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Alba S, Jacobs E, Kleipool E, Salehi A, Naeem A, Arab SR, Van Gurp M, Hamid N, Manalai P, Saeedzai SA, Safi S, Paiman F, Siddiqi AM, Gerretsen B, Gari S, Sondorp E. Third party monitoring for health in Afghanistan: the good, the bad and the ugly. BMJ Glob Health 2023; 8:e013470. [PMID: 38084481 PMCID: PMC10711846 DOI: 10.1136/bmjgh-2023-013470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/01/2023] [Indexed: 12/18/2023] Open
Abstract
Third party monitoring (TPM) is used in development programming to assess deliverables in a contract relationship between purchasers (donors or government) and providers (non-governmental organisations or non-state entities). In this paper, we draw from our experience as public health professionals involved in implementing and monitoring the Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS) as part of the SEHAT and Sehatmandi programs in Afghanistan between 2013 and 2021. We analyse our own TPM experience through the lens of the three parties involved: the Ministry of Public Health; the service providers implementing the BPHS/EPHS; and the TPM agency responsible for monitoring the implementation. Despite the highly challenging and fragile context, our findings suggest that the consistent investments and strategic vision of donor programmes in Afghanistan over the past decades have led to a functioning and robust system to monitor the BPHS/EPHS implementation in Afghanistan. To maximise the efficiency, effectiveness and impact of this system, it is important to promote local ownership and use of the data, to balance the need for comprehensive information with the risk of jamming processes, and to address political economy dynamics in pay-for-performance schemes. Our findings are likely to be emblematic of TPM issues in other sectors and other fragile and conflicted affected settings and offer a range of lessons learnt to inform the implementation of TPM schemes.
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Affiliation(s)
- Sandra Alba
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Eelco Jacobs
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | | | | | - Ahmad Naeem
- Assistance for Families and Indigent Afghans to Thrive (AFIAT), Kabul, Afghanistan
| | | | - Margo Van Gurp
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Nasir Hamid
- Care of Afghan Families (CAF), Kabul, Afghanistan
| | | | | | | | - Farhad Paiman
- Organization for Health Promotion and Management, Kabul, Afghanistan
| | | | | | | | - Egbert Sondorp
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
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2
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Alani AH, Miller L, Waweru I, Atwiine AB, Njagi S, Tonelli M, Kisarach K, Mohammed A, Mugera R, Ibrahim NM, Abdulhammed Mohamad D, Kiapi L. Lessons learned from implementing the Non-Communicable Diseases Kit in a humanitarian emergency: an operational evaluation in Sudan. BMJ Glob Health 2023; 7:e012077. [PMID: 37295806 PMCID: PMC10367079 DOI: 10.1136/bmjgh-2023-012077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/14/2023] [Indexed: 06/12/2023] Open
Abstract
Non-communicable diseases (NCDs) are a major global health concern, and their management is particularly challenging in humanitarian contexts where healthcare resources are limited. The WHO Non-Communicable Diseases Kit (WHO-NCDK) is a health system intervention targeted at the primary healthcare (PHC) level and designed to provide essential medicines and equipment for NCDs management in emergency settings, meeting the needs of 10 000 people for 3 months. This operational evaluation aimed to assess the effectiveness and utility of the WHO-NCDK in two PHC facilities in Sudan and identify key contextual factors that may influence its implementation and impact. Using a cross-sectional mixed-methods observational approach that combined quantitative and qualitative data, the evaluation found that the kit played a critical role in maintaining continuity of care when other supply chain solutions were disrupted. However, contextual factors such as local communities' unfamiliarity with healthcare facilities, the national integration of NCDs into PHC, and the existence of monitoring and evaluation systems were identified as important considerations for enhancing the WHO-NCDK's utility and usefulness. The evaluation suggests that the WHO-NCDK can be an effective intervention in emergency settings, provided that contextual factors such as local needs, facility capacity and healthcare worker capacity are considered before kit deployments.
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Affiliation(s)
- Ahmad Hecham Alani
- Health Technical Unit, International Rescue Committee, London, UK
- Independent Researcher, London, UK
| | - Laura Miller
- Health Technical Unit, International Rescue Committee, New York, New York, USA
| | - Isaac Waweru
- Health Technical Unit, International Rescue Committee, Nairobi, Kenya
| | - Aston B Atwiine
- Health Technical Unit, International Rescue Committee, Kampala, Uganda
| | - Stella Njagi
- Health Technical Unit, International Rescue Committee, Nairobi, Kenya
| | - Marcello Tonelli
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kisarach
- Health Technical Unit, International Rescue Committee, Khartoum, Sudan
| | | | - Ronald Mugera
- Health Technical Unit, International Rescue Committee, Nairobi, Kenya
| | | | - Dina Abdulhammed Mohamad
- Planning, Monitoring and Evaluation (M&E) & Surveillance, Federal Ministry of Health, Khartoum, Sudan
| | - Lilian Kiapi
- Health Technical Unit/Technical Excellence, International Rescue Committee, London, UK
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Hayman DTS, Barraclough RK, Muglia LJ, McGovern V, Afolabi MO, N'Jai AU, Ambe JR, Atim C, McClelland A, Paterson B, Ijaz K, Lasley J, Ahsan Q, Garfield R, Chittenden K, Phelan AL, Lopez Rivera A. Addressing the challenges of implementing evidence-based prioritisation in global health. BMJ Glob Health 2023; 8:e012450. [PMID: 37290897 PMCID: PMC10255200 DOI: 10.1136/bmjgh-2023-012450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/14/2023] [Indexed: 06/10/2023] Open
Abstract
Global health requires evidence-based approaches to improve health and decrease inequalities. In a roundtable discussion between health practitioners, funders, academics and policy-makers, we recognised key areas for improvement to deliver better-informed, sustainable and equitable global health practices. These focus on considering information-sharing mechanisms and developing evidence-based frameworks that take an adaptive function-based approach, grounded in the ability to perform and respond to prioritised needs. Increasing social engagement as well as sector and participant diversity in whole-of-society decision-making, and collaborating with and optimising on hyperlocal and global regional entities, will improve prioritisation of global health capabilities. Since the skills required to navigate drivers of pandemics, and the challenges in prioritising, capacity building and response do not sit squarely in the health sector, it is essential to integrate expertise from a broad range of fields to maximise on available knowledge during decision-making and system development. Here, we review the current assessment tools and provide seven discussion points for how improvements to implementation of evidence-based prioritisation can improve global health.
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Affiliation(s)
- David T S Hayman
- Molecular Epidemiology and Public Health Laboratory, Massey University, Palmerston North, New Zealand
| | - Rosemary K Barraclough
- Molecular Epidemiology and Public Health Laboratory, Massey University, Palmerston North, New Zealand
| | - Louis J Muglia
- Burroughs Wellcome Fund, Research Triangle Park, North Carolina, USA
| | - Victoria McGovern
- Burroughs Wellcome Fund, Research Triangle Park, North Carolina, USA
| | - Muhammed O Afolabi
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Alhaji U N'Jai
- Department of Microbiology, University of Sierra Leone College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
- Department of Biological Sciences, University of Sierra Leone Fourah Bay College, Freetown, Sierra Leone
| | - Jennyfer R Ambe
- The Global Emerging Pathogens Treatment Consortium, Lagos, Nigeria
| | - Chris Atim
- Results for Development (R4D), Accra, Ghana
| | | | - Beverley Paterson
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Kashef Ijaz
- Health Programs, The Carter Center, Atlanta, Georgia, USA
| | | | - Qadeer Ahsan
- Australia Indonesia Health Security Partnership, Jakarta, Indonesia
| | | | | | - Alexandra L Phelan
- Center for Health Security, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Abigail Lopez Rivera
- US Department of Health and Human Services, Washington, District of Columbia, USA
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Belgodère L, Pougheon Bertrand D, Jaulent MC, Rabeharisoa V, Janssens W, Rollason V, Barbot J, Vernant JP, Oualikene Gonin W, Maison P, Ankri J. Patient and public involvement in the benefit-risk assessment and decision concerning health products: position of the Scientific Advisory Board of the French National Agency for Medicines and Health Products Safety (ANSM). BMJ Glob Health 2023; 8:bmjgh-2023-011966. [PMID: 37208125 DOI: 10.1136/bmjgh-2023-011966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/24/2023] [Indexed: 05/21/2023] Open
Affiliation(s)
| | - Dominique Pougheon Bertrand
- Laboratoire Educations et Promotion de la santé, LEPS, UR 3412, Université Sorbonne Paris Nord, Villetaneuse, France
| | - Marie Christine Jaulent
- INSERM, Laboratoire d'Informatique Médicale et d'Ingénierie des Connaissances en e-Santé, LIMICS, Sorbonne Université, Paris, France
| | - Vololona Rabeharisoa
- Centre de sociologie de l'innovation, UMR CNRS i3 (9217), Mines Paris - PSL, Paris, France
| | - Walter Janssens
- Federal Agency for Medicines and Health Products, Brussel, Belgium
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Department of Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneve, Switzerland
| | - Janine Barbot
- Centre d'étude des mouvements sociaux (CNRS-EHESS 8044, INSERM 1276), INSERM, Paris, France
| | - Jean Paul Vernant
- Service Hématologie, Hôpital Universitaire Pitié Salpêtrière, Paris, France
- Sorbonne Université, Paris, France
| | | | - Patrick Maison
- Délégation scientifique, ANSM, Saint-Denis, France
- EA 7379, Faculté de Santé, Université Paris-Est Créteil Val de Marne, Creteil, France
| | - Joel Ankri
- Inserm U1018, Centre de Recherche en Épidémiologie et Santé des Populations (CESP), Universite Versailles Saint-Quentin-en-Yvelines UFR de Medecine, Montigny-Le-Bretonneux, France
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Paina L, Rodriguez DC, Zakumumpa H, Mackenzie C, Ssengooba F, Bennett S. Geographic prioritisation in Kenya and Uganda: a power analysis of donor transition. BMJ Glob Health 2023; 8:bmjgh-2022-010499. [PMID: 37236658 DOI: 10.1136/bmjgh-2022-010499] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction Donor transition for HIV/AIDS programmes remains sensitive, marking a significant shift away from the traditional investment model of large-scale, vertical investments to control the epidemic and achieve rapid scaling-up of services. In late 2015, the United States President's Emergency Plan for AIDS Relief (PEPFAR) headquarters instructed their country missions to implement 'geographic prioritisation' (GP), whereby PEPFAR investments would target geographic areas with high HIV burden and reduce or cease support in areas with low burden.Methods Using Gaventa's power cube framework, we compare how power is distributed and manifested using qualitative data collected in an evaluation of the GP's impact in Kenya and Uganda.Results We found that the GP was designed with little space for national and local actors to shape either the policy or its implementation. While decision-making processes limited the scope for national-level government actors to shape the GP, the national government in Kenya claimed such a space, proactively pressuring PEPFAR to change particular aspects of its GP plan. Subnational level actors were typically recipients of top-down decision-making with apparently limited scope to resist or change GP. While civil society had the potential to hold both PEPFAR and government actors accountable, the closed-door nature of policy-making and the lack of transparency about decisions made this difficult.Conclusion Donor agencies should exercise power responsibly, especially to ensure that transition processes meaningfully engage governments and others with a mandate for service delivery. Furthermore, subnational actors and civil society are often better positioned to understand the implications and changes arising from transition. Greater transparency and accountability would increase the success of global health programme transitions, especially in the context of greater decentralisation, requiring donors and country counterparts to be more aware and flexible of working within political systems that have implications for programmatic success.
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Affiliation(s)
- Ligia Paina
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Henry Zakumumpa
- Health Policy Planning & Management, Makerere University School of Public Health, Kampala, Uganda
| | | | - Freddie Ssengooba
- Health Policy Planning & Management, Makerere University School of Public Health, Kampala, Uganda
| | - Sara Bennett
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Minckas N, Kharel R, Ryan-Coker M, Lincetto O, Tunçalp Ö, Sacks E, Muzigaba M, Portela A. Measuring experience of and satisfaction with newborn care: a scoping review of tools and measures. BMJ Glob Health 2023; 8:e011104. [PMID: 37160360 PMCID: PMC10186411 DOI: 10.1136/bmjgh-2022-011104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 03/10/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Standardised measures on experience of care are essential to understanding the care women and newborns receive and to designing appropriate interventions and responses. This review builds on ongoing work in the realm of maternity care and complements it by reviewing existing tools and measures to assess experience of and satisfaction with the care of the newborn. METHODS We conducted a scoping review of published literature to identify measures and tools of experience (physiological or indirect) and satisfaction with newborn care. We systematically searched five bibliographic databases from 1 January 2010 through 1 December 2022 and contacted professional networks. Using a predefined evidence template, we extracted data on the studies and the tools' characteristics. We mapped the tools and measures against the WHO quality of care frameworks to identify the most frequent measured domains of care and to highlight existing gaps. RESULT We identified 18 292 records of which 72 were eligible. An innovative finding of this review is the inclusion of newborn perspectives through behavioural responses, physiological signals, pain profiles as well as other non-verbal cues as markers of newborn experience. Domains related to parental participation and decision-making, ensuring continuity of care and receiving coordinated care, were the most measured across the included tools. CONCLUSION Comprehensive and validated instruments measuring all aspects of care are needed. Developing a robust theoretical ground will be fundamental to the design and utilisation of standardised tools and measures. PROTOCOL REGISTRATION DETAILS This review was registered and published on protocol.io (dx.doi.org/10.17504/protocols.io.bvk7n4zn).
