Overview and project highlights of an initiative to integrate diabetic retinopathy screening and management in the public health system in India

Purpose:

Diabetes is a public health concern in India and diabetic retinopathy (DR) is an emerging cause of visual impairment and blindness. Approximately 3.35–4.55 million people with diabetes mellitus (PwDM) are at risk of vision-threatening DR (VTDR) in India. More than 2/3 of India's population resides in rural areas where penetration of modern medicine is mostly limited to the government public health system. Despite the increasing magnitude, there is no systematic screening for the complications of diabetes, including DR in the public health system. Therefore, a pilot project was initiated with the major objectives of management of DR at all levels of the government health system, initiating a comprehensive program for the detection of eye complications among PwDM at public health noncommunicable disease (NCD) clinics, augmenting the capacity of physicians, ophthalmologists and health support personnel and empowering carers/PwDM to control the risk of DR through increased awareness and self-management.

Methods:

A national task force (NTF) was constituted to oversee policy formulation and provide strategic direction. 10 districts were identified for implementation across 10 states. Protocols were developed to help implement training and service delivery.

Results:

Overall, 66,455 PwDM were screened and DR was detected in 16.2% (10,765) while VTDR was detected in 7.5%. 10.1% of those initially screened returned for the next annual assessment. There was a 7-fold increase in the number of PwDM screened and a 7.6-fold increase in the number of PwDM treated between 2016 and 2018.

Conclusion:

Services for detecting and managing DR can be successfully integrated into the existing public health system.

Establishing peer support groups for diabetic retinopathy in India: Lessons learned and way ahead

Purpose:

Complications of diabetes mellitus (DM) are a public health problem globally. DM management entails medication and self-management. Peer support groups (PSGs) can improve self-management and promote healthy behavior. The objectives of this study were to design, establish, and evaluate two PSG models for people who had been screened for diabetic retinopathy to assess self-reported lifestyle changes, satisfaction with meetings and barriers to attendance.

Methods:

Peer groups were established using a pre-tested facilitator's guide in 11 locations in 3 states. Group members were oriented on diabetes management and lifestyle changes to improve control. Attendees' experiences were ascertained through semi-structured interviews and self-report. Data were analyzed using MS Excel 2017.

Results:

Eleven PSGs were established in 3 states, in 10 community health centers and one eye hospital. 53 sessions were held and 195 people attended on 740 occasions. Lifestyle changes most frequently reported between first and second visits were taking medication regularly and dietary modification. Attendance declined in the eye hospital group. 83% of CHCs members were satisfied or very satisfied compared with 37% of eye hospital (EH) members. The barriers included distance and lack of family support.

Conclusion:

PSGs held in CHCs were more sustainable than those in an eye hospital, and group members were more satisfied and more likely to report positive lifestyle changes. Findings were self-reported and hence a major limitation for the study. Further studies should focus on obtaining objective measures of control of diabetes and risk factors for diabetic retinopathy from members attending peer support groups in CHCs.

One step forward, two steps back: Tensions between malaria elimination and improved malaria surveillance in the Solomon Islands

The Solomon Islands experienced, between 2010, an apparent meteoric fall in the level of malaria incidence and prevalence [1]. Thanks ostensibly to the efforts of bilateral and multilateral partners and donors, annual parasite incidence (API) fell from 70 to 40 per 1,000 population. With such dramatic progress, international efforts were hailed as dramatic successes and showcased as progress towards malaria elimination and eradication, Yet, paradoxically, the true caseload of malaria in the Solomon Islands has revealed a situation that calls for more, rather than less, support.

