[Continued care during and after the Covid-19 pandemic]

Covid-19 hit hospitals that were already weakened, and care work that had been reconfigured as a result of managerial approaches and financial austerity policies. However, care workers continued to pay attention, to care for patients by mobilising their representations of care.

[COVID-19, student aid, public health and solicitude]

Student aid policies are broad organizational lines. They must not be confused, despite the obvious solicitude of public actors, with the caregiver's posture. It is then necessary to reinterrogate solicitude to defend a form of prevention by the mobilization of the actors, namely the students themselves.

Social Democratic Solidarity and the Welfare State: Health Care and Single-Tier Universality in Sweden and Canada

Although it is not generally done, it is useful to compare the history of the evolution of universal health coverage (UHC) in Canada and Sweden. The majority of citizens in both countries have shared, and continue to share, a commitment to a strong form of single-tier universality in the design of their respective UHC systems. In the postwar era, they also share a remarkably similar timeline in the emergence and entrenchment of single-tier UHC, despite the political and social differences between the two countries. At the same time, UHC was initially designed, implemented, and managed by social democratic governments that held power for long periods of time, creating a path dependency for single-tier Medicare that was difficult for future governments of different ideological persuasions to alter.

[The contribution of the fight against AIDS to the health democracy]

There is a debate on the place and the role of users in the healthcare system. It is important to remember that the people concerned by AIDS and associations fighting against this pathology have initiated a new type of patient involvement in care and public policies. This could be taken as a model.

[Pace of care and wellbeing at work, exploratory study]

The economic models developed in health policies force hospitals to make decisions with regard to the reorganisation of work. These have impacts on nursing competences and ergonomics in particular. A study analysing a situation of ten minutes of nursing work highlighted the work pace as well as the mental, emotional and physical strains put upon the professional.

Impacts of the Interim Federal Health Program reforms: A stakeholder analysis of barriers to health care access and provision for refugees

BACKGROUND

Changes to the Interim Federal Health Program (IFHP) in 2012 reduced health care access for refugees and refugee claimants, generating concerns among key stakeholders. In 2014, a new IFHP temporarily reinstated access to some health services; however, little is known about these changes, and more information is needed to map the IFHP's impact.

OBJECTIVE

This study explores barriers occurring during the time period of the IFHP reforms to health care access and provision for refugees.

METHODS

A stakeholder analysis, using 23 semi-structured interviews, was conducted to obtain insight into stakeholder perceptions of the 2014 reforms, as well as stakeholders' position and their influence to assess the acceptability of the IFHP changes.

RESULTS

The majority of stakeholders expressed concerns about the 2014 IFHP changes as a result of the continuing barriers posed by the 2012 retrenchments and the emergence of new barriers to health care access and provision for refugees. Key barriers identified included lack of communication and awareness, lack of continuity and comprehensive care, negative political discourse and increased costs. A few stakeholders supported the reforms as they represented some, but limited, access to health care.

CONCLUSION

Overall, the reforms to the IFHP in 2014 generated barriers to health care access and provision that contributed to confusion among stakeholders, the transfer of refugee health responsibility to provincial authorities and the likelihood of increased health outcome disparities, as refugees and refugee claimants chose to delay seeking health care. The study recommends that policy-makers engage with refugee health stakeholders to formulate a policy that improves health care provision and access for refugee populations.

Impact of China's essential medicines scheme and zero-mark-up policy on antibiotic prescriptions in county hospitals: a mixed methods study

OBJECTIVE

To evaluate the impact of the national essential medicines scheme and zero-mark-up policy on antibiotic prescribing behaviour.

METHODS

In rural Guangxi, a natural experiment compared one county hospital which implemented the policy with a comparison hospital which did not. All outpatient and inpatient records in 2011 and 2014 were extracted from the two hospitals. Primary outcome indicator was antibiotic prescribing rate (APR) among children aged 2-14 presenting in outpatients with a primary diagnosis of upper respiratory tract infection (URTI). We organised independent physician reviews to determine inappropriate prescribing for inpatients. Difference-in-difference analyses based on multivariate regressions were used to compare APR over time after adjusting potential confounders. We conducted 12 in-depth interviews with paediatricians, hospital directors and health officials.

