Assessing health system performance in developing countries: a review of the literature

Ease and equity of access to free DR-TB services in Nigeria- a qualitative analysis of policies, structures and processes

Introduction

Persistent low rates of case notification and treatment coverage reflect that accessing diagnosis and treatment for drug-resistant tuberculosis (DR-TB) in Nigeria remains a challenge, even though it is provided free of charge to patients. Equity in health access requires availability of comparable, appropriate services to all, based on needs, and irrespective of socio-demographic characteristics. Our study aimed to identify the reasons for Nigeria’s low rates of case-finding and treatment for DR-TB. To achieve this, we analyzed elements that facilitate or hinder equitable access for different groups of patients within the current health system to support DR-TB management in Nigeria.

Methods

We conducted documentary review of guidelines and workers manuals, as well as 57 qualitative interviews, including 10 focus group discussions, with a total of 127 participants, in Nigeria. Between August and November 2017, we interviewed patients who were on treatment, their treatment supporter, and providers in Ogun and Plateau States, as well as program managers in Benue and Abuja. We adapted and used Levesque’s patient-centered access to care framework to analyze DR-TB policy documents and interview data.

Results

Thematic analysis revealed inequitable access to DR-TB care for some patient socio-demographic groups. While patients were mostly treated equally at the facility level, some patients experienced more difficulty accessing care based on their gender, age, occupation, educational level and religion. Health system factors including positive provider attitudes and financial support provided to the patients facilitated equity and ease of access. However, limited coverage and the absence of patients’ access rights protection and considerations in the treatment guidelines and workers manuals likely hampered access.

Conclusion

In the context of Nigeria’s low case-finding and treatment coverage, applying an equity of access framework was necessary to highlight gaps in care. Differing social contexts of patients adversely affected their access to DR-TB care. We identified several strengths in DR-TB care delivery, including the current financial support that should be sustained. Our findings highlight the need for government’s commitment and continued interventions.

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.

Frameworks of Performance Measurement in Public Health and Primary Care System: A Scoping Review and Meta-Synthesis

BACKGROUND

This study was conducted to synthesize the evidence on the dimensions of performance appraisal of the public health and primary care system through a scoping review and meta-synthesis.

METHODS

The review conducted systematically in 2018 with a scoping review approach. To identify pertinent studies, the following electronic databases were systematically searched until December 20, 2017: Cochrane, ISI Web of Science, PubMed, Scopus, Science Direct, and Embase. Reviewing the studies found on the search bases was carried out in three stages by two persons individually. According to refined studies, the data were extracted to meet the objectives and respond to the research questions. The thematic analysis was used to identify and categorize the dimensions of performance measurement.

RESULTS

Using this process, 20 studies were eligible for our research. The critical points in measuring the performance of the public health field were classified into eight main domains including leadership and stewardship, funding, resource generation, service delivery, quality, accessibility, efficiency/productivity, and community health status. The differences in measurement frameworks are inevitable. One reason for the differences in the health system performance measurement framework is the differences in the data or data collection, analysis, and reporting. Performance measurement in the field of health, especially primary care, was a multidimensional issue.

CONCLUSIONS

Each of the main dimensions had several sub-criteria, indicating the broadness and complexity of the performance of first-level care providers. Single-dimensional performance measurement could underpin incorrect policies and decisions.

Improving the quality of maternal and newborn care in the Pacific region: A scoping review

BACKGROUND

Quality care is essential for improving maternal and newborn health. Low- and middle-income Pacific Island nations face challenges in delivering quality maternal and newborn care. The aim of this review was to identify all published studies of interventions which sought to improve the quality of maternal and newborn care in Pacific low-and middle-income countries.

METHODS

A scoping review framework was used. Databases and grey literature were searched for studies published between January 2000 and July 2019 which described actions to improve the quality of maternal and newborn care in Pacific low- and middle-income countries. Interventions were categorised using a four-level health system framework and the WHO quality of maternal and newborn care standards. An expert advisory group of Pacific Islander clinicians and researchers provided guidance throughout the review process.

RESULTS

2010 citations were identified and 32 studies included. Most interventions focused on the clinical service or organisational level, such as healthcare worker training, audit processes and improvements to infrastructure. Few addressed patient experiences or system-wide improvements. Enablers to improving quality care included community engagement, collaborative partnerships, adequate staff education and training and alignment with local priorities.