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Combating the COVID-19 pandemic in a resource-constrained setting: insights from initial response in India

The low-and-middle-income country (LMIC) context is volatile, uncertain and resource-constrained. India, an LMIC, has put up a complex response to the COVID-19 pandemic. Using an analytic approach, we have described India’s response to combat the pandemic during the initial months (from 17 January to 20 April 2020). India issued travel advisories and implemented graded international border controls between January and March 2020. By early March, cases started to surge. States scaled up movement restrictions. On 25 March, India went into a nationwide lockdown to ramp up preparedness. The lockdown uncovered contextual vulnerabilities and stimulated countermeasures. India leveraged existing legal frameworks, institutional mechanisms and administrative provisions to respond to the pandemic. Nevertheless, the cross-sectoral impact of the initial combat was intense and is potentially long-lasting. The country could have further benefited from evidence-based policy and planning attuned to local needs and vulnerabilities. Experience from India offers insights to nations, especially LMICs, on the need to have contextualised pandemic response plans.

The Impact of Interdisciplinary Care on Cost Reduction in a Geriatric Trauma Population

The current growth of the geriatric population and increased burden on trauma services throughout the United States (US) has created a need for systems that can improve patient care and reduce hospital costs. We hypothesize that the multidisciplinary services provided through the Geriatric Injury Institute (GII) can reduce hospital costs, improve patient triage throughput, and decrease hospital length of stay (LOS).

Community engagement for health system resilience: evidence from Liberia's Ebola epidemic

The importance of community engagement (CE) for health system resilience is established in theoretical and empirical literature. The practical dimensions of how to operationalize theory and implement its principles have been less explored, especially within low-resource crisis settings. It is therefore unclear how CE is drawn upon and how, if at all, it facilitates health system resilience in times of health system crises. To address this critical gap, we adapt and apply existing theoretical CE frameworks to analyse qualitative data from 92 in-depth interviews and 16 focus group discussions collected with health system stakeholders in Liberia in the aftermath of the 2014-15 Ebola outbreak. Health system stakeholders indicated that CE was a crucial contributing factor in addressing the Ebola epidemic in Liberia. Multiple forms of CE were used during the outbreak; however, only some forms were perceived as meaningful, such as the formation of community-based surveillance teams. To achieve meaningful CE, participants recommended that communities be treated as active participants in-as opposed to passive recipients of-health response efforts and that communication platforms for CE be established ahead of a crisis. Participant responses highlight that meaningful CE led to improved communication with and increased trust in health authorities and programming. This facilitated health system response efforts, leading to a fortuitous cycle of increased trust, improved communication and continued meaningful CE-all necessary conditions for health system resilience. This study refines our understanding of CE and demonstrates the ways in which meaningful CE and trust work together in mutually reinforcing and beneficial ways. These findings provide empirical evidence on which to base policies and programmes aimed at improving health system resilience in low-resource settings to more effectively respond to health system crises.

Exploring the evolution of policies for universal antiretroviral therapy and their implementation across three sub-Saharan African countries: Findings from the SHAPE study

Universal antiretroviral therapy (ART) strategies have dramatically changed HIV programming across sub-Saharan Africa. We explored factors that influenced the development, adoption and implementation of universal ART policies in Tanzania, South Africa and Malawi. We conducted 26 key informant interviews and applied Kingdon's 'streams' model to explore how problems, policies and politics converged to provide a window of opportunity for universal ART roll-out. Weak health systems and sub-optimal care retention were raised as problems during Option B+ implementation, which preceded universal ART , and persisted after its implementation. The adoption and implementation of Option B+ policy facilitated the uptake of universal ART. Politics played out through pressures from different stakeholders to accelerate or slow down implementation, from governments, civil society groups, researchers and donors. Policy processes leading to universal ART were open to pressures and influence. The extraordinary financial support which enabled the widespread and rapid implementation of universal ART skewed the power balance and sometimes left little space for locally-derived solutions to respond to specific health system abilities and epidemiological contexts. Donors may be more effective if they ensure a greater focus on strengthening the whole health system as well as accounting for local contextual factors and recent policy development histories when funding policy implementation.