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Affiliation(s)
- Nicole Minckas
- Institute for Global Health, University College London, London, UK
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Rashmi Kharel
- Institute for Global Health, University College London, London, UK
| | | | - Ornella Lincetto
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Emma Sacks
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Moise Muzigaba
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Ridde V, Kane B, Mbow NB, Senghor I, Faye A. The resilience of two departmental health insurance units during the COVID-19 pandemic in Senegal. BMJ Glob Health 2022; 7:bmjgh-2022-010062. [PMID: 36526299 PMCID: PMC9764624 DOI: 10.1136/bmjgh-2022-010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In its pursuit of solutions for universal health coverage (UHC), Senegal has set up two departmental health insurance units (UDAMs) since 2014. Few studies on the resilience of health systems in Africa have examined health insurance organisations. This article aims to understand how these two UDAMs have been resilient during the COVID-19 pandemic and the restrictive measures imposed by the State to maintain services to their members and reimbursements to healthcare providers. METHODS This study was a multicase study with multiple levels of analysis using a conceptual framework of resilience and analysis of organisational configurations. Empirical data are derived from document analysis, observations for 6 months and 17 qualitative in-depth interviews. RESULTS The results identified three main configurations concerning (1) safety and hygiene, (2) organisation and planning and (3) communication for sustainable payment. The UDAM faced the pandemic with resilience processes to absorb the shock and maintain service to their members. The UDAM learnt positive lessons from crisis management, such as remote work or the ability to support members in their care in hospitals away from their headquarters. They have innovated (transformative resilience) with the organisation of electronic payment and the use of social networks to raise funds and communicate with members. Strengthening their effectiveness after the shock of the departure of the donors in 2017 contributed to the adaptation and even transformation from the pandemic shock of 2020 and 2021. The study shows that leadership, team dynamics and adaptation to contexts are drivers of resilience processes. CONCLUSION Both UDAMs adapted to the shocks of the pandemic and government measures to maintain the services of their members and their organisational routine. This resilience confirms that UDAMs are one of the possible solutions for UHC in the Sahel.
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Affiliation(s)
- Valéry Ridde
- Université Paris Cité, IRD, Ceped, Paris, France,Université Cheikh Anta Diop, Institut de santé et developpement, Dakar, Senegal
| | - Babacar Kane
- Université Cheikh Anta Diop, Institut de santé et developpement, Dakar, Senegal
| | - Ndeye Bineta Mbow
- Foundiougne, Sénégal, Departmental Health Insurance Unit, Foundiougne, Senegal
| | - Ibrahima Senghor
- Koungheul, Sénégal, Departmental Health Insurance Unit, Koungheul, Senegal
| | - Adama Faye
- Université Cheikh Anta Diop, Institut de santé et developpement, Dakar, Senegal
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Feng XL, Zhang Y, Hu X, Ronsmans C. Tracking progress towards universal health coverage for essential health services in China, 2008-2018. BMJ Glob Health 2022; 7:bmjgh-2022-010552. [PMID: 36446446 PMCID: PMC9710350 DOI: 10.1136/bmjgh-2022-010552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/07/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION We comprehensively evaluate whether the Chinese Government's goal of ensuring Universal Health Coverage for essential health services has been achieved. METHODS We used data from the 2008, 2013 and 2018 National Health Services Survey to report on the coverage of a range of Sustainable Development Goals (SDG) indicator 3.8.1. We created per capita household income deciles for urban and rural samples separately. We report time trends in coverage and the slope index (SII) and relative index (RII). RESULTS Despite much lower levels of income and education, rural populations made as much progress as their urban counterparts for most interventions. Coverage of maternal and child health interventions increased substantially in urban and rural areas, with decreasing rich-poor inequalities except for antenatal care. In rural China, one-fifth women could not access 5 or more antenatal visits. Coverage of 8 or more visits were 34% and 68%, respectively in decile D1 (the poorest) and decile D10 (the richest) (SII 35% (95% CI 22% to 48%)). More than 90% households had access to clean water, but basic sanitation was poor for rural households and the urban poorest, presenting bottom inequality. Effective coverage for non-communicable diseases was low. Medication for hypertension and diabetes were relatively high (>70%). But adequate management, counting in preventive interventions, were much lower and decreased overtime, although inequalities were small in size. Screening of cervical and breast cancer was low in both urban and rural areas, seeing no progress overtime. Cervical cancer screening was only 29% (urban) and 24% (rural) in 2018, presenting persisted top inequalities (SII 25% urban, 14% rural). CONCLUSION China has made commendable progress in protecting the poorest for basic care. However, the 'leaving no one behind' agenda needs a strategy targeting the entire population rather than only the poorest. Blunt investing in primary healthcare facilities seems neither effective nor efficient.
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Affiliation(s)
- Xing Lin Feng
- Department of Health Policy and Management, School of Public Health, Peking University, Beijing, China
| | - Yaoguang Zhang
- Division of Health Statistics, Centre for Health Statistics and Information, National Health Commission of China, Beijing, China
| | - Xuhuai Hu
- Research Department II of Shenzhen Health Development Research and Data Management Center, Shenzhen, China
| | - Carine Ronsmans
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Gomez Ponce de Leon R, Baccaro LF, Rubio Schweizer G, Bahamondes V, Messina A, de Francisco LA, Serruya Jacob S. Building a network of sentinel centres for the care of women in an abortion situation: advances in Latin America and the Caribbean. BMJ Glob Health 2022; 7:bmjgh-2022-010059. [PMID: 36283731 PMCID: PMC9608541 DOI: 10.1136/bmjgh-2022-010059] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022] Open
Abstract
Previous reports have already estimated the overall number of abortions and the number of unsafe abortions in Latin America. Conversely, there are few reliable data from this region to inform public policies aiming to meet women’s needs. In this context, the Latin American Centre of Perinatology (Centro Latinoamericano de Perinatología (CLAP)) created a network specialising in the care of women in an abortion situation (CLAP MUSA-Network) in an attempt to strengthen healthcare surveillance in Latin America by using the Perinatal Information System (Sistema Informático Perinatal (SIP)). This system was developed by the CLAP with a special module named SIP Abortion (SIP-A), a data collection tool designed by Latin American experts to be routinely used in cases of legal and incomplete abortions. The SIP-A follows the standards established by WHO, allowing investigators to systematise information, generate local reports and monitor changes after training and follow-up interventions based on national guidelines. This network promotes collaborative work between institutions to strengthen epidemiological surveillance, cooperative investigation and development of a critical mass of professionals skilled in sexual and reproductive health. Currently, 29 sentinel centres from 13 countries jointly work exchanging information to improve surveillance of healthcare indicators of women in an abortion situation. Latin America was the first region in the world to have a network of sentinel centres that continuously monitors healthcare provision to these women. Data collected by this network are already being used to design, implement and evaluate public policies.
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Affiliation(s)
- Rodolfo Gomez Ponce de Leon
- Latin-American Center of Perinatology Women’s and Reproductive Health (CLAP SMR), Pan American Health Organization Uruguay, Montevideo, Uruguay
| | | | | | | | - Analia Messina
- Hospital de Emergencias Dr Clemente Álvarez, Rosario, Argentina
| | | | - Suzanne Serruya Jacob
- Latin-American Center of Perinatology Women’s and Reproductive Health (CLAP SMR), Pan American Health Organization Uruguay, Montevideo, Uruguay
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Shalash A, Abu-Rmeileh NME, Kelly D, Elmusharaf K. The need for standardised methods of data collection, sharing of data and agency coordination in humanitarian settings. BMJ Glob Health 2022; 7:bmjgh-2021-007249. [PMID: 36210070 PMCID: PMC9540843 DOI: 10.1136/bmjgh-2021-007249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/15/2022] [Indexed: 11/03/2022] Open
Abstract
Humanitarian crises and emergencies are prevalent all over the world. With a surge in crises in the last decade, humanitarian agencies have increased their presence in these areas. Initiatives such as the Sphere Project and the Minimum Initial Service Package known as MISP were formed to set standards and priorities for humanitarian assistance agencies. MISP was initiated to coordinate and standardise data and collection methods and involve locals for programme sustainability. Developing policies and programmes based on available data in humanitarian crises is necessary to make evidence-based decisions. Data sharing between humanitarian agencies increases the effectiveness of rapid responses and limits duplication of services and research. In addition, standardising data collection methods helps alleviate the risk of inaccurate information and allows for comparison and estimates among different settings. Big data is a new collection method that can help assemble timely data if resources are available and turn the data into information. Further research on setting priority indicators for humanitarian situations can help guide agencies to collect quality data.
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Affiliation(s)
- Aisha Shalash
- Institute of Community and Public Health, Birzeit University, Ramallah, Palestine, State of,School of Medicine, University of Limerick, Limerick, Ireland
| | - Niveen M E Abu-Rmeileh
- Institute of Community and Public Health, Birzeit University, Ramallah, Palestine, State of
| | - Dervla Kelly
- School of Medicine, University of Limerick, Limerick, Ireland
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Thomas S, Sivaram S, Shroff Z, Mahal A, Desai S. ‘We are the bridge’: an implementation research study of SEWA Shakti Kendras to improve community engagement in publicly funded health insurance in Gujarat, India. BMJ Glob Health 2022; 7:bmjgh-2022-008888. [PMID: 36379589 PMCID: PMC9511541 DOI: 10.1136/bmjgh-2022-008888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction India’s efforts towards universal health coverage include a national health insurance scheme that aims to protect the most vulnerable from catastrophic health expenditure. However, emerging evidence on publicly funded health insurance, as well as experience from community-based schemes, indicates that women face specific barriers to access and utilisation. Community engagement interventions have been shown to improve equitable utilisation of public health services, but there is limited research specific to health insurance. We examined how existing community-based resource centres implemented by a women’s organisation could improve women’s access to, and utilisation of, health insurance. Methods We conducted an implementation research study in Gujarat, India to examine how SEWA Shakti Kendras, established by the Self-Employed Women’s Association, worked to improve community engagement in health insurance. SEWA organises women in the informal sector and provides social protection through health, insurance and childcare services. We examined administrative data, programme reports and conducted 30 in-depth qualitative interviews with users and staff. Data were analysed thematically to examine intervention content, context, and implementation processes and to identify enablers and barriers to improving women’s access to health insurance through SEWA’s community engagement approach. Results The centres worked through multiple channels—doorstep services, centre-based support and health system navigation—to strengthen women’s capability to access health insurance. Each centre’s approach varied by contextual factors, such as women’s digital literacy levels and rural–urban settings. Effective community engagement required local leadership, strong government partnerships and the flexibility to address a range of public services, with implementation by trusted local health workers. Conclusion SEWA Shakti Kendras demonstrate how a local, flexible and community-based model can serve as a bridge to improve utilisation of health insurance, by engaging women and their households through multiple channels. Scaling up this approach will require investing in partnerships with community-based organisations as part of strategies towards universal health coverage.
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Affiliation(s)
- Susan Thomas
- Lok Swasthya SEWA Trust, Self-Employed Women’s Association (SEWA), Ahmedabad, Gujarat, India
| | | | - Zubin Shroff
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Ajay Mahal
- The University of Melbourne Nossal Institute for Global Health, Carlton, Victoria, Australia
| | - Sapna Desai
- Population Council Institute, New Delhi, India
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Lim KS, Yap WA, Yip W. Consumer choice and public-private providers: The role of perceived prices. Health Econ 2022; 31:1898-1925. [PMID: 35661324 DOI: 10.1002/hec.4554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 12/04/2021] [Accepted: 05/13/2022] [Indexed: 06/15/2023]
Abstract
Governments often encourage health service providers to improve quality of care and reduce prices through competition. The efficacy of competition hinges on the assumption that consumers demand high quality care at low prices for any given health condition. In this paper, we examine this assumption by investigating the role of perceived price and quality on consumer choice for four different health conditions across public and private providers. We use a nationally representative survey in Malaysia to elicit respondents' perception on prices and quality, and their preferred choice of provider. We estimate a mixed logit model and show that consumers value different dimensions of quality depending on the health condition. Furthermore, increasing perceived prices for private providers reduces demand for minor, more frequent health conditions such as flu fever or cough, but increases demand for more complex, severe conditions such as coronary artery bypass graft. These findings provide empirical support for price regulation which differentiates the severity of underlying health conditions.