CONCLUSIONS

There are several quality improvement initiatives in low- and middle-income Pacific Island nations, most at the point of health service delivery. To effectively strengthen quality maternal and newborn care in this region, efforts must broaden to improve health system leadership, deliver sustaining education programs and encompass learnings from women and their communities.

Do performance measurement models have any impact on primary health care? A systematic review

Purpose

The purpose of this article is to analyze and compare between the frameworks of performance measurement in primary health care in the world. The subject of search is to compare if the frameworks of performance measurement in primary health care have an influence on performances of health centers.

Design/methodology/approach

We conducted a systematic review of the literature to (1) identify the conceptual framework for measuring quality management systems, (2) assess the effects of conceptual framework on quality improvement and quality of care outcomes. We opted for the frameworks that are more cited in the literature and we analyzed and compared between these frameworks.

Findings

Eight dimensions were identified for assessing performance in Primary Health Care Facilities “PHCF” in more than 50% frameworks: Effectiveness, Safety, Accessibility, Equity, Efficiency, Acceptability, Patient Centeredness and Timeliness.

Research limitations/implications

The limits of this study can be represented by the following elements: (1) lack of exhaustiveness with regard to the current Frameworks. (2) The evaluation of reliability and validity of the qualitative studies remains difficult to appreciate. (3) Most of the evaluation tools of the primary health care are not validated yet. (4) The difference in performance levels between countries, especially for the developed countries and the multitude of the frames of measure of performance, limits the comparability of the results.

Practical implications

This study provides a conceptual and descriptive literature on the different conceptual frameworks for performance measurement in primary health care, and a practical and useful tool for comparison between the different conceptual frameworks. Several organisations of accreditation or certification introduced, developed, incorporated and checked the indicators of clinical quality in the organizations of health care. Some studies revealed links with the governance, the access, the continuity, the coordination, the efficiency and the strength primary care (Dionne Kringos, 2018). Improvements in the quality of care have been observed in the results of accreditation and certification bodies regarding hospital infection control infrastructure, organization and performance.

Originality/value

Even if the links are not established within the framework of a scientific research, quality approaches are generally recognized as an essential tool to help establishments to improve the quality and the safety of the patients. Until now, it is not still common to make evaluation of the quality of care in the “PHCF” to obtain the relevant information. The necessity of having performance measurement tools, which puts in coherence the piloting of the operational level with the strategy, to integrate the organizational objectives into the measures of operational performances and make estimate its structures towards a real management by the quality.

Health Systems, Aging, and Inequity: An Example from Chile

Background: Just like many other countries around the world, Chile is facing the challenges of demographic transition and population aging. Considering this context, the question of how prepared the health system is to deal with these challenges arises; Methods: A framework to assess the health system's preparedness for aging was proposed, considering the health system's goals and features and using an equity approach. Indicators related to the health system's goals were calculated for the year 2015 using three nationally-representative sources: health status (suicide rate), financial protection (out-of-pocket and catastrophic expenditures), and responsiveness (satisfaction). Age ratios were used to compare the system's response to different age groups; Results: Results for Chile revealed the existence of inequities, particularly when assessing the system in terms of its ability to improve health status and financial protection. These gaps increase with age, suggesting that the Chilean health system is not prepared to meet older people's needs; and Conclusions: These results call for a reform in the health system, as well as the need for implementing a long-term care system in the country.

A consensus-based decision model for assessing the health systems

Many countries and international organisations have been developing health system performance assessment frameworks and indicators to support healthcare management and inform public health policy. Effectiveness, accessibility, safety and patient-centeredness were four dimensions that were most commonly measured. This paper develops a new consensus-based decision model to assess the health systems, in which different stakeholders of healthcare systems are identified by different decision approaches, i.e., the coefficient variation approach, the Shannon entropy approach and the distance-based approach, respectively. The consensus result is obtained by minimizing the total deviation from the ideal point. A numerical illustration with simulated data is presented to show the effectiveness of our model.

Health systems constraints and facilitators of human papillomavirus immunization programmes in sub-Saharan Africa: a systematic review

Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.