'Do you trust those data?'-a mixed-methods study assessing the quality of data reported by community health workers in Kenya and Malawi

High-quality data are essential to monitor and evaluate community health worker (CHW) programmes in low- and middle-income countries striving towards universal health coverage. This mixed-methods study was conducted in two purposively selected districts in Kenya (where volunteers collect data) and two in Malawi (where health surveillance assistants are a paid cadre). We calculated data verification ratios to quantify reporting consistency for selected health indicators over 3 months across 339 registers and 72 summary reports. These indicators are related to antenatal care, skilled delivery, immunization, growth monitoring and nutrition in Kenya; new cases, danger signs, drug stock-outs and under-five mortality in Malawi. We used qualitative methods to explore perceptions of data quality with 52 CHWs in Kenya, 83 CHWs in Malawi and 36 key informants. We analysed these data using a framework approach assisted by NVivo11. We found that only 15% of data were reported consistently between CHWs and their supervisors in both contexts. We found remarkable similarities in our qualitative data in Kenya and Malawi. Barriers to data quality mirrored those previously reported elsewhere including unavailability of data collection and reporting tools; inadequate training and supervision; lack of quality control mechanisms; and inadequate register completion. In addition, we found that CHWs experienced tensions at the interface between the formal health system and the communities they served, mediated by the social and cultural expectations of their role. These issues affected data quality in both contexts with reports of difficulties in negotiating gender norms leading to skipping sensitive questions when completing registers; fabrication of data; lack of trust in the data; and limited use of data for decision-making. While routine systems need strengthening, these more nuanced issues also need addressing. This is backed up by our finding of the high value placed on supportive supervision as an enabler of data quality.

Situation of India in the COVID-19 Pandemic: India's Initial Pandemic Experience

In this article, we investigate the impact of COVID-19 through screening and surveillance methods adopted in India, as well as the potential health system, social, political, and economic consequences. The research was done in a chronological manner, and data was collected between 30 January 2020 till 12 June 2020. Initial containment measures, including point of entry screenings and testing protocols, appeared insufficient. However, testing capacity was gradually expanded after the commencement of a nation-wide lockdown. Modeling predictions have shown varying results on the emergence of cases depending on the infectiousness of asymptomatic individuals, with a peak predicted in mid-July having over two million cases. The country also faces risks of the economic plunge by losing approximately 4% of its gross domestic product, due to containment measures and reduction in goods importation. The low public health expenditure combined with a lack of infrastructure and low fiscal response implies several challenges to scale up the COVID-19 response and management. Therefore, an emergency preparedness and response plan is essential to integrate into the health system of India.

Experience and perspectives on palliative or end-of-life care of Chinese people and their families as immigrants to high-income countries: a systematic review and thematic synthesis

BACKGROUND

A sizeable cohort of Chinese migrants in high-income non-Asian countries is reaching old age and many will develop life-limiting illnesses. They may benefit from palliative care, which is integrated into universal health coverage in many of these countries, but the uptake of this care among migrant communities remains low. Cultural differences between the Chinese and the host community, and poor language skills may be barriers to access, yet understanding the reasons hindering uptake are obscure.

AIMS

To understand the cultural perspective of how first generation Chinese migrants and their families perceive the provision of palliative care, to identify what exists which may limit their access in high-income non-Asian countries.

DESIGN

A systematic review and three-stage thematic synthesis of qualitative studies. Citations and full texts were reviewed against predefined inclusion criteria. All included studies were appraised for quality.

DATA SOURCE

MEDLINE, EMBASE, PsycINFO, CINAHL and PubMed were searched to July 2019.

RESULTS

Seven qualitative studies were identified (from USA, UK, Canada and Australia). Across the studies analytical themes that impacted on the use of palliative care services were identified: (1) migrants' intrinsic perceptions of cultural practices, (2) their expectations of and preparation for care at the end of life, (3) perspectives and influences of family and (4) knowledge and communication with palliative care providers in the host country. Key elements found that challenge access to palliative care services in the host countries were: Chinese culture is rooted in the core values of the family as opposed to the individual; migrants' limited experience in their place of origin in accessing healthcare; and practical issues including a lack of language skills of their host country.

CONCLUSIONS

Palliative care services do not always match the needs of Chinese migrants in non-Asian high-income countries. Engagement and education on multiethnic cultural awareness in both the host non-migrant and the migrant communities is needed.