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Affiliation(s)
- Kai Shen Lim
- Graduate School of Arts and Sciences, Harvard University, Boston, Massachusetts, USA
| | - Wei Aun Yap
- Quanticlear Solutions, Petaling Jaya, Malaysia
| | - Winnie Yip
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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13
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Witter S, Sheikh K, Schleiff M. Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Glob Health 2022; 7:bmjgh-2021-008115. [PMID: 36130793 PMCID: PMC9490579 DOI: 10.1136/bmjgh-2021-008115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/16/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Learning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings. Methods We adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge. Results The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels. We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions. Conclusion Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development & ReBUILD Consortium, Queen Margaret University Edinburgh, Edinburgh, UK
| | - Kabir Sheikh
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Meike Schleiff
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Patil SR, Nimmagadda S, Gopalakrishnan L, Avula R, Bajaj S, Diamond-Smith N, Paul A, Fernald L, Menon P, Walker D. Can digitally enabling community health and nutrition workers improve services delivery to pregnant women and mothers of infants? Quasi-experimental evidence from a national-scale nutrition programme in India. BMJ Glob Health 2022; 6:bmjgh-2021-007298. [PMID: 35835476 PMCID: PMC9296874 DOI: 10.1136/bmjgh-2021-007298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 04/05/2022] [Indexed: 11/05/2022] Open
Abstract
Background India’s 1.4 million community health and nutrition workers (CHNWs) serve 158 million beneficiaries under the Integrated Child Development Services (ICDS) programme. We assessed the impact of a data capture, decision support, and job-aid mobile app for the CHNWs on two primary outcomes—(1) timeliness of home visits and (2) appropriate counselling specific to the needs of pregnant women and mothers of children <12 months. Methods We used a quasi-experimental pair-matched controlled trial using repeated cross-sectional surveys to evaluate the intervention in Bihar and Madhya Pradesh (MP) separately using an intention-to-treat analysis. The study was powered to detect difference of 5–9 percentage points (pp) with type I error of 0.05 and type II error of 0.20 with endline sample of 6635 mothers of children <12 months and 2398 pregnant women from a panel of 841 villages. Results Among pregnant women and mothers of children <12 months, recall of counselling specific to the trimester of pregnancy or age of the child as per ICDS guidelines was higher in both MP (11.5pp (95% CI 7.0pp to 16.0pp)) and Bihar (8.0pp (95% CI 5.3pp to 10.7pp)). Significant differences were observed in the proportion of mothers of children <12 months receiving adequate number of home visits as per ICDS guidelines (MP 8.3pp (95% CI 4.1pp to 12.5pp), Bihar: 7.9pp (95% CI 4.1pp to 11.6pp)). Coverage of children receiving growth monitoring increased in Bihar (22pp (95% CI 0.18 to 0.25)), but not in MP. No effects were observed on infant and young child feeding practices. Conclusion The at-scale app integrated with ICDS improved provision of services under the purview of CHNWs but not those that depended on systemic factors, and was relatively more effective when baseline levels of services were low. Overall, digitally enabling CHNWs can complement but not substitute efforts for strengthening health systems and addressing structural barriers. Trial registration number ISRCTN83902145.
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Affiliation(s)
- Sumeet R Patil
- Center for Causal Research and Evaluations, NEERMAN, Mumbai, India
| | - Sneha Nimmagadda
- Center for Causal Research and Evaluations, NEERMAN, Mumbai, India
- Department of Economics, University of Southern California, Los Angeles, CA, USA
| | | | - Rasmi Avula
- International Food Policy Research Institute, New Delhi, India
| | - Sumati Bajaj
- International Food Policy Research Institute, New Delhi, India
| | - Nadia Diamond-Smith
- Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Anshuman Paul
- Center for Causal Research and Evaluations, NEERMAN, Mumbai, India
| | - Lia Fernald
- Community Health Sciences, School of Public Health, UC Berkeley, Berkeley, CA, USA
| | - Purnima Menon
- International Food Policy Research Institute, New Delhi, India
| | - Dilys Walker
- Department of Obstetrics Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, USA
- Global Health Sciences, University of California San Francisco, San Francisco, California, USA
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15
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Shajarizadeh A, Grépin KA. The impact of institutional delivery on neonatal and maternal health outcomes: evidence from a road upgrade programme in India. BMJ Glob Health 2022; 7:bmjgh-2021-007926. [PMID: 35793838 PMCID: PMC9260806 DOI: 10.1136/bmjgh-2021-007926] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 05/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Persistently high rates of neonatal and maternal mortality have been associated with home births in many low-income and middle-income countries (LMICs). However, causal evidence of the effect of institutional deliveries on neonatal and maternal health outcomes is limited in these settings. METHODS We investigate the effect of institutional deliveries on neonatal mortality and maternal postpartum complications in rural India using data from the 2015-2016 Indian Demographic and Health Survey and an instrumental variable methodology to overcome selection bias issues inherent in observational studies. Specifically, we exploit plausibly exogenous variation in exposure to a road upgrade programme that quasi-randomly upgraded roads to villages across India. RESULTS We find large effects of the road construction programme on the probability that a woman delivered in a health facility: moving from an unconnected village to a connected village increased the probability of an institutional delivery by 13 percentage points, with the biggest increases in institutional delivery observed in public hospitals and among women with lower levels of education and from poorer households. However, we find no evidence that increased institutional delivery rates improved rates of neonatal mortality or postpartum complications, regardless of whether the delivery occurred in a public or private facility, or if it was with a skilled birth attendant. CONCLUSION Policies that encourage institutional delivery do not always translate into increased health outcomes and should thus be complemented with efforts to improve the quality of care to improve neonatal and maternal health outcomes in LMICs.
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Affiliation(s)
| | - Karen Ann Grépin
- School of Public Health, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, China
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16
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Boniol M, Kunjumen T, Nair TS, Siyam A, Campbell J, Diallo K. The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage? BMJ Glob Health 2022; 7:bmjgh-2022-009316. [PMID: 35760437 PMCID: PMC9237893 DOI: 10.1136/bmjgh-2022-009316] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/17/2022] [Indexed: 11/21/2022] Open
Abstract
Objective The 2016 Global Strategy on Human Resources for Health: Workforce 2030 projected a global shortage of 18 million health workers by 2030. This article provides an assessment of the health workforce stock in 2020 and presents a revised estimate of the projected shortage by 2030. Methods Latest data reported through WHO’s National Health Workforce Accounts (NHWA) were extracted to assess health workforce stock for 2020. Using a stock and flow model, projections were computed for the year 2030. The global health workforce shortage estimation was revised. Results In 2020, the global workforce stock was 29.1 million nurses, 12.7 million medical doctors, 3.7 million pharmacists, 2.5 million dentists, 2.2 million midwives and 14.9 million additional occupations, tallying to 65.1 million health workers. It was not equitably distributed with a 6.5-fold difference in density between high-income and low-income countries. The projected health workforce size by 2030 is 84 million health workers. This represents an average growth of 29% from 2020 to 2030 which is faster than the population growth rate (9.7%). This reassessment presents a revised global health workforce shortage of 15 million health workers in 2020 decreasing to 10 million health workers by 2030 (a 33% decrease globally). WHO African and Eastern Mediterranean regions’ shortages are projected to decrease by only 7% and 15%, respectively. Conclusions The latest NHWA data show progress in the increasing size of the health workforce globally as more jobs are and will continue to be created in the health economy. It however masks considerable inequities, particularly in WHO African and Eastern Mediterranean regions, and alarmingly among the 47 countries on the WHO Support and Safeguards List. Progress should be acknowledged with caution considering the immeasurable impact of COVID-19 pandemic on health workers globally.
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Affiliation(s)
- Mathieu Boniol
- Health Workforce department, World Health Organization, Geneva, Switzerland
| | - Teena Kunjumen
- Health Workforce department, World Health Organization, Geneva, Switzerland
| | | | - Amani Siyam
- Health Workforce department, World Health Organization, Geneva, Switzerland
| | - James Campbell
- Health Workforce department, World Health Organization, Geneva, Switzerland
| | - Khassoum Diallo
- Health Workforce department, World Health Organization, Geneva, Switzerland
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Gourlay A, Floyd S, Magut F, Mulwa S, Mthiyane N, Wambiya E, Otieno M, Kamire V, Osindo J, Chimbindi N, Ziraba A, Kwaro D, Shahmanesh M, Birdthistle I. Impact of the DREAMS Partnership on social support and general self-efficacy among adolescent girls and young women: causal analysis of population-based cohorts in Kenya and South Africa. BMJ Glob Health 2022; 7:bmjgh-2021-006965. [PMID: 35232812 PMCID: PMC8889325 DOI: 10.1136/bmjgh-2021-006965] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to influence psychosocial processes that promote empowerment among adolescent girls and young women (AGYW), and reduce HIV incidence. We estimated the impact of DREAMS on aspects of AGYW's collective and individual agency (specifically, social support and self-efficacy), in three settings where DREAMS was implemented from 2016 until at least end 2018. METHODS Research cohorts of ~1500 AGYW aged 13-22 were randomly selected from demographic platforms in Kenya (Nairobi; Gem) and South Africa (uMkhanyakude) and followed up from 2017 to 2019. Social support was based on questions about female networks and access to safe places to meet with peers; general self-efficacy was measured using a scale previously validated in other settings. We conducted multivariable logistic regression, and estimated the causal effect of invitation to DREAMS on each outcome in 2018 and 2019 by comparing counter-factual scenarios in which all, vs no, AGYW were DREAMS invitees. RESULTS In Nairobi, Gem and uMkhanyakude, respectively, 74%, 57% and 53% were invited to DREAMS by 2018. Social support was higher among DREAMS invitees versus non-invitees (eg, adjusted OR 2.0 (95% CI 1.6 to 2.6), Gem, 2018). In 2018, DREAMS increased social support in all settings and age groups, for example, from 28% if none were DREAMS invitees to 43% if all were invitees (+15% (95% CI 10% to 20%)) in Gem. Effects were strongest in Kenya, but weakened in 2019, particularly among older AGYW. In uMkhanyakude, DREAMS invitees had greater self-efficacy compared with non-invitees in 2018 (+9% (95% CI 3% to 13%), 2018) but less so in 2019. In Kenyan settings, there was weak evidence for impact on self-efficacy among younger AGYW in Gem (+6% (95% CI 0% to 13%)) and older AGYW in Nairobi (+9% (95% CI -3% to +20%)) in 2019. CONCLUSIONS DREAMS impacted on social support and, less consistently, on self-efficacy. Weakening effects over time may reflect changes in access to safe spaces and social networks as AGYW age and change circumstances, and withdrawal of DREAMS from uMkhanyakude in 2018, highlighting the importance of programme sustainability and improving programming for older participants.
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Affiliation(s)
- Annabelle Gourlay
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian Floyd
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Faith Magut
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Sarah Mulwa
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Nondumiso Mthiyane
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Elvis Wambiya
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Moses Otieno
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Vivienne Kamire
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jane Osindo
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Natsayi Chimbindi
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Abdhalah Ziraba
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Daniel Kwaro
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Isolde Birdthistle
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Diallo BA, Usuf E, Ceesay O, D'Alessandro U, Roca A, Martinez-Alvarez M. Clinical research on COVID-19: perceptions and barriers to participation in The Gambia. BMJ Glob Health 2022; 7:e007533. [PMID: 35190459 PMCID: PMC8861886 DOI: 10.1136/bmjgh-2021-007533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/29/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The need to rapidly identify safe and efficacious drug therapies for COVID-19 has resulted in the implementation of multiple clinical trials investigating potential treatment options. These are being undertaken in an unprecedented research environment and at a higher speed than ever before. It is unclear how West African communities perceive such activities and how such perceptions influence participation in COVID-19 clinical trials. This qualitative study was conducted to assess the level of acceptability of a clinical trial on the prevention and treatment of COVID-19 in The Gambia and identify strategies to better engage communities in participating in such a trial. METHODS Data were collected using digitally recorded semistructured interviews (SSIs) and focus group discussions (FGDs) in Brikama and Kanifing local government areas. These are two of the most densely populated administrative subdivisions in The Gambia, where the clinical trial was to be implemented by the MRC Unit The Gambia. 26 men and 22 women aged between 19 and 70 years, with diverse socioeconomic profiles, participated in 8 FGDs (n=36) and 12 SSIs (n=12). Thematic analysis was used to analyse the data. RESULTS Fear of stigmatisation of patients with COVID-19 was a recurring theme in most FGDs and SSIs, with detrimental effects on willingness to accept COVID-19 testing and home visits to follow up patients with COVID-19 and their household contacts. Preserving the privacy of individuals enrolled in the study was key to potentially increase trial participation. Trust in the implementing institution and its acknowledged expertise were facilitators to accepting the administration of investigational products to sick individuals and their close contacts. CONCLUSION COVID-19 is a stigmatising disease. Developing a research-participant collaboration through an ongoing engagement with community members is crucial to a successful enrolment in COVID-19 clinical trials. Trust and acknowledged expertise of the implementing institution are key facilitators to foster such collaboration.
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Affiliation(s)
- Brahima Amara Diallo
- Disease Control and Elimination (DCE), Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Effua Usuf
- Disease Control and Elimination (DCE), Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Omar Ceesay
- Disease Control and Elimination (DCE), Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Umberto D'Alessandro
- Disease Control and Elimination (DCE), Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Anna Roca
- Disease Control and Elimination (DCE), Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Melisa Martinez-Alvarez
- Disease Control and Elimination (DCE), Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
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Malik MA, Rohm LR, van Baal P, van Doorslaer EVD. Improving maternal and child health in Pakistan: a programme evaluation using a difference in difference analysis. BMJ Glob Health 2022; 6:bmjgh-2021-006453. [PMID: 34969679 PMCID: PMC8718473 DOI: 10.1136/bmjgh-2021-006453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/08/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Pakistan is a country with high maternal and infant mortality. Several large foreign funded projects were targeted at improving maternal, neonatal and child health. The Norway-Pakistan Partnership Initiative (NPPI) was one of these projects. This study aims to evaluate whether NPPI was successful in improving access and use of skilled maternal healthcare. Methods We used data from three rounds (2009–2010, 2011–2012 and 2013–2014) of the Pakistan Social and Living Standards Measurement Survey (PSLM). A difference-in-difference regression framework was used to estimate the effectiveness of NPPI and its different programme components with respect to maternal healthcare seeking behaviour of pregnant women. Various parts of the PSLM were combined to examine the healthcare seeking behaviour response of pregnant women to exposure to NPPI. Results Trends in maternal care seeking behaviour of pregnant women were similar in districts exposed to NPPI and control districts. Consequently, only a weak and insignificant impact of NPPI on maternal care seeking behaviour was found. However, women in districts which used vouchers or which implemented contracting were more likely to seek skilled assistance with their delivery. Conclusion We conclude that the objective to improve access to and use of skilled care was not achieved by NPPI. The small effects identified for vouchers and contracts on skilled birth attendance hold some promise for further experimentation.