Monitoring Sustainable Development Goals 3: Assessing the Readiness of Low- and Middle-Income Countries

Background: The Millennium Development Goals (MDGs) availed opportunities for scaling up service coverage but called for stringent monitoring and evaluation (M&E) focusing mainly on MDG related programs. The Sustainable Development Goals 3 (SDGs) and the universal health coverage (UHC) agenda present a broader scope and require more sophisticated M&E systems. We assessed the readiness of low- and middle-income countries to monitor SDG 3.

Methods: Employing mixed methods, we reviewed health sector M&E plans of 6 countries in the World Health Organization (WHO) Africa Region to assess the challenges to M&E, the indicator selection pattern and the extent of multisectoral collaboration. Qualitative data were analysed using content thematic analysis while quantitative data were analysed using Excel.

Results: Challenges to monitoring SDG 3 include weak institutional capacity; fragmentation of M&E functions; inadequate domestic financing; inadequate data availability, dissemination and utilization of M&E products. The total number of indictors in the reviewed plans varied from 38 for Zimbabwe to 235 for Zanzibar. Sixty-nine percent of indicators for the Gambia and 89% for Zanzibar were not classified in any domain in the M&E results chain. Countries lay greater M&E emphasis on service delivery, health systems, maternal and child health as well as communicable diseases with a seeming neglect of the non-communicable diseases (NCDs). Inclusion of SDG 3 indicators only ranged from 48% for Zanzibar to 67% for Kenya. Although monitoring SDG 3 calls for multisectoral collaboration, consideration of the role of other sectors in the M&E plans was either absent or limited to the statistical departments.

Conclusion: There are common challenges confronting M&E at county-level. Countries have omitted key indicators for monitoring components of the SDG 3 targets especially those on NCDs and injuries. The role of other sectors in monitoring SDG 3 targets is not adequately reflected. These could be bottlenecks to tracking progress towards SDG 3 if not addressed. Beyond providing compendium of indicators to guide countries, we advocate for a more binding minimum set of indicators for all countries to which they may add depending on their context. Ministries of Health (MoHs) should prioritise M&E as an important pillar for health service planning and implementation and not as an add-on activity.

Effectiveness of Integrated Health Systems in Africa: A Systematic Review

Background and objective: Traditional medicine (TM) was integrated into health systems in Africa due to its importance within the health delivery setup in fostering increased health care accessibility through safe practices. However, the quality of integrated health systems in Africa has not been assessed since its implementation. The objective of this paper was to extensively and systematically review the effectiveness of integrated health systems in Africa. Materials and Methods: A systematic literature search was conducted from October, 2019 to March, 2020 using Ovid Medline, Scopus, Emcare, Web of Science, Cumulative Index to Nursing and Allied Health (CINAHL), and Google Scholar, in order to retrieve original articles evaluating the integration of TM into health systems in Africa. A quality assessment of relevant articles was also carried out using the Quality Assessment Tool for Studies with Diverse Designs (QATDSS) critical appraisal tool. Results: The results indicated that the formulation and execution of health policies were the main measures taken to integrate TM into health systems in Africa. The review also highlighted relatively low levels of awareness, usage, satisfaction, and acceptance of integrated health systems among the populace. Knowledge about the existence of an integrated system varied among study participants, while satisfaction and acceptance were low among orthodox medicine practitioners. Health service users' satisfaction and acceptance of the practice of an integrated health system were high in the countries assessed. Conclusion: The review concluded that existing health policies in Africa are not working, so the integration of TM has not been successful. It is critical to uncover the barriers in the health system by exploring the perceptions and experiences of stakeholders, in order to develop solutions for better integration of the two health systems.

Poverty and health-related quality of life: a cross-sectional study in rural China

BACKGROUND

The association between poverty and health has been widely assessed. However, whether the association between poverty and health-related quality of life (HRQOL) holds among different groups is unknown. This study aimed to 1) assess the association between poverty and HRQOL among rural residents in China and 2) examine whether the association holds among different populations, thereby supporting policy-making and implementation.

METHODS

A multistage, stratified, random household survey was conducted with self-administered questionnaires. Matched samples were generated by the censored exact matching method to reduce selection bias between the poverty and comparison groups. We applied Tobit and ordinal logit regression models to evaluate the association between poverty and HRQOL measured by the EQ-5D-3 L among different groups.