Alternative payment models and innovation: a case study of US health system adoption of a sacubitril/valsartan to treat acute decompensated heart failure

AIM

To understand the financial impact of health system adoption of novel heart failure medications under US alternative payment models (APMs).

MATERIALS AND METHODS

This study used a decision tree model to assess the financial impact of health system adoption of sacubitril/valsartan to treat acute decompensated heart failure (ADHF). A comparator scenario modeled current health care utilization and cost for treating hospitalized ADHF patients with angiotensin-converting-enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB). The study then measured the impact of adopting sacubitril/valsartan to treat ADHF on health system economic outcomes. Differences in treatment efficacy were based on the PIONEER-HF clinical trial. The financial impact of changes in patient outcomes under the sacubitril/valsartan and ACEi/ARB arms was assessed across three APMs: the Medicare Shared Savings Program, Bundled Payments for Care Improvement, and fee-for-service payments adjusted according to the Hospital Readmission Reduction Program.

RESULTS

Sacubitril/valsartan reduced re-hospitalizations after an initial ADHF admission by 46.3% for individuals aged 18-64 years and 23.4% for individuals aged ≥65 years. Health systems' financial benefit of adopting sacubitril/valsartan was $740 per ADHF case per year (PCPY). Savings were larger for patients aged ≥65 years ($803 PCPY) compared to those <65 years ($653 PCPY). The majority of the health system financial benefit came from changes in APM bonus and penalty reimbursements. Value-based payments from the Hospital Readmission Reduction Program ($1,190 financial gain PCPY) and the Bundled Care Payment Improvement Initiative ($645 financial gain PCPY) produced larger financial benefits than participation in the Medicare Shared Savings Program ($253 financial gain PCPY).

LIMITATIONS

The model uses clinical trial data, which may not reflect real-world outcomes. Further, the financial implications were modeled based only on three widely used APMs.

CONCLUSION

Sacubitril/valsartan adoption decreased hospitalizations and led to a positive net financial impact on health systems after accounting for APM bonus payments.

The empirical evidence underpinning the concept and practice of person-centred care for serious illness: a systematic review

INTRODUCTION

Person-centred care has become internationally recognised as a critical attribute of high-quality healthcare. However, the concept has been criticised for being poorly theorised and operationalised. Serious illness is especially aligned with the need for person-centredness, usually necessitating involvement of significant others, management of clinical uncertainty, high-quality communication and joint decision-making to deliver care concordant with patient preferences. This review aimed to identify and appraise the empirical evidence underpinning conceptualisations of 'person-centredness' for serious illness.

METHODS

Search strategy conducted in May 2020. Databases: CINAHL, Embase, PubMed, Ovid Global Health, MEDLINE and PsycINFO. Free text search terms related to (1) person-centredness, (2) serious illness and (3) concept/practice. Tabulation, textual description and narrative synthesis were performed, and quality appraisal conducted using QualSyst tools. Santana et al's person-centred care model (2018) was used to structure analysis.

RESULTS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow data: n=12,446 studies screened by title/abstract, n=144 full articles assessed for eligibility, n=18 studies retained. All studies (n=18) are from high-income countries, and are largely of high quality (median score 0.82). The findings suggest that person-centred care encompasses the patient and family being respected, given complete information, involved in decision-making and supported in their physical, psychological, social and existential needs. The studies highlight the importance of involving and supporting family/friends, promoting continuation of normality and self-identity, and structuring service organisation to enable care continuity.

CONCLUSION

Person-centred healthcare must value the social network of patients, promote quality of life and reform structurally to improve patients' experience interacting with the healthcare system. Staff must be supported to flexibly adapt skills, communication, routines or environments for individual patients. There remains a need for primary data investigating the meaning and practice of PCC in a greater diversity of diagnostic groups and settings, and a need to ground potential components of PCC within broader universal values and ethical theory.

Are health systems redesigning how health care is delivered?

OBJECTIVE

To explore why and how health systems are engaging in care delivery redesign (CDR)-defined as the variety of tools and organizational change processes health systems use to pursue the Triple Aim.