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Affiliation(s)
- Muhammad Ashar Malik
- Department of Community Health Sciences, Aga Khan Univeristy, Karachi, Sindh, Pakistan .,Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Lara Riedige Rohm
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Pieter van Baal
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Eddy van Doorslaer van Doorslaer
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus School of Economics, Erasmus University, Rotterdam, The Netherlands
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Viegas da Silva E, Hartwig FP, Barros F, Murray J. Effectiveness of a large-scale home visiting programme (PIM) on early child development in Brazil: quasi-experimental study nested in a birth cohort. BMJ Glob Health 2022; 7:e007116. [PMID: 35074788 PMCID: PMC8788193 DOI: 10.1136/bmjgh-2021-007116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/16/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND A large-scale parenting programme with weekly home visits (Primeira Infância Melhor (PIM)) has been implemented in the south of Brazil for nearly two decades, but lacks evaluation of its effects on early childhood development (ECD). This quasi-experimental study aimed to assess the effects of PIM in real-life settings within a population-based birth cohort study. METHODS Data from the 2015 Pelotas Birth Cohort Study and the state programme information system were linked to identify study children who received PIM. Propensity score matching was used to create a comparable control group (using one-to-one matching) to estimate the effect of PIM on ECD measured at age 4 years. First, the impact of any enrolment in PIM was evaluated; then the intervention group was stratified according to whether enrolment occurred during pregnancy or after birth. Double adjustment was applied in linear regression to analyse child development scores, and Poisson regression for delayed development (below the 10th percentile of whole cohort). Effect modification due to family income was explored. RESULTS There was no evidence that any enrolment in PIM (601 pairs) by age 4 years was associated with child development. However, PIM starting during pregnancy (estimated for 121 pairs) predicted higher development scores (0.27 SD; 95% CI 0.02 to 0.52), and 71% lower prevalence of delayed development (prevalence ratio=0.29; 95% CI 0.13 to 0.69), compared with the control group. There was strong statistical evidence (p=0.003, test of interaction) that the effect of PIM starting in pregnancy was larger than when starting after birth (480 pairs). The effect of PIM starting during pregnancy was found to be restricted to poorer families. CONCLUSIONS In a real-life setting, PIM was effective only when starting during pregnancy and only for poorer families. A higher-quality programme might be more effective with a broader population.
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Affiliation(s)
- Eduardo Viegas da Silva
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
- Human Development and Violence Research Centre (DOVE), Federal University of Pelotas, Pelotas, RS, Brazil
- State Health Surveillance Centre of Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Fernando Pires Hartwig
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
| | - Fernando Barros
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
| | - Joseph Murray
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil
- Human Development and Violence Research Centre (DOVE), Federal University of Pelotas, Pelotas, RS, Brazil
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Rose SM, Paterra M, Isaac C, Bell J, Stucke A, Hagens A, Tyrrell S, Guterbock M, Nuzzo JB. Analysing COVID-19 outcomes in the context of the 2019 Global Health Security (GHS) Index. BMJ Glob Health 2021; 6:bmjgh-2021-007581. [PMID: 34893478 PMCID: PMC9065770 DOI: 10.1136/bmjgh-2021-007581] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 11/17/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction The Global Health Security Index benchmarks countries’ capacities to carry out the functions necessary to prevent, detect and respond to biological threats. The COVID-19 pandemic served as an opportunity to evaluate whether the Index contained the correct array of variables that influence countries’ abilities to respond to these threats; assess additional variables that may influence preparedness; and examine how the impact of preparedness components change during public health crises. Methods Linear regression models were examined to determine the relationship between excess mortality per capita for the first 500 days of countries’ COVID-19 pandemic and internal Index variables, as well as external variables including social cohesion; island status; perceived corruption; elderly population size; previous epidemic experience; stringency of non-pharmaceutical interventions; and social and political polarisation. Results COVID-19 outcomes were significantly associated with sociodemographic, political and governance variables external to the 2019 Index: social cohesion, reduction in social polarisation and reduced perceptions of corruption were consistently correlated with reduced excess mortality throughout the pandemic. The association of other variables assessed by the Index, like epidemiological workforce robustness, changed over time. Fixed country features, including geographic connectedness, larger elderly population and lack of prior coronavirus outbreak experience were detrimental to COVID-19 outcomes. Finally, there was evidence that countries that lacked certain capacities were able to develop these over the course of the pandemic. Conclusions Additional sociodemographic, political and governance variables should be included in future indices to improve their ability to characterise preparedness. Fixed characteristics, while not directly addressable, are useful for establishing countries’ inherent risk profile and can motivate those at greater risk to invest in preparedness. Particular components of preparedness vary in their impact on outcomes over the course of the pandemic, which may inform resource direction during ongoing crises. Future research should seek to further characterise time-dependent impacts as additional COVID-19 outcome data become available.
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Affiliation(s)
- Sophie M Rose
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA .,Johns Hopkins Center for Health Security, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | - Jennifer B Nuzzo
- Johns Hopkins Center for Health Security, Baltimore, Maryland, USA
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22
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Improving Health in Slums Collaborative. Inequity of healthcare access and use and catastrophic health spending in slum communities: a retrospective, cross-sectional survey in four countries. BMJ Glob Health 2021; 6:e007265. [PMID: 34844998 DOI: 10.1136/bmjgh-2021-007265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/23/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Tracking the progress of universal health coverage (UHC) is typically at a country level. However, country-averages may mask significant small-scale variation in indicators of access and use, which would have important implications for policy choice to achieve UHC. Methods We conducted a retrospective cross-sectional household and individual-level survey in seven slum sites across Nigeria, Kenya, Bangladesh and Pakistan. We estimated the adjusted association between household capacity to pay and report healthcare need, use and spending. Catastrophic health expenditure was estimated by five different methods. Results We surveyed 7002 households and 6856 adults. Gini coefficients were wide, ranging from 0.32 to 0.48 across the seven sites. The total spend of the top 10% of households was 4–47 times more per month than the bottom 10%. Households with the highest budgets were: more likely to report needing care (highest vs lowest third of distribution of budgets: +1 to +31 percentage points (pp) across sites), to spend more on healthcare (2.0 to 6.4 times higher), have more inpatient and outpatient visits per year in five sites (1.0 to 3.0 times more frequently), spend more on drugs per visit (1.1 to 2.2 times higher) and were more likely to consult with a doctor (1.0 to 2.4 times higher odds). Better-off households were generally more likely to experience catastrophic health expenditure when calculated according to four methods (−1 to +12 pp), but much less likely using a normative method (−60 to −80 pp). Conclusions Slums have a very high degree of inequality of household budget that translates into inequities in the access to and use of healthcare. Evaluation of UHC and healthcare access interventions targeting these areas should consider distributional effects, although the standard measures may be unreliable.
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Seward N, Hanlon C, Hinrichs-Kraples S, Lund C, Murdoch J, Taylor Salisbury T, Verhey R, Shidhaye R, Thornicroft G, Araya R, Sevdalis N. A guide to systems-level, participatory, theory-informed implementation research in global health. BMJ Glob Health 2021; 6:e005365. [PMID: 34969685 PMCID: PMC8718460 DOI: 10.1136/bmjgh-2021-005365] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022] Open
Abstract
Implementation research is a multidisciplinary field that addresses the complex phenomenon of how context influences our ability to deliver evidence-informed healthcare. There is increasing realisation of the importance of applying robust implementation research to scale-up life-saving interventions that meet health-related sustainable development goals. However, the lack of high-quality implementation research is impeding our ability to meet these targets, globally. Within implementation research, theory refers to the proposed hypothesis and/or explanation of how an intervention is expected to interact with the local context and actors to bring about change. Although there is increasing interest in applying theory to understand how and why implementation programmes work in real-world settings, global health actors still tend to favour impact evaluations conducted in controlled environments. This may, in part, be due to the relative novelty as well as methodological complexity of implementation research and the need to draw on divergent disciplines, including epidemiology, implementation science and social sciences. Because of this, implementation research is faced with a particular set of challenges about how to reconcile different ways of thinking and constructing knowledge about healthcare interventions. To help translate some of the ambiguity surrounding how divergent theoretical approaches and methods contribute to implementation research, we draw on our multidisciplinary expertise in the field, particularly in global health. We offer an overview of the different theoretical approaches and describe how they are applied to continuously select, monitor and evaluate implementation strategies throughout the different phases of implementation research. In doing so, we offer a relatively brief, user-focused guide to help global health actors implement and report on evaluation of evidence-based and scalable interventions, programmes and practices.
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Affiliation(s)
- Nadine Seward
- Centre for Implementation Science, Department of Health Service and Population Research, King's College London, London, UK
| | - Charlotte Hanlon
- Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, King's College London, London, UK
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Crick Lund
- King's College London, London, UK
- University of Cape Town, Rondebosch, South Africa
| | - Jamie Murdoch
- University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | | | - Ruth Verhey
- Research Support Centre, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Rahul Shidhaye
- Pravara Institute of Medical Sciences, Loni, Maharashtra, India
| | | | | | - Nick Sevdalis
- Health Service & Population Research Department, King's College London, London, UK
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24
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Borghi J, Binyaruka P, Mayumana I, Lange S, Somville V, Maestad O. Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania. BMJ Glob Health 2021; 6:e006409. [PMID: 34916272 PMCID: PMC8679076 DOI: 10.1136/bmjgh-2021-006409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes. METHODS We conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change. RESULTS Programme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding. CONCLUSION Our study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.
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Affiliation(s)
- Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Binyaruka
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Chr Michelsen Institute, Bergen, Norway
| | - Iddy Mayumana
- Ifakara Health Institute, Ifakara, Morogoro, Tanzania, United Republic of
| | - Siri Lange
- Chr Michelsen Institute, Bergen, Norway
- Department of Health Promotion and Development, University of Bergen, Bergen, Hordaland, Norway
| | - Vincent Somville
- Chr Michelsen Institute, Bergen, Norway
- NHH Norwegian School of Economics, Bergen, Norway
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25
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Hasman A, Imohe A, Krasevec J, Moloney G, Aguayo VM. COVID-19 caused significant declines in regular vitamin A supplementation for young children in 2020: what is next? BMJ Glob Health 2021; 6:bmjgh-2021-007507. [PMID: 34785507 PMCID: PMC8595293 DOI: 10.1136/bmjgh-2021-007507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/24/2021] [Indexed: 12/29/2022] Open
Affiliation(s)
- Andreas Hasman
- Nutrition Section, Programme Group, UNICEF, New York, New York, USA
| | - Annette Imohe
- Nutrition Section, Programme Group, UNICEF, New York, New York, USA
| | - Julia Krasevec
- Division of Data, Analytics, Planning and Monitoring, UNICEF, New York, New York, USA
| | - Grainne Moloney
- Nutrition Section, Programme Group, UNICEF, New York, New York, USA
| | - Victor M Aguayo
- Nutrition Section, Programme Group, UNICEF, New York, New York, USA
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26
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Streeton AM, Kitsell F, Kung M, Oo M, Rowse V, Wadd V, Shere H. The Improving Global Health Programme - leadership development in the NHS through overseas placement. BMJ Glob Health 2021; 6:e004533. [PMID: 34853065 PMCID: PMC8633998 DOI: 10.1136/bmjgh-2020-004533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 03/06/2021] [Accepted: 03/12/2021] [Indexed: 11/03/2022] Open
Abstract
The Improving Global Health (IGH) programme develops leadership capacity within the National Health Service (NHS) in a novel way. NHS employees collaboratively run quality improvement projects within organisations in low-income and middle-income countries with whom long-standing healthcare partnerships have been built. Leadership behaviours are developed through theoretical and experiential learning, alongside induction and mentorship. The health systems of overseas partners are strengthened through projects that align with local priorities. This article develops solutions to two main problems: how reciprocal global health programmes can be designed and how global health programmes based in leadership can attract women and black and minority ethnic groups into leadership. The outcomes of both sides of the IGH programme are described here. The overseas perspective is described using the reflections of two current partners, highlighting improvements in the local healthcare system and demonstrating growth in local team members. The UK perspective is evaluated using two surveys sent to different groups of returned IGH participants. Leadership, global health and quality improvement skills improve, having a significant and long-lasting impact on career trajectory. The IGH programme is attracting women and black and minority ethnic groups into leadership. Through collaboration and reciprocity, the IGH programme is developing a new cadre of NHS leader that is diverse and inclusive. The use of long-standing healthcare partnerships ensures that learning is shared and growth is mutual, creating development within the overseas and UK partner alike.