RESULTS

The health utility score of the poverty group was 6.1% lower than that of comparison group (95% CI = - 0.085, - 0.037), with anxiety/depression being most common (95% CI = 1.220, 1.791). The association between poverty and HRQOL was significantly stronger among residents from central China, males, people who were middle-aged, elderly, highly educated, married, or widowed, those living far from healthcare facilities, and those without chronic disease. Male and highly educated subjects reported worse mobility, self-care, usual activities, pain/discomfort and anxiety/depression dimensions than the other respondents. Middle-aged (95% CI = 1.692, 2.851) and married respondents (95% CI = 1.692, 2.509) and respondents with chronic diseases (95% CI = 1.770, 2.849) were most affected in the anxiety/depression.

CONCLUSIONS

The HRQOL of individuals living in poverty is lower than that of the general population, and the mental health dimension is most affected by poverty among respondents who are middle-aged or married and respondents with chronic diseases. The identification of populations that are more affected by poverty is critical to improve their HRQOL. Various associations have indicated the need for integrated policies and specific decision-making.

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.

Strengths and weaknesses of eye care services in sub-Saharan Africa: a meta-synthesis of eye health system assessments

BACKGROUND

In sub-Saharan Africa (SSA), the delivery of eye care services continues to be undermined by health systems performance bottlenecks. There is a growing focus by partners in the sector on the analysis of the different components of eye care within the wider health system context to diagnose and manage interactions in ways that achieve more effective improvements. However, there has been no attempt to date to systematically synthesize these studies. In this study, we conducted a meta-synthesis of eye health system assessments to gain a more comprehensive understanding of the current systems and how they can be strengthened across different SSA contexts.

METHODS

We conducted a comprehensive search for eye health system assessment reports using global and regional websites of the WHO and other organizations supporting eye care in sub-Saharan Africa. A range of online databases with no language restrictions (PubMed, EMBASE, MEDLINE, PsycINFO and CINAHL) were searched for peer-reviewed publications referring to eye health system assessment (EHSA) or eye care service assessment tool (ECSAT). Assessments were included if they used the ECSAT or EHSA tool; were conducted in sub-Saharan Africa; and had been completed with full reports available in the public domain by January 15, 2019. A combination of framework and thematic syntheses was used.

RESULTS

Our search strategies yielded a total of 12 assessments conducted in nine countries using the ECSAT/EHSA tool in Sub-Saharan Africa. Eight assessments met our inclusion criteria: four were from West Africa, two from East Africa and two from Southern Africa. Across the eight countries, findings show considerable progress and improvements in the areas of governance, organisation, financing, provision, and coverage of eye care. However, several systemwide weaknesses were found to continue to impede quality eye health service planning and delivery across the countries included in this review.

CONCLUSIONS

These findings highlight the need for national governments and iNGOs to invest in conducting and wider use of these assessments. Such analyses are particularly useful in building links between different system elements and in finding innovative, more flexible solutions and partnerships - needed to address avoidable vision loss in resource poor settings.

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.

Going operational with health systems governance: supervision and incentives to health workers for increased quality of care in Tanzania

Improving the quality of care is increasingly recognized as a priority of health systems in low- and middle-income countries. Given the labour-intensive nature of healthcare interventions, quality of care largely depends upon the number, training and management of health workers involved in service delivery. Policies available to boost the performance of health workers-and thus the quality of healthcare-include regulation, incentives and supervision-all of which are typically included in quality improvement frameworks and policies. This was the case in Tanzania, where we assessed the role of selected quality improvement policies. To do so, we analysed data from a representative sample of Tanzanian government-managed health facilities, part of the 2014/15 Service Provision Assessment component of the Demographic and Health Survey. We constructed two healthcare quality indicators from data on patient visits: (1) compliance with Integrated Management of Childhood Illness (IMCI) guidelines and (2) patient satisfaction. Using multilevel ordered logistic regression models, we estimated the associations between the outcomes and selected indicators of incentives and supervisory activity at health worker and health facility level. We did not identify any association for the different indicators of top-down supervision at facility and individual level, neither with IMCI compliance nor with patients' satisfaction. Bottom-up supervision, defined as meetings between community and health facility staff, was significantly associated with higher patient satisfaction. Financial incentives in the form of salary top-ups were positively associated with both IMCI compliance and patient satisfaction. Both housing allowances and government-subsidized housing were positively associated with our proxies of quality of care. Good healthcare quality is crucial for promoting health in Tanzania not only through direct outcomes of the process of care but also through increased care-seeking behaviour in the communities. The results of this study highlight the role of community involvement, better salary conditions and housing arrangements for health workers.