STUDY SETTING

A purposive sample of 24 health systems across 4 states as part of the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative.

STUDY DESIGN

An exploratory qualitative study design to gain an "on the ground" understanding of health systems' motivations for, and approaches to, CDR, with the goals of identifying key dimensions of CDR, and gauging the depth of change that is possible based on the particular approaches to redesign care being adopted by the health systems.

DATA COLLECTION

Semi-structured telephone interviews with health system executives and physician organization leaders from 24 health systems (n = 162).

PRINCIPAL FINDINGS

We identify and define 13 CDR activities and find that the health systems' efforts are varied in terms of both the combination of activities they are engaging in and the depth of innovation within each activity. Health system executives who report strong internal motivation for their CDR efforts describe more confidence in their approach to CDR than those who report strong external motivation. Health system leaders face uncertainty when implementing CDR due to a limited evidence base and because of the slower than expected pace of payment change.

CONCLUSIONS

The ability to validly and reliably measure CDR activities-particularly across varying organizational contexts and markets-is currently limited but is key to better understanding CDR's impact on intended outcomes, which is important for guiding both health system decision making and policy making.

How health systems approached respiratory viral pandemics over time: a systematic review

BACKGROUND

Several healthcare systems facing respiratory viral infections outbreaks, like COVID-19, have not been prepared to manage them. Public health mitigation solutions ranging from isolation of infected or suspected cases to implementation of national lockdowns have proven their effectiveness for the outbreak's control. However, the adjustment of public health measures is crucial during transition phases to avoid new outbreaks. To address the need for designing evidence-based strategies, we performed a systematic review to identify healthcare systems interventions, experiences and recommendations that have been used to manage different respiratory viral infections outbreaks in the past.

METHODS

PubMed, Web of Science, Scopus and Cochrane were searched to retrieve eligible studies of any study design, published in English until 17 April 2020. Double-blinded screening process was conducted by titles/abstracts and subsequently eligible full texts were read and pertinent data were extracted. When applicable, quality assessment was conducted for the included articles. We performed a narrative synthesis of each implemented public health approaches.

RESULTS

We included a total of 24 articles addressing the public health approaches implemented for respiratory viral infections outbreaks for COVID-19, influenza A H1N1, MERS and severe acute respiratory syndrome . The identified approaches are ascribable to two main categories: healthcare system strategies and healthcare provider interventions. The key components of an effective response on respiratory viral outbreaks included the implementation of evidence-based contextual policies, intrahospital management actions, community healthcare facilities, non-pharmaceutical interventions, enhanced surveillance, workplace preventive measures, mental health interventions and communication plans.

CONCLUSION

The identified healthcare system strategies applied worldwide to face epidemics or pandemics are a useful knowledge base to inform decision-makers about control measures to be used in the transition phases of COVID-19 and beyond.

Achieving flexible competence: bridging the investment dichotomy between infectious diseases and cancer

Today's global health challenges in underserved communities include the growing burden of cancer and other non-communicable diseases (NCDs); infectious diseases (IDs) with epidemic and pandemic potential such as COVID-19; and health effects from catastrophic 'all hazards' disasters including natural, industrial or terrorist incidents. Healthcare disparities in low-income and middle-income countries and in some rural areas in developed countries make it a challenge to mitigate these health, socioeconomic and political consequences on our globalised society. As with IDs, cancer requires rapid intervention and its effective medical management and prevention encompasses the other major NCDs. Furthermore, the technology and clinical capability for cancer care enables management of NCDs and IDs. Global health initiatives that call for action to address IDs and cancer often focus on each problem separately, or consider cancer care only a downstream investment to primary care, missing opportunities to leverage investments that could support broader capacity-building. From our experience in health disparities, disaster preparedness, government policy and healthcare systems we have initiated an approach we call flex-competence which emphasises a systems approach from the outset of program building that integrates investment among IDs, cancer, NCDs and disaster preparedness to improve overall healthcare for the local community. This approach builds on trusted partnerships, multi-level strategies and a healthcare infrastructure providing surge capacities to more rapidly respond to and manage a wide range of changing public health threats.