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Affiliation(s)
- Ann-Marie Streeton
- Health Education England, Volunteer Global Engagement Directorate, UK
- General Practice Clinic, Clevedon Medical Centre, Clevedon, UK
| | - Fleur Kitsell
- Health Education England, Global Engagement Directorate, UK
| | | | - Myint Oo
- General Practitioners Society, Yangon, Myanmar
- Family Medicine, Win Family Health Clinic, Yangon, Myanmar
| | - Vicki Rowse
- Health Education England, Volunteer Global Engagement Directorate, UK
| | - Viki Wadd
- Health Education England, Volunteer Global Engagement Directorate, UK
- Transition Programme Director, Wiltshire, UK
| | - Harriet Shere
- Health Education England, Global Engagement Directorate, UK
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Caviglia M, Putoto G, Conti A, Tognon F, Jambai A, Vandy MJ, Youkee D, Buson R, Pini S, Rosi P, Hubloue I, Della Corte F, Ragazzoni L, Barone-Adesi F. Association between ambulance prehospital time and maternal and perinatal outcomes in Sierra Leone: a countrywide study. BMJ Glob Health 2021; 6:e007315. [PMID: 34844999 PMCID: PMC8634006 DOI: 10.1136/bmjgh-2021-007315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/09/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Sierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyse NEMS operational times for obstetric emergencies in respect the access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality. METHODS We collected prehospital data of 6387 obstetric emergencies referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data. RESULTS At the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120 and 180 min of PT was 1.8%, 3.8% and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18% and 25%. CONCLUSION NEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within 2 hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the 2-hour target, therefore, any reduction of the time to reach the hospital, may translate into improved patient outcomes.
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Affiliation(s)
- Marta Caviglia
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Italy
| | - Giovanni Putoto
- Research Section, Doctors with Africa CUAMM, Padova, Veneto, Italy
| | - Andrea Conti
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Italy
| | - Francesca Tognon
- Research Section, Doctors with Africa CUAMM, Padova, Veneto, Italy
| | - Amara Jambai
- Ministry of Health and Sanitation, Government of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Matthew Jusu Vandy
- Ministry of Health and Sanitation, Government of Sierra Leone, Freetown, Western Area, Sierra Leone
| | - Daniel Youkee
- School of population health and environmental sciences, King's College London, London, UK
| | - Riccardo Buson
- Research Section, Doctors with Africa CUAMM, Padova, Veneto, Italy
- Cuamm Medical Doctors for Africa, Padova, Veneto, Italy
| | - Sara Pini
- Research Section, Doctors with Africa CUAMM, Padova, Veneto, Italy
- Cuamm Medical Doctors for Africa, Padova, Veneto, Italy
| | - Paolo Rosi
- SUEM 118 - Servizio Urgenza Emergenza Medica, Azienda ULSS 3 Serenissima, Venezia, Veneto, Italy
| | - Ives Hubloue
- Research Group on Emergency and Disaster Medicine, VUB, Brussel, Belgium
| | - Francesco Della Corte
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Italy
| | - Luca Ragazzoni
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Italy
| | - Francesco Barone-Adesi
- CRIMEDIM - Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro Scuola di Medicina, Novara, Italy
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Quach A, Tosif S, Nababan H, Duke T, Graham SM, Were WM, Muzigaba M, Russell FM. Assessing the quality of care for children attending health facilities: a systematic review of assessment tools. BMJ Glob Health 2021; 6:bmjgh-2021-006804. [PMID: 34607894 PMCID: PMC8491295 DOI: 10.1136/bmjgh-2021-006804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 09/09/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Assessing quality of healthcare is integral in determining progress towards equitable health outcomes worldwide. Using the WHO 'Standards for improving quality of care for children and young adolescents in health facilities' as a reference standard, we aimed to evaluate existing tools that assess quality of care for children. METHODS We undertook a systematic literature review of publications/reports between 2008 and 2020 that reported use of quality of care assessment tools for children (<15 years) in health facilities. Identified tools were reviewed against the 40 quality statements and 510 quality measures from the WHO Standards to determine the extent each tool was consistent with the WHO Standards. The protocol was registered in PROSPERO ID: CRD42020175652. RESULTS Nine assessment tools met inclusion criteria. Two hospital care tools developed by WHO-Europe and WHO-South-East Asia Offices had the most consistency with the WHO Standards, assessing 291 (57·1%) and 208 (40·8%) of the 510 quality measures, respectively. Remaining tools included between 33 (6·5%) and 206 (40·4%) of the 510 quality measures. The WHO-Europe tool was the only tool to assess all 40 quality statements. The most common quality measures absent were related to experience of care, particularly provision of educational, emotional and psychosocial support to children and families, and fulfilment of children's rights during care. CONCLUSION Quality of care assessment tools for children in health facilities are missing some key elements highlighted by the WHO Standards. The WHO Standards are, however, extensive and applying all the quality measures in every setting may not be feasible. A consensus of key indicators to monitor the WHO Standards is required. Existing tools could be modified to include priority indicators to strengthen progress reporting towards delivering quality health services for children. In doing so, a balance between comprehensiveness and practical utility is needed. PROSPERO REGISTRATION NUMBER CRD42020175652.
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Affiliation(s)
- Alicia Quach
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia .,Asia Pacific Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Shidan Tosif
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Herfina Nababan
- Health System Strengthening Unit, World Health Organisation Country Office for Indonesia, Jakarta, Indonesia
| | - Trevor Duke
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Stephen M Graham
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,International Child Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Wilson M Were
- Maternal, Newborn, Child and Adolescent Health and Ageing Department, World Health Organization, Geneva, Switzerland
| | - Moise Muzigaba
- Maternal, Newborn, Child and Adolescent Health and Ageing Department, World Health Organization, Geneva, Switzerland
| | - Fiona M Russell
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,Asia Pacific Health Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
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Doubova SV, Leslie HH, Kruk ME, Pérez-Cuevas R, Arsenault C. Disruption in essential health services in Mexico during COVID-19: an interrupted time series analysis of health information system data. BMJ Glob Health 2021; 6:e006204. [PMID: 34470746 PMCID: PMC8413469 DOI: 10.1136/bmjgh-2021-006204] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/15/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has disrupted health systems around the world. The objectives of this study are to estimate the overall effect of the pandemic on essential health service use and outcomes in Mexico, describe observed and predicted trends in services over 24 months, and to estimate the number of visits lost through December 2020. METHODS We used health information system data for January 2019 to December 2020 from the Mexican Institute of Social Security (IMSS), which provides health services for more than half of Mexico's population-65 million people. Our analysis includes nine indicators of service use and three outcome indicators for reproductive, maternal and child health and non-communicable disease services. We used an interrupted time series design and linear generalised estimating equation models to estimate the change in service use and outcomes from April to December 2020. Estimates were expressed using average marginal effects on the risk ratio scale. RESULTS The study found that across nine health services, an estimated 8.74 million patient visits were lost in Mexico. This included a decline of over two thirds for breast and cervical cancer screenings (79% and 68%, respectively), over half for sick child visits and female contraceptive services, approximately one-third for childhood vaccinations, diabetes, hypertension and antenatal care consultations, and a decline of 10% for deliveries performed at IMSS. In terms of patient outcomes, the proportion of patients with diabetes and hypertension with controlled conditions declined by 22% and 17%, respectively. Caesarean section rate did not change. CONCLUSION Significant disruptions in health services show that the pandemic has strained the resilience of the Mexican health system and calls for urgent efforts to resume essential services and plan for catching up on missed preventive care even as the COVID-19 crisis continues in Mexico.
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Affiliation(s)
- Svetlana V Doubova
- Epidemiology and Health Services Research Unit CMN Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Hannah H Leslie
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Prevention Science, University of California San Francisco, San Francisco, California, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ricardo Pérez-Cuevas
- Division of Social Protection and Health, Inter-American Development Bank, Kingston, Jamaica
| | - Catherine Arsenault
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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30
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Ntinginya NE, Kuchaka D, Orina F, Mwebaza I, Liyoyo A, Miheso B, Aturinde A, Njeleka F, Kiula K, Msoka EF, Meme H, Sanga E, Mwanyonga S, Olomi W, Minja L, Joloba M, Mmbaga BT, Amukoye E, Gillespie SH, Sabiiti W. Unlocking the health system barriers to maximise the uptake and utilisation of molecular diagnostics in low-income and middle-income country setting. BMJ Glob Health 2021; 6:bmjgh-2021-005357. [PMID: 34429298 PMCID: PMC8386239 DOI: 10.1136/bmjgh-2021-005357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 07/21/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Early access to diagnosis is crucial for effective management of any disease including tuberculosis (TB). We investigated the barriers and opportunities to maximise uptake and utilisation of molecular diagnostics in routine healthcare settings. METHODS Using the implementation of WHO approved TB diagnostics, Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) and Line Probe Assay (LPA) as a benchmark, we evaluated the barriers and how they could be unlocked to maximise uptake and utilisation of molecular diagnostics. RESULTS Health officers representing 190 districts/counties participated in the survey across Kenya, Tanzania and Uganda. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policy-maker engagement workshops. Xpert MTB/RIF coverage was 66%, falling behind microscopy and clinical diagnosis by 33% and 1%, respectively. Stratified by HCF type, Xpert MTB/RIF implementation was 56%, 96% and 95% at district, regional and national referral hospital levels. LPA coverage was 4%, 3% below culture across the three countries. Out of 111 HCFs with Xpert MTB/RIF, 37 (33%) used it to full capacity, performing ≥8 tests per day of which 51% of these were level five (zonal consultant and national referral) HCFs. Likewise, 75% of LPA was available at level five HCFs. Underutilisation of Xpert MTB/RIF and LPA was mainly attributed to inadequate-utilities, 26% and human resource, 22%. Underfinancing was the main reason underlying failure to acquire molecular diagnostics. Second to underfinancing was lack of awareness with 33% healthcare administrators and 49% practitioners were unaware of LPA as TB diagnostic. Creation of a national health tax and decentralising its management was proposed by policy-makers as a booster of domestic financing needed to increase access to diagnostics. CONCLUSION Our findings suggest higher uptake and utilisation of molecular diagnostics at tertiary level HCFs contrary to the WHO recommendation. Country-led solutions are crucial for unlocking barriers to increase access to diagnostics.
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Affiliation(s)
- Nyanda Elias Ntinginya
- Mbeya Medical Research Centre, National Institute for Medical Research, Mbeya, United Republic of Tanzania
| | - Davis Kuchaka
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Fred Orina
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ivan Mwebaza
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alphonce Liyoyo
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Barbara Miheso
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Augustus Aturinde
- Department of Physical Geography and Ecosystem Science, Lund University, Lund, Sweden.,Department of Lands and Architectural Studies, Kyambogo University, Kampala, Uganda
| | - Fred Njeleka
- Mbeya Medical Research Centre, National Institute for Medical Research, Mbeya, United Republic of Tanzania
| | - Kiula Kiula
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania.,Humanities and Social sciences, The University of Dodoma College, Dodoma, United Republic of Tanzania
| | - Elizabeth F Msoka
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Helen Meme
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Erica Sanga
- Mbeya Medical Research Centre, National Institute for Medical Research, Mbeya, United Republic of Tanzania.,Mwanza Research Centre, National Institute for Medical Research, Mwanza, United Republic of Tanzania
| | - Simeon Mwanyonga
- Mbeya Medical Research Centre, National Institute for Medical Research, Mbeya, United Republic of Tanzania
| | - Willyhelmina Olomi
- Mbeya Medical Research Centre, National Institute for Medical Research, Mbeya, United Republic of Tanzania
| | - Linda Minja
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Moses Joloba
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre, Moshi, United Republic of Tanzania
| | - Evans Amukoye
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Stephen Henry Gillespie
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| | - Wilber Sabiiti
- Division of Infection and Global Health, School of Medicine, University of St Andrews, St Andrews, Scotland, UK
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Arsenault C, Yakob B, Kassa M, Dinsa G, Verguet S. Using health management information system data: case study and verification of institutional deliveries in Ethiopia. BMJ Glob Health 2021; 6:bmjgh-2021-006216. [PMID: 34426404 PMCID: PMC8383857 DOI: 10.1136/bmjgh-2021-006216] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/03/2021] [Indexed: 11/05/2022] Open
Abstract
Health management information systems (HMIS) are a crucial source of timely health statistics and have the potential to improve reporting in low-income countries. However, concerns about data quality have hampered their widespread adoption in research and policy decisions. This article presents results from a data verification study undertaken to gain insights into the quality of HMIS data in Ethiopia. We also provide recommendations for working with HMIS data for research and policy translation. We linked the HMIS to the 2016 Emergency Obstetric and Newborn Care Assessment, a national census of all health facilities that provided maternal and newborn health services in Ethiopia. We compared the number of visits for deliveries and caesarean sections (C-sections) reported in the HMIS in 2015 (January–December) to those found in source documents (paper-based labour and delivery and operating theatre registers) in 2425 facilities across Ethiopia. We found that two-thirds of facilities had ‘good’ HMIS reporting for deliveries (defined as reporting within 10% of source documents) and half had ‘very good’ reporting (within 5% of source documents). Results were similar for reporting on C-section deliveries. We found that good reporting was more common in urban areas (OR: 1.30, 95% CI 1.06 to 1.59), public facilities (OR: 2.95, 95% CI 1.38 to 6.29) and in hospitals compared with health centres (OR: 1.71, 95% CI 1.13 to 2.61). Facilities in the Somali and Afar regions had the lowest odds of good reporting compared with Addis Ababa and were more likely to over-report deliveries in the HMIS. Further work remains to address remaining discrepancies in the Ethiopian HMIS. Nonetheless, our findings corroborate previous data verification exercises in Ethiopia and support greater use and uptake of HMIS data for research and policy decisions (particularly, greater use of HMIS data elements (eg, absolute number of services provided each month) rather than coverage indicators). Increased use of these data, combined with feedback mechanisms, is necessary to maintain data quality.
