amenities. Even in urban areas, only about 90% of respondents had access to cold running water in their home (60% in Kyrgyzstan). In rural areas, less than one-third had cold running water in their homes (44% in Russia, under 10% in Kyrgyzstan and Moldova). Between one-third and one-half of rural respondents in some countries (such as Belarus, Kazakhstan and Moldova) obtained their water from wells and similar sources. Access to hot running water inside the homes was an exception in rural households, reflecting the lack of modern heating methods in villages. Similarly, indoor access to toilets is common in urban areas but rare in rural areas. Access to all amenities was better in Russia compared with elsewhere in the region. Indoor access to cold water was significantly more common among rural residents living in apartments, and in settlements served by asphalt roads rather than dirt roads. People with more assets or income and living with other people were significantly more likely to have water on tap. In addition, people who had moved in more recently were more likely to have an indoor water supply.

CONCLUSIONS

This was the largest single study of its kind undertaken in this region, and demonstrates that a significant number of people living in rural parts of the former Soviet Union do not have indoor access to running water and sanitation. There are significant variations among countries, with the worse situation in central Asia and the Caucasus, and the best situation in Russia. Access to water strongly correlates with socio-economic characteristics. These findings suggest a need for sustained investment in rebuilding basic infrastructure in the region, and monitoring the impact of living conditions on health.

Patterns of alcohol consumption in Bulgaria

Alcohol is increasingly being recognized as a major cause of the greater burden of disease and premature death in eastern Europe than in the west. This requires a robust policy response but, in most countries in the region, there is little empirical data on patterns of consumption on which to base such a response. Until now, there has been no information on prevalence of drinking among the Bulgarian population. This paper describes a survey that seeks to address this weakness by describing the pattern of drinking in Bulgaria and its relationship with socio-demographic factors. It uses a multivariate analysis of data on patterns of alcohol consumption from a multi-stage nationwide survey of 1550 adults in Bulgaria, in 1997 which found that overall 50.7% of men and 13.6% of women drink at least weekly. In both sexes, drinking is least common among the elderly and those living in villages. It is also less common among those reporting their financial status as poor. Muslims are less likely to drink than are orthodox Christians. Drinking is most common among those living in cities, with higher education and high incomes. Heavy drinking, defined as 80 g/day or more, is rare among women, but is ascribed to 18.2% of men. Heavy drinking was much more common among men living in Sofia and was less common among those whose financial situation was poor. At the levels of drinking reported, it can be expected that alcohol is making a substantial contribution to the burden of disease and premature mortality in Bulgaria. A coordinated, effective policy response is required. Although some of the legal prerequisites are in place, they are poorly enforced and there is no overall strategy to address this issue.

Patterns of smoking in Bulgaria

BACKGROUND

Although the rate of smoking-related deaths in Bulgaria is still relatively low, in international terms, it has been rising rapidly. This is likely to become worse in the future as Bulgaria faces growing pressure from transnational tobacco companies. There is, however, little information on patterns of smoking, which is necessary for development of effective policies to tackle tobacco consumption.

OBJECTIVE

To describe the pattern of smoking in Bulgaria and its relationship with sociodemographic factors.

DESIGN

Multivariate analysis of data on patterns of tobacco consumption from a multi-stage nationwide survey of 1550 adults.

SETTING

Bulgaria, in 1997.

MAIN OUTCOME MEASURE

Prevalence of current cigarette smoking.

RESULTS

38.4% of men and 16.7% of women smoke. Smoking rates are strongly associated with age, with 58% of men and 30% of women aged 30-39 smoking whereas only 5% of men aged 70 years and older and almost no women of this age smoke. Smoking is more common in cities, among those who are widowed or divorced, or who do not own their home. There is no clear association with household income or, for men, with education, although there is a suggestion that smoking may be more common among more highly educated women.

CONCLUSIONS

The observed pattern of smoking indicates the need for a robust policy to tackle smoking in Bulgaria, especially among the young in large cities, informed by a better understanding of why smoking rates vary among different groups.

Under-the-counter payments for health care: evidence from Bulgaria

Against a background of falling revenues and increasing expectations, health care systems in central and eastern Europe are facing increasing budgetary gaps. There is extensive anecdotal evidence that these gaps are being filled by informal or 'under-the-table' payments. These are important because of their implications for estimates of future funding requirements, for equity, and for the possible perverse incentives they introduce for those providing and managing health services. There is, however, relatively little information on either their scale or how they are perceived in these countries. We report the results of a small survey from Bulgaria that begins to address these issues. Data were collected by means of an interviewer-administered household survey in which those who had used state-provided health services in the preceding 2 years were identified. The survey took place throughout Bulgaria in 1994. One thousand people were approached and 706 (70.6%) provided information suitable for analysis; 42.9% had paid for services that were officially free. Payments had been for a wide range of services and to differing groups, including medical, nursing and ancillary staff. Payments to individuals during consultations were between 3% and 14% of average monthly income but the average cost of an operation was 83% of mean monthly income. There were large differences in the amounts paid by individuals. Most people were in favour of both official user fees and health care reform, except among the old, the poor, and those in poor health. Despite certain limitations, this study gives some indication of the scale of informal payments in Bulgaria. Several possibilities exist to address them. Contrary to what is often argued, there seems to be a popular willingness for them to be converted into formal co-payments. Before this can be done, there is a need for more research on the impact that this would have on equity and affordability.