RESULTS

A total of 8219 and 4142 outpatient prescriptions of childhood URTIs were included in the intervention and comparison hospitals, respectively. In 2011, APR was 30% in the intervention and 88% in the comparison hospital. In 2014, the intervention hospital significantly reduced outpatient APR by 21% (95% CI:-23%, -18%), intravenous infusion by 58% (95% CI: -64%, -52%) and prescription cost by 31 USD (95% CI: -35, -28), compared with the controls. We collected 251 inpatient records, but did not find reductions in inappropriate antibiotic use. Interviews revealed that the intervention hospital implemented a thorough antibiotics stewardship programme containing training, peer review of prescriptions and restrictions for overprescribing.

CONCLUSION

The national essential medicines scheme and zero-mark-up policy, when implemented with an antimicrobial stewardship programme, may be associated with reductions in outpatient antibiotic prescribing and intravenous infusions.

The Dishwater Menace: Healthy Drinking Spaces and the Public Good in Post-Prohibition Ontario

This paper examines inter-bureaucracy tension, negotiation, and resolution in the case of the oversight of beverage room sanitation in Ontario in the 1930s and 1940s. Both the Liquor Control Board of Ontario (LCBO) and various public health authorities claimed authority over the health status of public drinking spaces. But the LCBO had legislative priority. The ensuing debates regarding health and cleanliness linked issues of beverage room glass sanitation to a biopolitical approach to public drinking. Developing a more scientifically sophisticated approach to beverage glass cleaning required a balancing of administrative priorities. Perfect sanitation was expensive and complicated, and the LCBO's mandate demanded attention to the financial viability of beverage rooms. The LCBO needed to forge a trade off between safety and viability, while maintaining a public drinking system that dissuaded illegal drinking. The subsequent compromise in beverage room glass sanitation tied contemporary chemical sanitizers to the challenging economics of depression-era beverage room management.

Contribution des acteurs régionaux à la réduction des inégalités sociales de santé : le cas de la France

Depuis le rapport de la Commission sur les Déterminants Sociaux de la Santé, plusieurs pays ont commencé à intégrer à leurs plans de santé la question des déterminants et de leur impact sur les inégalités de santé. En France, la création des Agences Régionales de Santé en 2009 est considérée comme une opportunité pour agir sur les inégalités sociales de santé (ISS) avec les instances régionales, départementales et locales qui détiennent les leviers appropriés. A la suite d'une analyse thématique des projets régionaux de santé, visant à identifier l'intégration des ISS ainsi que les approches retenues pour les aborder, quatre régions ont été étudiées plus finement. Des entretiens collectifs et individuels ( N = 45 interviewés) ont été menés auprès d'acteurs de terrain et institutionnels, afin de mieux comprendre et identifier les types de programmes et processus pour réduire les ISS. Nos analyses font ressortir une prise en compte généralisée des ISS dans les documents de planification et de programmation des instances régionales, des stratégies régionales qui restent centrées sur les populations vulnérables avec une faible considération du gradient social, l'existence d'instances de concertations intersectorielles dans les quatre régions qui constituent un potentiel de gouvernance important à mieux exploiter, l'existence de modalités de suivi et d'évaluation des ISS qui restent à consolider, et une forte mobilisation de plusieurs secteurs dans les processus régionaux de consultation des publics et des acteurs, mais des résultats variables, souvent reliés au niveau de ressources investies et des approches privilégiées. L'analyse de ces expériences françaises démontre un intérêt croissant pour l'action sur les déterminants sociaux de la santé et les ISS ; mais leur opérationnalisation, toujours en cours, appelle à des analyses plus fines qui permettront de mieux éclairer les politiques publiques.

[The fight against bacterial resistance, a public health priority]

The increase in the number of antibiotic resistant bacteria represents a major danger for the health of humans and animals. Combined with an almost complete absence of new antibiotics, it is one of the most alarming public health issues of our time. Measures must be taken in order to control the use of these drugs and safeguard their effectiveness.

Medical pluralism among indigenous peoples in northeast India - implications for health policy

OBJECTIVES

The government of India is promoting and increasing investment in the traditional medicine systems of Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH) in the northeast region of India. But there are few empirical data that support this policy decision. This study estimates the awareness and use of the different medical systems in rural Meghalaya, a state in north-east India with a predominantly ethnic tribal population.

METHOD

We conducted a cross-sectional multistage random sample household survey across all districts of Meghalaya. To enable appropriate estimates for the whole of rural Meghalaya, the data were weighted to allow for the probability of selection of households at each stage of the sampling process.