Building cooperative learning to address alcohol and other drug abuse in Mpumalanga, South Africa: a participatory action research process

Background: Alcohol and other drug (AOD) abuse is a major public health challenge disproportionately affecting marginalised communities. Involving communities in the development of responses can contribute to acceptable solutions.

Objectives: To: (1) document forms, processes, and contexts of engaging communities to nominate health concerns and generate new knowledge for action; (2) further build participation in the local health system by reflecting on and adapting the process.

Methods: PAR was progressed with 48 community stakeholders across three rural villages in the MRC/Wits Agincourt Health and Socio Demographic Surveillance System (HDSS) in Mpumalanga, South Africa. A series of workshops explored community-nominated topics, systematised lived experience into shared accounts and considered actions to address problems identified. Photovoice was also used to generate visual evidence. Narrative and visual data were thematically analysed, situated within practice frameworks, and learning and adaption elicited.

Results: AOD abuse was identified as a topic of high priority. It was understood as an entrenched social problem with destructive effects. Biopsychosocial impacts were mapped and related to unemployment, poverty, stress, peer pressure, criminal activity, corruption, and a proliferating number of taverns. Integrated action agendas were developed focussed on demand, supply, and harm reduction underpinned by shared responsibility among community, state, and non-state actors. Community stakeholders appreciated systematising and sharing knowledge, taking active roles, developing new skills in planning and public speaking, and progressing shared accountability processes. Expectations required sensitive management, however.

Conclusion: There is significant willingness and capacity among community stakeholders to work in partnership with authorities to address priority health concerns. As a process, participation can help to raise and frame issues, which may help to better inform action and encourage shared responsibility. Broader understandings of participation require reference to, and ultimately transfer of power towards, those most directly affected, developing community voice as continuous processes within social and political environments.

Health service delivery and workforce in northern Australia: a scoping review

INTRODUCTION

Delivering health services and improving health outcomes of the 1.3 million people residing in northern Australia, a region spanning 3 million km2 across the three jurisdictions of Western Australia, Northern Territory and Queensland, presents specific challenges. This review addresses a need for systems level analysis of the issues influencing the coverage, quality and responsiveness of health services across this region by examining the available published literature and identifying key policy-relevant gaps.

METHODS

A scoping review design was adopted with searches incorporating both peer-reviewed and grey literature (eg strategy documents, annual reports and budgets). Grey literature was predominantly sourced from websites of key organisations in the three northern jurisdictions, with peer-reviewed literature sourced from electronic database searches and reference lists. Key articles and documents were also contributed by health sector experts. Findings were synthesised and reported narratively using the WHO health system 'building blocks' to categorise the data.

RESULTS

From the total of 324 documents and data sources included in the review following screening and eligibility assessment, 197 were peer-reviewed journal articles and 127 were grey literature. Numerous health sector actors across the north - comprising planning bodies, universities and training organisations, peak bodies and providers - deliver primary, secondary and tertiary healthcare and workforce education and training in highly diverse contexts of care. Despite many exemplar health service and workforce models in the north, this synthesis describes a highly fragmented sector with many and disjointed stakeholders and funding sources. While the many strengths of the northern health system include expertise in training and supporting a fit-for-purpose health workforce, health systems in the north are struggling to meet the health needs of highly distributed populations with poorly targeted resources and ill-suited funding models. Ageing of the population and rising rates of chronic disease and mental health issues, underpinned by complex social, cultural and environmental determinants of health, continue to compound these challenges.

CONCLUSION

Policy goals about developing northern Australia economically need to build from a foundation of a healthy and productive population. Improving health outcomes in the north requires political commitment, local leadership and targeted investment to improve health service delivery, workforce stability and evidence-based strengthening of community-led comprehensive primary health care. This requires intersectoral collaboration across many organisations and the three jurisdictions, drawing from previous collaborative experiences. Further evaluative research, linking structure to process and outcomes, and responding to changes in the healthcare landscape such as the rapid emergence of digital technologies, is needed across a range of policy areas to support these efforts.