Hospital survey on patient safety culture (HSOPSC): a multi-method approach for target-language instrument translation, adaptation, and validation to improve the equivalence of meaning for cross-cultural research

BACKGROUND

The Hospital Survey on Patient Safety Culture (HSOPSC) is widely utilized in multiple languages across the world. Despite culture and language variations, research studies from Latin America use the Spanish language HSOPSC validated for Spain and the United States. Yet, these studies fail to report the translation method, cultural adaptation process, and the equivalence assessment strategy. As such, the psychometric properties of the HSOPSC are not well demonstrated for cross-cultural research in Latin America, including Peru. The purpose of this study was to develop a target-language HSOPSC for cross-cultural research in Peru that asks the same questions, in the same manner, with the same intended meaning, as the source instrument.

METHODS

This study used a mixed-methods approach adapted from the translation guideline recommended by Agency for Healthcare Research and Quality. The 3-phase, 7-step process incorporated translation techniques, pilot testing, cognitive interviews, clinical participant review, and subject matter expert evaluation.

RESULTS

The instrument was translated and evaluated in 3 rounds of cognitive interview (CI). There were 37 problem items identified in round 1 (14 clarity, 12 cultural, 11 mixed); and resolved to 4 problems by round 3. The pilot-testing language clarity inter-rater reliability was S-CVI/Avg = 0.97 and S-CVI/UA = 0.86; and S-CVI/Avg = 0.96 and S-CVI/UA = 0.83 for cultural relevance. Subject matter expert agreement in matching items to the correct dimensions was substantially equivalent (Kappa = 0.72). Only 1 of 12 dimensions had a low Kappa (0.39), borderline fair to moderate. The remaining dimensions performed well (7 = almost perfect, 2 = substantial, and 2 = moderate).

CONCLUSIONS

The HSOPSC instrument developed for Peru was markedly different from the other Spanish-language versions. The resulting items were equivalent in meaning to the source, despite the new language and different cultural context. The analysis identified negatively worded items were problematic for target-language translation. With the limited literature about negatively worded items in the context of cross-cultural research, further research is necessary to evaluate this finding and the recommendation to include negatively worded items in instruments. This study demonstrates cross-cultural research with translated instruments should adhere to established guidelines, with cognitive interviews, based on evidence-based strategies.

Profile of Long-Term Care Recipients Receiving Home and Community-Based Services and the Factors That Influence Utilization in Taiwan

In response to the irreversible aging trend, the Taiwan government has promoted the Long-Term Care (LTC) policy 1.0 launched in 2007 and the LTC policy 2.0 reform since 2016. This study aimed to explore the utilization of formal home and community-based care under LTC policy 1.0 to add scientific support for the on-going LTC policy 2.0 reform. Methods: By using Andersen and Aday’s behavioral model of healthcare utilization, the long-term care dataset was analyzed from 2013 to 2016. A total of 101,457 care recipients were identified after data cleaning. Results: The results revealed that about 40.7% of the care recipients stayed in the care system for more than two years. A common factor influencing the length of home and community-based services (HCBS) utilization period included need factors, where more dependent recipients leave the LTC system regardless of their socio-economic status. However, the utilization period of non-low-income households is significantly affected by the level of service resources. Conclusion: For long-term care needs, the phenomenon of a short utilization period was concerning. This study adds information which suggests policy should reconsider care capacity and quality, especially for moderate to severely dependent recipients. This will allow for better understanding to help maintain care recipients in their own communities to achieve the goal of having an aging in place policy.

Relationship between breakfast consumption, BMI status and physical fitness of Ghanaian school-aged children

BACKGROUND

Good nutrition and physical activity of school-aged children are important for ensuring optimum growth and reducing obesity. This present study assessed associations between breakfast consumption, BMI-for-Age (BMI) and physical fitness in a cross-section of school-aged children attending government-owned primary schools in Kumasi, Ghana.