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Affiliation(s)
- Catherine Arsenault
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Bereket Yakob
- Fenot project, School of Population and Public Health, University of British Columbia, Addis Ababa, Ethiopia
| | - Munir Kassa
- Minister's Office, Ministry of Health, Addis Ababa, Ethiopia
| | - Girmaye Dinsa
- Fenot project, School of Population and Public Health, University of British Columbia, Addis Ababa, Ethiopia.,Department of Public Health and Health Policy, Haramaya University, Hararamaya, Ethiopia
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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32
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Khalil K, Das P, Kammowanee R, Saluja D, Mitra P, Das S, Gharai D, Bhatt D, Kumar N, Franzen S. Ethical considerations of phone-based interviews from three studies of COVID-19 impact in Bihar, India. BMJ Glob Health 2021; 6:bmjgh-2021-005981. [PMID: 34404691 PMCID: PMC8375446 DOI: 10.1136/bmjgh-2021-005981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 05/30/2021] [Indexed: 11/30/2022] Open
Abstract
Phone-based interviews present a range of ethical challenges, including how to ensure informed consent and privacy and maintain confidentiality. Our paper presents conceptual and practical ethical considerations taken into account across three telephone studies on the impact of COVID-19 conducted following India’s nationwide lockdown imposed in March 2020. Two studies captured COVID-19 response impact on primary-level Reproductive Maternal Neonatal and Child Health (RMNCH) services and on provider wellness, respectively. The third study focused on how the gendered experience of COVID-19 and the state’s response to control transmission impacted women’s lives, focusing on health services, livelihood, entitlements and social change, by interviewing individual women. The ethical challenges as well as the advantages of digital data collection are presented with recommendations for low-resource settings. Ethical considerations included the above challenges as well as avoiding posing unreasonable time burden on the respondents, framing questions with a gendered lens, considering emotional states given contagion concerns and economic uncertainties, and redressing pandemic-induced distress. Using scripted Hindi was challenging in consent-taking, as was protecting household respondents’ privacy and confidentiality during lockdown. Unanticipated positive ethical implications of using a telephone approach included providing respondents privacy and catharsis, respondents choosing convenient interview times and affording health providers more privacy than institutional inperson interviews. Internalising empathy, respect and appreciative enquiry are key to establishing rapport in the absence of prior relationships. Institutional Review Board (IRB) time limits on call duration need to be flexible to allow for ‘active listening’ and empathetic enquiry in surveys on the impact of COVID-19.
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Affiliation(s)
- Karima Khalil
- Software and Gender, Oxford Policy Management, New Delhi, India
| | - Priya Das
- Health System Software and Gender, Oxford Policy Management, New Delhi, India
| | - Rochana Kammowanee
- Health System Software and Gender, Oxford Policy Management, New Delhi, India
| | - Deepika Saluja
- Health System Software and Gender, Oxford Policy Management, New Delhi, India
| | - Priyanjali Mitra
- Sociology, University of Chicago Division of the Social Sciences, Chicago, Illinois, USA
| | - Shamayita Das
- Software and Gender, Oxford Policy Management, New Delhi, India
| | | | - Dinesh Bhatt
- Training and Survey Operations, Oxford Policy Management, New Delhi, India
| | - Navneet Kumar
- Training and Survey Operations, Oxford Policy Management, Oxford, UK
| | - Samuel Franzen
- Monitoring and Evaluation, Health Portfolio, Oxford Policy Management, Oxford, UK
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Glandon D, Paina L, Hoe C. Reflections on benefits and challenges of longitudinal organisational network analysis as a tool for health systems research and practice. BMJ Glob Health 2021; 6:bmjgh-2021-005849. [PMID: 34385160 PMCID: PMC8362700 DOI: 10.1136/bmjgh-2021-005849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/25/2021] [Indexed: 11/05/2022] Open
Abstract
As health systems practitioners and researchers increasingly turn towards systems thinking approaches and work on building interorganisational networks, they have demonstrated increasing interest in network analysis for investigating relationships and interactions between system actors, both at the individual and organisational levels. Despite the potential of network-based approaches to improve health system efficiency, effectiveness and responsiveness, both the theoretical and practical guidance on designing and evaluating network-building strategies is underdeveloped within the field. While there are multiple tools and resources to help users collect, manage and analyse network data, there is much less guidance on the practical applications of this information. One apparent gap is the limited application of longitudinal organisational network analysis, in which data are collected from the same organisational actors repeatedly over multiple time points. This yields insights into the dynamic nature of networks, including how the network structure and interactions change over time. Given that networks are rarely static, the addition of the time dimension has the potential to substantially enhance the analytical value of network analysis and contribute to more nuanced guidance for interested practitioners and policymakers. In this article, the authors draw on their experiences in conducting longitudinal network analysis of interorganisational relationships in the USA and India to comment on the opportunities and challenges of the methodology within the field of health systems research. We also provide suggestions as to how some of these challenges may be addressed or mitigated.
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Affiliation(s)
- Douglas Glandon
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ligia Paina
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Connie Hoe
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Schierhout G, Praveen D, Patel B, Li Q, Mogulluru K, Ameer MA, Patel A, Clifford GD, Joshi R, Heritier S, Maulik P, Peiris D. Why do strategies to strengthen primary health care succeed in some places and fail in others? Exploring local variation in the effectiveness of a community health worker managed digital health intervention in rural India. BMJ Glob Health 2021; 6:bmjgh-2021-005003. [PMID: 34312146 PMCID: PMC8314716 DOI: 10.1136/bmjgh-2021-005003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Digital health interventions (DHIs) have huge potential as support modalities to identify and manage cardiovascular disease (CVD) risk in resource-constrained settings, but studies assessing them show modest effects. This study aims to identify variation in outcomes and implementation of SMARTHealth India, a cluster randomised trial of an ASHA-managed digitally enabled primary healthcare (PHC) service strengthening strategy for CVD risk management, and to explain how and in what contexts the intervention was effective. Methods We analysed trial outcome and implementation data for 18 PHC centres and collected qualitative data via focus groups with ASHAs (n=14) and interviews with ASHAs, PHC facility doctors and fieldteam mangers (n=12) Drawing on principles of realist evaluation and an explanatory mixed-methods design we developed mechanism-based explanations for observed outcomes. Results There was substantial between-cluster variation in the primary outcome (overall: I2=62.4%, p<=0.001). The observed heterogeneity in trial outcomes was not attributable to any single factor. Key mechanisms for intervention effectiveness were community trust and acceptability of doctors’ and ASHAs’ new roles, and risk awareness. Enabling local contexts were seen to evolve over time and in response to the intervention. These included obtaining legitimacy for ASHAs’ new roles from trusted providers of curative care; ASHAs’ connections to community and to qualified providers; their responsiveness to community needs; and the accessibility, quality and appropriateness of care provided by higher level medical providers, including those outside of the implementing (public) subsystem. Conclusion Local contextual factors were significant influences on the effectiveness of this DHI-enabled PHC service strategy intervention. Local adaptions need to be planned for, monitored and responded to over time. By identifying plausible explanations for variation in outcomes between clusters, we identify potential strategies to strengthen such interventions.
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Affiliation(s)
- Gill Schierhout
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Devarsetty Praveen
- The George Institute for Global Health India, Hyderabad, India .,UNSW Sydney, Sydney, New South Wales, Australia
| | - Bindu Patel
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Qiang Li
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Kishor Mogulluru
- The George Institute for Global Health India, New Delhi, Delhi, India
| | | | - Anushka Patel
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
| | - Gari D Clifford
- Department of Biomedical Informatics and Biomedical Engineering, Emory University, Atlanta, Georgia, USA.,Department of Biomedical Informatics and Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Rohina Joshi
- The George Institute for Global Health, Newtown, New South Wales, Australia.,The George Institute for Global Health India, New Delhi, Delhi, India
| | | | - Pallab Maulik
- UNSW, Sydney, New South Wales, Australia.,George Institute for Global Health India, New Delhi, India
| | - David Peiris
- The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, New South Wales, Australia
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Wulandari LPL, Khan M, Liverani M, Ferdiana A, Mashuri YA, Probandari A, Wibawa T, Batura N, Schierhout G, Kaldor J, Guy R, Law M, Day R, Hanefeld J, Parathon H, Jan S, Yeung S, Wiseman V. Prevalence and determinants of inappropriate antibiotic dispensing at private drug retail outlets in urban and rural areas of Indonesia: a mixed methods study. BMJ Glob Health 2021; 6:e004993. [PMID: 34344668 PMCID: PMC8336216 DOI: 10.1136/bmjgh-2021-004993] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 06/29/2021] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION The aim of this mixed-method study was to determine the extent and determinants of inappropriate dispensing of antibiotics by licensed private drug retail outlets in Indonesia. METHODS Standardised patients (SPs) made a total of 495 visits to 166 drug outlets (community pharmacies and drug stores) between July and August 2019. The SPs presented three clinical cases to drug outlet staff: parent of a child at home with diarrhoea; an adult with presumptive tuberculosis (TB); and an adult with upper respiratory tract infection (URTI). The primary outcome was the dispensing of an antibiotic without prescription, with or without the client requesting it. We used multivariable random effects logistic regression to assess factors associated with the primary outcome and conducted 31 interviews with drug outlet staff to explore these factors in greater depth. RESULTS Antibiotic dispensing without prescription occurred in 69% of SP visits. Dispensing antibiotics without a prescription was more likely in standalone pharmacies and pharmacies attached to clinics compared with drug stores, with an OR of 5.9 (95% CI 3.2 to 10.8) and OR of 2.2 (95% CI 1.2 to 3.9); and more likely for TB and URTI SP-performed cases compared with child diarrhoea cases, with an OR of 5.7 (95% CI 3.1 to 10.8) and OR of 5.2 (95% CI 2.7 to 9.8). Interviews revealed that inappropriate antibiotic dispensing was driven by strong patient demand for antibiotics, unqualified drug sellers dispensing medicines, competition between different types of drug outlets, drug outlet owners pushing their staff to sell medicines, and weak enforcement of regulations. CONCLUSION This study shows that inappropriate dispensing of antibiotics by private drug retail outlets is widespread. Interventions will need to address not only the role of drug sellers, but also the demand for antibiotics among clients and the push from drug outlet owners to compete with other outlets.
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Affiliation(s)
- Luh Putu Lila Wulandari
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Faculty of Medicine, Universitas Udayana, Denpasar, Bali, Indonesia
| | - Mishal Khan
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Pathology & Community Health Sciences, The Aga Khan University, Karachi, Sindh, Pakistan
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - Astri Ferdiana
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Universitas Mataram, Mataram, Nusa Tenggara Barat, Indonesia
| | - Yusuf Ari Mashuri
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia
| | - Ari Probandari
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Jawa Tengah, Indonesia
| | - Tri Wibawa
- Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Neha Batura
- Institute for Global Health, University College London, London, UK
| | - Gill Schierhout
- The George Institute for Global Health, UNSW Sydney, Newtown, New South Wales, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Rebecca Guy
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Matthew Law
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Richard Day
- St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Johanna Hanefeld
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Centre for International Health Protection, Robert Koch Institute, Berlin, Germany
| | - Harry Parathon
- Antibiotic Resistance Control Committee, Indonesian Ministry of Health, Jakarta, Indonesia
| | - Stephen Jan
- The George Institute for Global Health, UNSW Sydney, Newtown, New South Wales, Australia
| | - Shunmay Yeung
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Bashingwa JJH, Shah N, Mohan D, Scott K, Chamberlain S, Mulder N, Rahul S, Arora S, Chakraborty A, Ummer O, Ved R, LeFevre AE. Examining the reach and exposure of a mobile phone-based training programme for frontline health workers (ASHAs) in 13 states across India. BMJ Glob Health 2021; 6:e005299. [PMID: 34429283 PMCID: PMC8386225 DOI: 10.1136/bmjgh-2021-005299] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 11/06/2022] Open
Abstract
Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states.
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Affiliation(s)
- Jean Juste Harrisson Bashingwa
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, Cape Town, Western Cape, South Africa
| | - Neha Shah
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Diwakar Mohan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kerry Scott
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Nicola Mulder
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, Cape Town, South Africa
| | - Sai Rahul
- BeeHyv Software Solutions Pvt. Ltd, Hyderabad, Telangana, India
| | - Salil Arora
- BBC Media Action, India, New Delhi, Delhi, India
| | | | - Osama Ummer
- BBC Media Action, India, New Delhi, Delhi, India
- Oxford Policy Management, New Delhi, Delhi, India
| | - Rajani Ved
- National Health Systems Resource Centre, New Delhi, Delhi, India
| | - Amnesty Elizabeth LeFevre
- International Health, Baltimore, Maryland, USA
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Bashingwa JJH, Mohan D, Chamberlain S, Arora S, Mendiratta J, Rahul S, Chauhan V, Scott K, Shah N, Ummer O, Ved R, Mulder N, LeFevre AE. Assessing exposure to Kilkari: a big data analysis of a large maternal mobile messaging service across 13 states in India. BMJ Glob Health 2021; 6:e005213. [PMID: 34312148 PMCID: PMC8327807 DOI: 10.1136/bmjgh-2021-005213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/27/2021] [Accepted: 03/31/2021] [Indexed: 11/22/2022] Open
Abstract
The Kilkari programme is being implemented by the Government of India in 13 states. Designed by BBC Media Action and scaled in collaboration with the Ministry of Health and Family Welfare from January 2016, Kilkari had provided mobile health information to over 10 million subscribers by the time BBC Media Action transitioned the service to the government in April 2019. Despite the reach of Kilkari in terms of the absolute number of subscribers, no longitudinal analysis of subscriber exposure to health information content over time has been conducted, which may underpin effectiveness and changes in health outcomes. In this analysis, we draw from call data records to explore exposure to the Kilkari programme in India for the 2018 cohort of subscribers. We start by assessing the timing of the first successful call answered by subscribers on entry to the programme during pregnancy or postpartum, and then assess call volume, delivery, answering and listening rates over time. Findings suggest that over half of subscribers answer their first call after childbirth, with the remaining starting in the pregnancy period. The system handles upwards of 1.2 million calls per day on average. On average, 50% of calls are picked up on the first call attempt, 76% by the third and 99.5% by the ninth call attempt. Among calls picked up, over 48% were listened to for at least 50% of the total content duration and 43% were listened to for at least 75%. This is the first analysis of its kind of a maternal mobile messaging programme at scale in India. Study analyses suggest that multiple call attempts may be required to reach subscribers. However, once answered, subscribers tend to listen the majority of the call-a figure consistent across states, over time, and by health content area.