Face and content validity of a prospective multidimensional performance instrument for service delivery in district health systems in low-income countries: a Delphi study

BACKGROUND

Valid performance indicators help to track and improve health services. The aim of this study was to test the face and content validity of a set of performance indicators for service delivery in district health systems of low-income countries.

METHODS

A Delphi method with three stages was used. A panel of experts voted (yes vs no) on the face value of performance indicators. Agreement on the inclusion of indicators was a score of >75% and ≥50% during stages one and two, respectively. During stage three, indicators with a mean score of ≥3.8 on a five-point scale were included. The panel also rated the content validity of the overall set of indicators.

RESULTS

The panel agreed on the face value of 59 out of 238 performance indicators. Agreement on the content validity of the set of indicators reached 100%. Most of the retained indicators were related to the capacity of health facilities, the quality of maternal and child health services and HIV care and treatment.

CONCLUSIONS

Policymakers in low-income countries could use a set of performance indicators with modest face and high content validity, and mainly aspects of capacity and quality to improve health service delivery in districts.

Understanding fragility: implications for global health research and practice

Advances in population health outcomes risk being slowed—and potentially reversed—by a range of threats increasingly presented as ‘fragility’. Widely used and critiqued within the development arena, the concept is increasingly used in the field of global health, where its relationship to population health, health service delivery, access and utilization is poorly specified. We present the first scoping review seeking to clarify the meaning, definitions and applications of the term in the global health literature. Adopting the theoretical framework of concept analysis, 10 bibliographic and grey literature sources, and five key journals, were searched to retrieve documents relating to fragility and health. Reviewers screened titles and abstracts and retained documents applying the term fragility in relation to health systems, services, health outcomes and population or community health. Data were extracted according to the protocol; all documents underwent bibliometric analysis. Narrative synthesis was then used to identify defining attributes of the concept in the field of global health. A total of 377 documents met inclusion criteria. There has been an exponential increase in applications of the concept in published literature over the last 10 years. Formal definitions of the term continue to be focused on the characteristics of ‘fragile and conflict-affected states’. However, synthesis indicates diverse use of the concept with respect to: level of application (e.g. from state to local community); emphasis on particular antecedent stressors (including factors beyond conflict and weak governance); and focus on health system or community resources (with an increasing tendency to focus on the interface between two). Amongst several themes identified, trust is noted as a key locus of fragility at this interface, with critical implications for health seeking, service utilization and health system and community resilience.

The role of the state in financing and regulating primary care in Europe: a taxonomy

Traditional health systems typologies were based on health system financing type, such as the well-known OECD typology. However, the number of dimensions captured in classifications increased to reflect health systems complexity. This study aims to develop a taxonomy of primary care (PC) systems based on the actors involved (state, societal and private) and mechanisms used in governance, financing and regulation, which conceptually represents the degree of decentralisation of functions. We use nonlinear canonical correlations analysis and agglomerative hierarchical clustering on data obtained from the European Observatory on Health Systems and Policy and informants from 24 WHO European Region countries. We obtain four clusters: 1) Bosnia Herzegovina, Czech Republic, Germany, Slovakia and Switzerland: corporatist and/or fragmented PC system, with state involvement in PC supply regulation, without gatekeeping; 2) Greece, Ireland, Israel, Malta, Sweden, and Ukraine: public and (re)centralised PC financing and regulation with private involvement, without gatekeeping; 3) Finland, Norway, Spain and United Kingdom: public financing and devolved regulation and organisation of PC, with gatekeeping; and 4) Bulgaria, Croatia, France, North Macedonia, Poland, Romania, Serbia, Slovenia and Turkey: public and deconcentrated with professional involvement in supply regulation, and gatekeeping. This taxonomy can serve as a framework for performance comparisons and a means to analyse the effect that different actors and levels of devolution or fragmentation of PC delivery may have in health outcomes.