METHOD

The sample consisted of 438 pupils (boys = 213; girls = 225; mean age 11.1 ± 1.1), attending 10 randomly selected schools. Weight (kg), height (cm) and Mid Upper Arm Circumference (MUAC) were measured for each participant, and BMI-for-age z-scores determined using the World Health Organisation (WHO) anthroplus software. Participants were stratified into thinness, normal weight, overweight/obese using WHO cut offs. Physical fitness was assessed using forward jump, left and right handgrips, flexibility, sit-ups and 50 metre run following standard procedures and converted to scores of 1 to 10 following Japanese standards, based on which percentiles were derived. Total fitness score for each pupil was computed by adding all scores. A questionnaire was used to assess meal intake patterns.

RESULTS

The mean BMI-for-age z-score for participants was - 0.24 ± 0.99. Thinness, normal weight and overweight/obesity were 2.7, 86.5, and 10.5% respectively among the pupils. Overweight was higher in girls (14.2%) compared to boys (4.2%), p = 0.003. Similarly, mean MUAC was significantly (p = 0.021) higher in the girls (22.0 ± 3.2 cm) than the boys (20.7 ± 7.3 cm). For physical fitness, the girls scored higher in forward jump (p < 0.0001), 50-m run (p = 0.002) and overall fitness score than the boys (21.0 ± 6.2 versus 19.2 ± 8.3, p = 0.012). However, a larger proportion of boys performed excellently and poorly than girls (p = 0.019). A positive correlation was observed between BMI z-score and hand grip (r = 0.21, p < 0.001), while sit up (r = - 0.11, p = 0.018) showed a negative correlation with BMI z-score. No other fitness test varied by BMI. Overweight children performed best in handgrip. Majority of children said they engaged in exercise (89.9%) and consumed breakfast (78.9%). Breakfast consumption was not associated with BMI z-score (x2 0.0359, p = 0.549) but non-breakfast consumers performed better in 50 m run compared to consumers (7.0 seconds ± 2.3 vrs 6.3 seconds ± 2.5, p = 0.022). Children who reported to exercise were physically fitter than those who did not.

CONCLUSION

Underweight levels were low while overweight was over 10% in these children. Girls were more than 3 times affected by overweight than boys, and were also physically fitter than boys. Breakfast consumption was not related to weight or fitness.

Frameworks for health systems performance assessment: how comprehensive is Ghana's holistic assessment tool?

Background

Measuring the performance of a health system is an essential requirement in creating systems that generate efficient, equitable, patient-focused, accessible and sustainable results. A fundamental requirement for a performance measurement system is the development of an assessment framework within which specific performance measures could be defined and applied regularly. This paper examines the comprehensiveness of Ghana’s health system assessment framework called the Holistic Assessment Tool in relation to some of the internationally recognized frameworks. The paper also analyzes trends in the performance of the health system to understand whether or not an improvement has been recorded following the adoption and implementation of the Holistic Assessment Tool.

Methods

Mainly secondary data were used in this analysis. Searches were conducted on Google Scholar, PubMed, Scopus and Science Direct between May and July, 2019 for published documents on health system performance assessment. We also obtained unpublished documents from Ghana’s Ministry of Health, Ghana Health Service website, and Ghana Statistical Service database. Descriptive statistics were used to examine trends in the performance of the Ghanaian health system.

Results

While the tool provides a national framework for evaluating the performance of the Ghana Health system in several domains, the Holistic Assessment Tool does not cover key health system domains such as information systems for health, access to essential medicines, and patient-centeredness. Also, the scope of the assessment program seems limited to the evaluation of the Ministry of Health’s annual plans, programs and projects. However, the health system has recorded improvements in population health indicators, such as life expectancy at birth, infant mortality, under-5 mortality, HIV prevalence and disease burden (in terms of disability adjusted life years).

Conclusions

The Holistic Assessment Tool is a useful framework, but needs further refinement, both in scope and in conceptual robustness. Future studies should consider exploring factors influencing performance of the Ghanaian health system. Such information will help in strategizing for better and more improvements.