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Affiliation(s)
- Jean Juste Harrisson Bashingwa
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Diwakar Mohan
- International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | | | | | - Sai Rahul
- Beehyv Software Solutions Pvt Ltd, Hyderabad, India
| | | | - Kerry Scott
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Neha Shah
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Osama Ummer
- BBC Media Action, Delhi, India
- Oxford Policy Management-Delhi, Delhi, India
| | - Rajani Ved
- National Health Systems Resource Centre, New Delhi, Delhi, India
| | - Nicola Mulder
- Computational Biology Division, Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Amnesty Elizabeth LeFevre
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Hompashe DM, Gerdtham UG, Christian CS, Smith A, Burger R. 'The nurse did not even greet me': how informed versus non-informed patients evaluate health systems responsiveness in South Africa. BMJ Glob Health 2021; 6:bmjgh-2020-004360. [PMID: 33893142 PMCID: PMC8074562 DOI: 10.1136/bmjgh-2020-004360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/13/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Universal Health Coverage is not only about access to health services but also about access to high-quality care, since poor experiences may deter patients from accessing care. Evidence shows that quality of care drives health outcomes, yet little is known about non-clinical dimensions of care, and patients’ experience thereof relative to satisfaction with visits. This paper investigates the role of non-clinical dimensions of care in patient satisfaction. Methods Our study describes the interactions of informed and non-informed patients with primary healthcare workers at 39 public healthcare facilities in two metropolitan centres in two South African provinces. Our analysis included 1357 interactions using standardised patients (for informed patients) and patients’ exit interviews (for non-informed patients). The data were combined for three types of visits: contraception, hypertension and tuberculosis. We describe how satisfaction with care was related to patients’ experiences of non-clinical dimensions. Results We show that when real patients (RPs) reported being satisfied (vs dissatisfied) with a visit, it was associated with a 30% increase in the probability that a patient is greeted at the facilities. Likewise, when the RPs reported being satisfied (vs dissatisfied) with the visit, it was correlated with a 15% increase in the prospect that patients are pleased with healthcare workers’ explanations of health conditions. Conclusion Informed patients are better equipped to assess health-systems responsiveness in healthcare provision. Insights into responsiveness could guide broader efforts aimed at targeted education and empowerment of primary healthcare users to strengthen health systems and shape expectations for appropriate care and conduct.
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Affiliation(s)
- Dumisani MacDonald Hompashe
- Economics, University of Fort Hare Faculty of Management and Commerce, Alice, South Africa .,Economics, Stellenbosch University Faculty of Economic and Management Sciences, Stellenbosch, South Africa
| | | | | | - Anja Smith
- Economics, Stellenbosch University Faculty of Economic and Management Sciences, Stellenbosch, South Africa
| | - Ronelle Burger
- Economics, Stellenbosch University Faculty of Economic and Management Sciences, Stellenbosch, South Africa
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Said A, Sirili N, Massawe S, Pembe AB, Hanson C, Malqvist M. Mismatched ambition, execution and outcomes: implementing maternal death surveillance and response system in Mtwara region, Tanzania. BMJ Glob Health 2021; 6:bmjgh-2021-005040. [PMID: 34020994 PMCID: PMC8144036 DOI: 10.1136/bmjgh-2021-005040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/07/2022] Open
Abstract
Background Since 2015, Tanzania has been implementing the Maternal Death Surveillance and Response (MDSR) system. The system employs interactions of health providers and managers to identify, notify and review maternal deaths and recommend strategies for preventing further deaths. We aimed to analyse perceptions and experiences of health providers and managers in implementing the MDSR system. Methods An exploratory qualitative study was carried out with 30 purposively selected health providers and 30 health managers in four councils from the Mtwara region between June and July 2020. Key informant interviews and focus group discussions were used to collect data. Inductive thematic analysis was used to analyse data. Results Two main themes emerged from this study: ‘Accomplishing by ambitions’ and ‘A flawed system’. The themes suggest that health providers and managers have a strong desire to make the MDSR system work by making deliberate efforts to implement it. They reported working hard to timely notify, review death and implement action plans from meetings. Health providers and managers reported that MDSR has produced changes in care provision such as behavioural changes towards maternal care, increased accountability and policy changes. The system was however flawed by lack of training, organisational problems, poor coordination with other reporting and quality improvements systems, assigning blame and lack of motivation. Conclusion The implementation of the MDSR system in Tanzania faces systemic, contextual and individual challenges. However, our results indicate that health providers and managers are willing and committed to improve service delivery to avoid maternal deaths. Empowering health providers and managers by training and addressing the flaws will improve the system and quality of care.
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Affiliation(s)
- Ali Said
- Department of Women and Children's Health, Uppsala University, Uppsala, Sweden .,Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Nathanael Sirili
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Siriel Massawe
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Andrea B Pembe
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden.,Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Mats Malqvist
- Department of Women and Children's Health, Uppsala University, Uppsala, Sweden
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Croke K, Telaye Mengistu A, O'Connell SD, Tafere K. The impact of a health facility construction campaign on health service utilisation and outcomes: analysis of spatially linked survey and facility location data in Ethiopia. BMJ Glob Health 2021; 5:bmjgh-2020-002430. [PMID: 32859649 PMCID: PMC7454195 DOI: 10.1136/bmjgh-2020-002430] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/21/2020] [Accepted: 05/23/2020] [Indexed: 11/03/2022] Open
Abstract
Background Access to health facilities in many low-income and middle-income countries remains low, with a strong association between individuals’ distance to facilities and health outcomes. Yet plausibly causal estimates of the effects of facility construction programmes are rare. Starting in 2004, more than 2800 government health facilities were built in Ethiopia. This study estimates the impact of this programme on maternal health service utilisation and birth outcomes. Methods We analyse the impact of Ethiopia’s health centre construction programme on health service utilisation and outcomes, using a difference-in-difference design. We match facility opening years to child birth years in four rounds of Demographic and Health Surveys (DHS) using georeferenced data. We also use event study models to test for pre-trends in the outcomes of interest. Results Opening of new health facilities within 5 km increases facility delivery by 7.2 percentage points (95% CI 5.2 to 9.1) and antenatal care by 0.38 visits (95% CI 0.24 to 0.52). It is not significantly associated with changes in caesarean section births or neonatal mortality. Opening of district hospitals increases facility delivery by 18.2 percentage points (95% CI 12.7 to 23.7), and caesarean section births by 6.8 percentage points (95% CI 2.5 to 11.2), but is not associated with reduction of neonatal mortality. Conclusions Ethiopia’s facility construction program improved access to antenatal and delivery care. However, there was no detectable association between facility construction and neonatal mortality. Increased access to care must be combined with health system quality improvements and broader social development initiatives to sustainably improve health outcomes.
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Affiliation(s)
- Kevin Croke
- Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | | | | | - Kibrom Tafere
- Development Economics Group, World Bank Group, Washington, DC, USA
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Mukonda E, Hsiao NY, Vojnov L, Myer L, Lesosky M. Mixed-method estimation of population-level HIV viral suppression rate in the Western Cape, South Africa. BMJ Glob Health 2021; 5:bmjgh-2020-002522. [PMID: 32816953 PMCID: PMC7437711 DOI: 10.1136/bmjgh-2020-002522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION There are few population-wide data on viral suppression (VS) that can be used to monitor programmatic targets in sub-Saharan Africa. We describe how routinely collected viral load (VL) data from antiretroviral therapy (ART) programmes can be extrapolated to estimate population VS and validate this using a combination of empiric and model-based estimates. METHODS VL test results from were matched using a record linkage algorithm to obtain linked results for individuals. Test-level and individual-level VS rates were based on test VL values <1000 cps/mL, and individual VL <1000 cps/mL in a calendar year, respectively. We calculated population VS among people living with HIV (PLWH) in the province by combining census-derived midyear population estimates, HIV prevalence estimates and individual level VS estimates from routine VL data. RESULTS Approximately 1.9 million VL test results between 2008 and 2018 were analysed. Among individuals in care, VS increased from 85.5% in 2008 to 90% in 2018. Population VS among all PLWH in the province increased from 12.2% in 2008 to 51.0% in 2017. The estimates derived from this method are comparable to those from other published studies. Sensitivity analyses showed that the results are robust to variations in linkage method, but sensitive to the extreme combinations of assumed VL testing coverage and population HIV prevalence. CONCLUSION While validation of this method in other settings is required, this approach provides a simple, robust method for estimating population VS using routine data from ART services that can be employed by national programmes in high-burden settings.
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Affiliation(s)
- Elton Mukonda
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Nei-Yuan Hsiao
- National Health Laboratory Services, Groote Schuur Hospital, Cape Town, South Africa.,Division of Medical Virology, Department of Pathology, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Lara Vojnov
- World Health Organization, Geneva, GE, Switzerland
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Maia Lesosky
- Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, Western Cape, South Africa
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Iyer HS, Flanigan J, Wolf NG, Schroeder LF, Horton S, Castro MC, Rebbeck TR. Geospatial evaluation of trade-offs between equity in physical access to healthcare and health systems efficiency. BMJ Glob Health 2021; 5:bmjgh-2020-003493. [PMID: 33087394 PMCID: PMC7580044 DOI: 10.1136/bmjgh-2020-003493] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 02/05/2023] Open
Abstract
Introduction Decisions regarding the geographical placement of healthcare services require consideration of trade-offs between equity and efficiency, but few empirical assessments are available. We applied a novel geospatial framework to study these trade-offs in four African countries. Methods Geolocation data on population density (a surrogate for efficiency), health centres and cancer referral centres in Kenya, Malawi, Tanzania and Rwanda were obtained from online databases. Travel time to the closest facility (a surrogate for equity) was estimated with 1 km resolution using the Access Mod 5 least cost distance algorithm. We studied associations between district-level average population density and travel time to closest facility for each country using Pearson’s correlation, and spatial autocorrelation using the Global Moran’s I statistic. Geographical clusters of districts with inefficient resource allocation were identified using the bivariate local indicator of spatial autocorrelation. Results Population density was inversely associated with travel time for all countries and levels of the health system (Pearson’s correlation range, health centres: −0.89 to −0.71; cancer referral centres: −0.92 to −0.43), favouring efficiency. For health centres, negative spatial autocorrelation (geographical clustering of dissimilar values of population density and travel time) was weaker in Rwanda (−0.310) and Tanzania (−0.292), countries with explicit policies supporting equitable access to rural healthcare, relative to Kenya (−0.579) and Malawi (−0.543). Stronger spatial autocorrelation was observed for cancer referral centres (Rwanda: −0.341; Tanzania: −0.259; Kenya: −0.595; Malawi: −0.666). Significant geographical clusters of sparsely populated districts with long travel times to care were identified across countries. Conclusion Negative spatial correlations suggested that the geographical distribution of health services favoured efficiency over equity, but spatial autocorrelation measures revealed more equitable geographical distribution of facilities in certain countries. These findings suggest that even when prioritising efficiency, thoughtful decisions regarding geographical allocation could increase equitable physical access to services.