RESULTS

Both local tribal medicine and biomedicine were widely accepted and used, but the majority (68.7%, 95% CI: 51.9-81.7) had not heard of AYUSH and even fewer had used it. Tribal medicine was used (79.1%, 95% CI 66.3-88.0), thought to be effective (87.5%, 95% CI: 74.2-94.1) and given in a variety of disorders, including both minor and major diseases. In the 3 months prior to the survey, 46.2% (95% CI: 30.5-62.8) had used tribal medicine. Only 10.5% (95% CI: 6.1-17.6) reported ever using any of the AYUSH systems.

CONCLUSION

Our comparative estimates of the awareness and use of tribal medicine, different systems of AYUSH and of biomedicine among indigenous populations of India question the basis on which AYUSH is promoted in the northeast region of India and in the state of Meghalaya in particular.

Health policy for sickle cell disease in Africa: experience from Tanzania on interventions to reduce under-five mortality

Tanzania has made considerable progress towards reducing childhood mortality, achieving a 57% decrease between 1980 and 2011. This epidemiological transition will cause a reduction in the contribution of infectious diseases to childhood mortality and increase in contribution from noncommunicable diseases (NCDs). Haemoglobinopathies are amongst the most common childhood NCDs, with sickle cell disease (SCD) being the commonest haemoglobinopathy in Africa. In Tanzania, 10 313 children with SCD under 5 years of age (U5) are estimated to die every year, contributing an estimated 7% of overall deaths in U5 children. Key policies that governments in Africa are able to implement would reduce mortality in SCD, focusing on newborn screening and comprehensive SCD care programmes. Such programmes would ensure that interventions such as prevention of infections using penicillin plus prompt diagnosis and treatment of complications are provided to all individuals with SCD.

Early career retention of Malawian medical graduates: a retrospective cohort study

Objective

There have been longstanding concerns over Malawian doctors migrating to high‐income countries. Early career is a particularly vulnerable period. After significant policy changes, we examined the retention of recent medical graduates within Malawi and the public sector.

Methods

We obtained data on graduates between 2006 and 2012 from the University of Malawi College of Medicine and Malawi Ministry of Health. We utilised the alumni network to triangulate official data and contacted graduates directly for missing or uncertain data. Odds ratios and chi‐squared tests were employed to investigate relationships by graduation year and gender.

Results

We traced 256 graduates, with complete information for more than 90%. Nearly 80% of registered doctors were in Malawi (141/178, 79.2%), although the odds of emigration doubled with each year after graduation (odds ratio = 1.98, 95% CI = 1.54–2.56, P < 0.0001). Of the 37 graduates outside Malawi (14.5%), 23 (62.2%) were training in South Africa under a College of Medicine sandwich programme. More than 80% of graduates were working in the public sector (185/218, 82.6%), with the odds declining by 27% for each year after graduation (odds ratio = 0.73, 95% CI = 0.61–0.86, P < 0.0001).

Conclusions

While most doctors remain in Malawi and the public sector during their early careers, the odds of leaving both increase with time. The majority of graduates outside Malawi are training in South Africa under visa restrictions, reflecting the positive impact of postgraduate training in Malawi. Concerns over attrition from the public sector are valid and require further exploratory work.

Policy challenges facing integrated community case management in Sub-Saharan Africa

OBJECTIVE

To report an in-depth analysis of policy change for integrated community case management of childhood illness (iCCM) in six sub-Saharan African countries. We analysed how iCCM policies developed and the barriers and facilitators to policy change.

METHODS

Qualitative retrospective case studies drawing from document reviews, semi-structured interviews and in-country validation workshops were conducted in Burkina Faso, Kenya, Malawi, Mali, Mozambique and Niger. These countries were selected to maximise variation in iCCM policy status, community health worker (CHW) models and different African regions.

RESULTS

Country iCCM policies evolved in an ad hoc fashion, but were substantially influenced by the history of primary health care and the nature of CHW programmes. Technical officers within Ministries of Health led iCCM policy change with support from international donors, but neither communities nor political leadership was mobilised. Concerns about achieving the Millennium Development Goals, together with recognition of the shortcomings of existing child health programmes, led to the adoption of iCCM policies. Availability of external financing played a critical role in facilitating policy change.

CONCLUSIONS

iCCM policy change has been promoted by international agencies, but national governments have struggled to align iCCM with country health systems. Greater investment is needed in tailoring global policy initiatives to match country needs. High-level, political ownership of iCCM policies could facilitate policy change, as could clearer strategies for ensuring the long-term sustainability of such policies.