Measuring horizontal inequity in healthcare utilisation: a review of methodological developments and debates

Equity in healthcare is an overarching goal of many healthcare systems around the world. Empirical studies of equity in healthcare utilisation primarily rely on the horizontal inequity (HI) approach which measures unequal utilisation of healthcare services by socioeconomic status (SES) for equal medical need. The HI method examines, quantifies, and explains inequity which is based on regression analysis, the concentration index, and the decomposition technique. However, this method is not beyond limitations and criticisms, and it has been subject to several methodological challenges in the past decade. This review presents a summary of the recent developments and debates on various methodological issues and their implications on the assessment of HI in healthcare utilisation. We discuss the key disputes centred on measurement scale of healthcare variables as well as the evolution of the decomposition technique. We also highlight the issues about the choice of variables as the indicator of SES in measuring inequity. This follows a discussion on the application of the longitudinal method and use of administrative data to quantify inequity. Future research could exploit the potential for health administrative data linked to social data to generate more comprehensive estimates of inequity across the healthcare continuum. This review would be helpful to guide future applied research to examine inequity in healthcare utilisation.

A Meta-summarization of Qualitative Findings About Health Systems Performance Evaluation Models: Conceptual Problems and Comparability Limitations

Due to the replacement of the issue of performance measurement in health policies worldwide this study identifies and analyzes the models for evaluating health systems performance. For this purpose, a systematic review of the literature on the topic "health systems performance evaluation" is done, making it compatible with a qualitative meta-synthesis of the type "meta-summarization." It works with all databases related to the theme (PubMed, Scopus, EMBASE, PubAdm and Lilacs/Scielo). Portuguese, English, and Spanish are elected as language limit. Of the total number of articles (n = 32), 23 articles (71.8%) do not have a definition on "performance." In those who have a definition, "performance" could be summed up in 6 central ideas. Among the most frequent subsidiary concepts that makes up the performance idea are the concepts of "efficiency" (11.9%), "quality" (9.5%) and "effectiveness" (7.1%). Six models were found in this review: "dashboard," "balanced scorecard," "open system model," "PCATool," "analyze dimension and performance indicators" and "standardized checklist and interview." The "dashboard" was the most frequent performance evaluation model, found in 35.7% of studies. Only 25% of the reviewed studies presented the performance evaluation model applied specifically to health systems. Far from being configured as management tools useful to comprehension of health systems, these performance evaluation models have shortcomings that compromise their systemic evaluative power. This reinforces the inversion of reality in the relationship between quality and performance. Also, the performance evaluation models used try to adapt to the object, however in most them with relevant analytical problems compromising the specificities in depth of the health system under analysis. This generates inaccuracies and replaces the question about its use and their limitations to compare health systems.

Using standardised patients to assess the quality of medical records: an application and evidence from rural China

BACKGROUND

Medical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries.

OBJECTIVE

To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.

METHODS

A sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.

RESULTS

Medical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider's income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β -0.87, 95% CI -1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness.

CONCLUSION

Despite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.

Appraisal of Health Maintenance Organisations' Performance in the Nigerian Healthcare Service Sector

The quality of healthcare service delivery under the existing health maintenance organisations (HMOs) in Nigeria has been a major concern to enrollees who have contested the value received from their respective HMO accredited hospitals under the program. This paper appraised health maintenance organisations' performance in the Nigerian healthcare service sector capturing enrollees' experience on the issues of access, responsiveness, and quality of healthcare service choice to measure the success or failure of the program since inception. The study adopted survey design with three hundred forty enrollees of ten leading HMOs in Nigeria that operate in different parts of Lagos Metropolis. Data collected were analysed with relevant descriptive and inferential statistics while hypotheses tested were at 0.05 level of significance. Findings revealed that HMO accredited hospitals have not ensured adequate access of enrollees to healthcare services, their responsiveness to enrollees' healthcare requests have not been impressive, and quality of healthcare services to enrollees have also not been excellent. Based on the findings, the study recommends that HMOs and government should improve on monitoring the quality of healthcare service delivery at their accredited hospitals and concluded that the performance of the HMOs in the area of healthcare service delivery is not world class when it comes to access, responsiveness, and quality of service delivery.

Cost-effectiveness of a mentorship and quality improvement intervention to enhance the quality of antenatal care at rural health centers in Rwanda

OBJECTIVE

To estimate cost-effectiveness of Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) intervention to strengthen the quality of antenatal care at rural health centers in rural Rwanda.