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Affiliation(s)
- Hari S Iyer
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA .,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, United States
| | - John Flanigan
- Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Nicholas G Wolf
- Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | | | - Susan Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
| | - Marcia C Castro
- Department of Global Health and Population, Harvard University T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Timothy R Rebbeck
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, United States.,Zhu Family Center for Global Cancer Prevention, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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Chalkidou K, Towse A, Silverman R, Garau M, Ramakrishnan G. Market-driven, value-based, advance commitment (MVAC): accelerating the development of a pathbreaking universal drug regimen to end TB. BMJ Glob Health 2021; 5:bmjgh-2019-002061. [PMID: 32332035 PMCID: PMC7204919 DOI: 10.1136/bmjgh-2019-002061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Kalipso Chalkidou
- Center of Global Development, Washington, District of Columbia, USA .,Global Health and Development Group, Imperial College London, London, United Kingdom
| | | | - Rachel Silverman
- Center of Global Development, Washington, District of Columbia, USA
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Jalloh MF, Hickler B, Parmley LE, Sutton R, Kulkarni S, Mansaray A, Eleeza O, Patel P, Wilhelm E, Conklin L, Akinjeji A, Toure M, Wolff B, Prybylski D, Wallace AS, Lahuerta M. Using immunisation caregiver journey interviews to understand and optimise vaccination uptake: lessons from Sierra Leone. BMJ Glob Health 2021; 6:bmjgh-2021-005525. [PMID: 34045184 PMCID: PMC8162096 DOI: 10.1136/bmjgh-2021-005525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/10/2021] [Indexed: 11/10/2022] Open
Abstract
Quantitative and qualitative assessments have revealed diverse factors that influence the uptake of childhood immunisation services and shed light on reasons for vaccination delays and refusals. UNICEF and partner organisations developed the Immunisation Caregiver Journey Framework as a novel way to understand caregiver experiences in accessing and receiving immunisation services for children. This framework aims to help immunisation programmes identify vaccination barriers and opportunities to improve vaccination uptake by enhancing the overall caregiver journey in a systems-focused manner, using human-centred design principles. In this paper, we adapt the framework into a flexible qualitative inquiry approach with theoretical guidance from interpretative phenomenology. We draw from the implementation experiences in Sierra Leone to inform methodological guidance on how to design and implement the Immunisation Caregiver Journey Interviews (ICJI) to understand the lived experiences of caregivers as they navigate immunisation services for their children. Practical guidance is provided on sampling techniques, conducting interviews, data management, data analysis and the use of data to inform programmatic actions. When properly implemented, the ICJI approach generates a rich qualitative understanding of how caregivers navigate household and community dynamics, as well as primary healthcare delivery systems. We argue that understanding and improving the caregiver journey will enhance essential immunisation outcomes, such as the completion of the recommended vaccination schedule, timeliness of vaccination visits and reduction in dropouts between vaccine doses.
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Affiliation(s)
- Mohamed F Jalloh
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Lauren E Parmley
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, USA
| | - Roberta Sutton
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, USA
| | - Shibani Kulkarni
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, USA
| | - Anthony Mansaray
- Sierra Leone Country Office, ICAP at Columbia University, Freetown, Sierra Leone
| | - Oliver Eleeza
- Sierra Leone Country Office, ICAP at Columbia University, Freetown, Sierra Leone
| | - Palak Patel
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, USA
| | - Elisabeth Wilhelm
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Laura Conklin
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Adewale Akinjeji
- Sierra Leone Country Office, ICAP at Columbia University, Freetown, Sierra Leone
| | - Mame Toure
- Sierra Leone Country Office, ICAP at Columbia University, Freetown, Sierra Leone
| | - Brent Wolff
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dimitri Prybylski
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Aaron S Wallace
- Immunization Systems Branch, Global Immunization Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maria Lahuerta
- ICAP at Columbia University, Mailman School of Public Health, New York, New York, USA.,Department of Epidemiology, Mailman School of Public Health, New York, New York, USA
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Mirzoev T, Kane S, Al Azdi Z, Ebenso B, Chowdhury AA, Huque R. How do patient feedback systems work in low-income and middle-income countries? Insights from a realist evaluation in Bangladesh. BMJ Glob Health 2021; 6:bmjgh-2020-004357. [PMID: 33568396 PMCID: PMC7878124 DOI: 10.1136/bmjgh-2020-004357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/21/2020] [Accepted: 01/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Well-functioning patient feedback systems can contribute to improved quality of healthcare and systems accountability. We used realist evaluation to examine patient feedback systems at health facilities in Bangladesh, informed by theories of citizenship and principal–agent relationships. Methods We collected and analysed data in two stages, using: document review; secondary analysis of data from publicly available web-portals; in-depth interviews with patients, health workers and managers; non-participant observations of feedback environments; and stakeholder workshops. Stage 1 focused on identifying and articulating the initial programme theory (PT) of patient feedback systems. In stage 2, we iteratively tested and refined this initial theory, through analysing data and grounding emerging findings within substantive theories and empirical literature, to arrive at a refined PT. Results Multiple patient feedback systems operate in Bangladesh, essentially comprising stages of collection, analysis and actions on feedback. Key contextual enablers include political commitment to accountability, whereas key constraints include limited patient awareness of feedback channels, lack of guidelines and documented processes, local political dynamics and priorities, institutional hierarchies and accountability relationships. Findings highlight that relational trust may be important for many people to exercise citizenship and providing feedback, and that appropriate policy and regulatory frameworks with clear lines of accountability are critical for ensuring effective patient feedback management within frontline healthcare facilities. Conclusion Theories of citizenship and principal–agent relationships can help understand how feedback systems work through spotlighting the citizenship identity and agency, shared or competing interests, and information asymmetries. We extend the understanding of these theories by highlighting how patients, health workers and managers act as both principals and agents, and how information asymmetry and possible agency loss can be addressed. We highlight the importance of awareness raising and non-threatening environment to provide feedback, adequate support to staff to document and analyse feedback and timely actions on the information.
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Affiliation(s)
- Tolib Mirzoev
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Sumit Kane
- Nossal Institute for Global Health Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Bassey Ebenso
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | | | - Rumana Huque
- Research and Development, ARK Foundation, Dhaka, Bangladesh.,Department of Economics, University of Dhaka, Dhaka, Bangladesh
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Ponka D, Coffman M, Fraser-Barclay KE, Fortier RDW, Howe A, Kidd M, Lennon RP, Madaki JKA, Mash B, Mohd Sidik S, van Weel C, Zawaly K, Goodyear-Smith F. Fostering global primary care research: a capacity-building approach. BMJ Glob Health 2021; 5:bmjgh-2020-002470. [PMID: 32624501 PMCID: PMC7337619 DOI: 10.1136/bmjgh-2020-002470] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 01/15/2023] Open
Abstract
The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the micro (practice), meso (institutional) and macro (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.
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Affiliation(s)
- David Ponka
- Besrour Centre for Global Family Medicine, College of Family Physicians of Canada, Mississauga, Ontario, Canada .,Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Megan Coffman
- Robert Graham Center Policy Studies in Family Medicine and Primary Care, Washington DC, District of Columbia, USA
| | | | - Richard D W Fortier
- General Practice, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand.,Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Amanda Howe
- Primary Care, University of East Anglia Norwich Medical School, Norwich, Norfolk, UK
| | - Michael Kidd
- Department of Family and Community Medicine, University of Toronto, Canada and Southgate Institute for Health, Toronto, Ontario, Canada
| | - Robert P Lennon
- Family and Community Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jeremiah K A Madaki
- Family Medicine, University of Jos, Jos, Plateau, Nigeria.,Family Medicine, Jos University Teaching Hospital, Jos, Plateau, Nigeria
| | - Bob Mash
- Family and Emergency Medicine, Stellenbosch University, Cape Town, South Africa.,Stellenbosch University, Cape Town, South Africa
| | - Sherina Mohd Sidik
- Psychiatry, Universiti Putra Malaysia Faculty of Medicine and Health Sciences, Serdang, Selangor, Malaysia
| | - Chris van Weel
- Department Primary and Community Care, Radboud Universiteit Nijmegen, Nijmegen, The Netherlands.,Department of Health Services Research and Policy, Australian National University, Acton, Australian Capital Territory, Australia
| | - Kristina Zawaly
- Family Medicine, McGill University, Montreal, Quebec, Canada.,General Practice and Primary Health Care, The University of Auckland, Auckland, New Zealand
| | - Felicity Goodyear-Smith
- General Practice, University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand.,University of Auckland, Auckland, New Zealand
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Ku CC, Chen CC, Dixon S, Lin HH, Dodd PJ. Patient pathways of tuberculosis care-seeking and treatment: an individual-level analysis of National Health Insurance data in Taiwan. BMJ Glob Health 2021; 5:bmjgh-2019-002187. [PMID: 32565426 PMCID: PMC7307534 DOI: 10.1136/bmjgh-2019-002187] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction Patients with tuberculosis (TB) often experience difficulties in accessing diagnosis and treatment. Patient pathway analysis identifies mismatches between TB patient care-seeking patterns and service coverage, but to date, studies have only employed cross-sectional aggregate data. Methods We developed an algorithmic approach to analyse and interpret patient-level routine data on healthcare use and to construct patients’ pathways from initial care-seeking to treatment outcome. We applied this to patients with TB in a simple random sample of one million patients’ records in the Taiwan National Health Insurance database. We analysed heterogeneity in pathway patterns, delays, service coverage and patient flows between different health system levels. Results We constructed 7255 pathways for 6258 patients. Patients most commonly initially sought care at the primary clinic level, where the capacity for diagnosing TB patients was 12%, before eventually initiating treatment at higher levels. Patient pathways are extremely heterogeneous prior to diagnosis, with the 10% most complex pathways accounting for 48% of all clinical encounters, and 55% of those pathways yet to initiate treatment after a year. Extended consideration of alternative diagnoses was more common for patients aged 65 years or older and for patients with chronic lung disease. Conclusion Our study demonstrates that longitudinal analysis of routine individual-level healthcare data can be used to generate a detailed picture of TB care-seeking pathways. This allows an understanding of several temporal aspects of care pathways, including lead times to care and the variability in patient pathways.
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Affiliation(s)
- Chu-Chang Ku
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Chien-Chou Chen
- Center for Applied Artificial Intelligence Research, Soochow University, Taipei, Taiwan
| | - Simon Dixon
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Hsien Ho Lin
- Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Peter J Dodd
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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Guzman J, O'Connell E, Kikule K, Hafner T. The WHO Global Benchmarking Tool: a game changer for strengthening national regulatory capacity. BMJ Glob Health 2021; 5:bmjgh-2020-003181. [PMID: 32784212 PMCID: PMC7418656 DOI: 10.1136/bmjgh-2020-003181] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022] Open
Abstract
Many low-income and middle-income countries lack the capacity to effectively and efficiently regulate medical products in their countries. To support countries in strengthening their capacity, WHO has developed the Global Benchmarking Tool (GBT) as the global standard for objectively assessing regulatory capacity for medicines and vaccines. The GBT is a game changer because it is the first globally accepted tool for assessing and strengthening national regulatory authorities. The inclusion of an institutional development plan in the GBT methodology provides context-specific actionable steps countries can take to advance their system’s functionality and maturity. The GBT facilitates coordination and improves the effectiveness of regulatory strengthening efforts. The tool also facilitates regulatory reliance and harmonisation, which helps to improve timely access to quality-assured medicines, and creates incentives for trade, particularly in countries and regions with a strong pharmaceutical manufacturing base. The GBT is a necessary tool for creating strong and effective regulatory systems, which are critical for ensuring the efficacy, safety and quality assurance of medicines and populations’ timely access to these medicines. In outlining the benefits of the GBT, this paper also offers some specific ideas for strengthening the GBT framework and process.
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Affiliation(s)
- Javier Guzman
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Inc, Arlington, Virginia, USA
| | - Erin O'Connell
- Program Delivery Group, Management Sciences for Health, Inc, Arlington, Virginia, USA
| | - Kate Kikule
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Inc, Arlington, Virginia, USA
| | - Tamara Hafner
- USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Inc, Arlington, Virginia, USA
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McManus D, Naughton BD. A systematic review of substandard, falsified, unlicensed and unregistered medicine sampling studies: a focus on context, prevalence, and quality. BMJ Glob Health 2021; 5:bmjgh-2020-002393. [PMID: 32859648 PMCID: PMC7454198 DOI: 10.1136/bmjgh-2020-002393] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 02/06/2023] Open
Abstract
Substandard and falsified (SF) medicines are a global issue contributing to antimicrobial resistance and causing economic and humanitarian harm. To direct law enforcement efficiently, halt the spread of SF medicines and antimicrobial resistance, academics, NGOs and government organisations use medicine quality sampling studies to estimate the prevalence of the problem. A systematic review of medicine quality studies was conducted to estimate how the methodological quality of these studies and SF prevalence has changed between 2013 and 2018. We also aimed to critique medicine sampling study methodologies, and the systematic review process which generates prevalence estimates. Based on 33 studies, the overall estimated median (Q1-Q3) prevalence of SF medicines appears to have remained high at 25% (7.7%-34%) compared with 28.5% in 2013. Furthermore, the methodological quality of prevalence studies has improved over the last 25 years. Definitive conclusions regarding the prevalence of SF medicines cannot be drawn due to the variability in sample sizes, consistency of design methods, and a lack of information concerning contextual factors affecting medicine quality studies. We contend that studies which present cumulative average prevalence figures are useful in a broad sense but could be improved to create more reliable estimates. We propose that medicine quality studies record the context of the study environment to allow systematic reviewers to compare like with like. Although, the academic rigour of medicine quality studies is improving, medicine sampling study limitations still exist. These limitations inhibit the accurate estimation of SF medicine prevalence which is needed to support detailed policy changes.
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Affiliation(s)
- Dominic McManus
- School of Pharmacy (Formerly of), University College London, London, UK
| | - Bernard David Naughton
- Saïd Business School, University of Oxford, Oxford, UK .,Pharmacy Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Razavi A, Erondu N, Okereke E. The Global Health Security Index: what value does it add? BMJ Glob Health 2021; 5:bmjgh-2020-002477. [PMID: 32349994 PMCID: PMC7213809 DOI: 10.1136/bmjgh-2020-002477] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ahmed Razavi
- International Health Regulations Strengthening Project, Public Health England, London, UK
| | - Ngozi Erondu
- International Health Regulations Strengthening Project, Public Health England, London, UK
| | - Ebere Okereke
- International Health Regulations Strengthening Project, Public Health England, London, UK
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