DESIGN

Cost-effectiveness analysis of the MESH-QI intervention using the provider perspective.

SETTING

Kirehe and Rwinkwavu District Hospital catchment areas, Rwanda.

INTERVENTION

MESH-QI.

MAIN OUTCOME MEASURES

Incremental cost per antenatal care visit with complete danger sign and vital sign assessments.

RESULTS

The total annual costs of standard antenatal care supervision was 10 777.21 USD at the baseline, whereas the total costs of MESH-QI intervention was 19 656.53 USD. Human resources (salary and benefits) and transport drove the majority of program expenses, (44.8% and 40%, respectively). Other costs included training of mentors (12.9%), data management (6.5%) and equipment (6.5%). The incremental cost per antenatal care visit attributable to MESH-QI with all assessment items completed was 0.70 USD for danger signs and 1.10 USD for vital signs.

CONCLUSIONS

MESH-QI could be an affordable and effective intervention to improve the quality of antenatal care at health centers in low-resource settings. Cost savings would increase if MESH-QI mentors were integrated into the existing healthcare systems and deployed to sites with higher volume of antenatal care visits.

Establishing activity centers for elderly people in metropolitan areas of Vietnam: preference and willingness-to-pay

Purpose and aim

The activity center (AC), an effective model for health support and health-related quality of life improvements for older people, has been operating for many years worldwide. This study aimed to assess the necessity of and preference for attending AC and its desired functions and facilities in elderly people in Vietnam.

Subjects and methods

A cross-sectional study was conducted at parks and senior clubs, with 121 participants from 6 February to 20 April 2017, in Hanoi. The health status, preference, and willingness-to-pay for AC use of respondents were assessed.

Results

Over 75% of respondents agreed to establish an AC for older people. Among them, approximately 71.7% were willing to pay a monthly fee for this center. Elderly individuals who obtain regular physical examination when feeling pain/discomfort and who were participating in clubs for elder people were more likely to agree to establish and pay for an AC. Meanwhile, women who have to take care of grandchildren, people who were saving money and people who had children working in organizations or who were freelancers were less likely to agree to establish and pay for AC.

Conclusion

The results suggest the feasibility of establishment of ACs in Vietnam, with a high proportion of participants agreeing to such establishing and willing to pay for the AC.

Methods for development of structure, process and outcome indicators for prioritized spinal cord injury rehabilitation Domains: SCI-High Project

Background: High-quality rehabilitation care following spinal cord injury or disease (SCI/D) is critical for optimizing neurorecovery and long-term health outcomes. This manuscript describes the methods used for developing, refining, and implementing a framework of structure, process, and outcome indicators that reflect high-quality rehabilitation among adults with SCI/D in Canada. Methods: This quality improvement initiative was comprised of the following processes: (1) prioritization of care Domains by key stakeholders (scientists, clinicians, therapists, patients and stakeholder organizations); (2) assembly of 11 Domain-specific Working Groups including 69 content experts; (3) conduct of literature searches, guideline and best practice reviews, and outcome synthesis by the Project Team; (4) refinement of Domain aim and construct definitions; (5) conduct of cause and effect analysis using Driver diagrams; (6) selection and development of structure, process and outcome indicators; (7) piloting and feasibility analysis of indicators and associated evaluation tools; and, (8) dissemination of the proposed indicators. Result: The Project Team established aims, constructs and related structure, process, and outcome indicators to facilitate uniform measurement and benchmarking across 11 Domains of rehabilitation, at admission and for 18 months thereafter, among adult Canadians by 2020. Conclusion: These processes led to the selection of a feasible set of indicators that once implemented should ensure that adults with SCI/D receive timely, safe, and effective rehabilitation services. These indicators can be used to assess health system performance, monitor the quality of care within and across rehabilitation settings, and evaluate the rehabilitation outcomes of the population to ultimately enhance healthcare quality and equity.

Assessing trends in the content of maternal and child care following a health system strengthening initiative in rural Madagascar: A longitudinal cohort study

BACKGROUND

In order to reach the health-related Sustainable Development Goals (SDGs) by 2030, gains attained in access to primary healthcare must be matched by gains in the quality of services delivered. Despite the broad consensus around the need to address quality, studies on the impact of health system strengthening (HSS) have focused predominantly on measures of healthcare access. Here, we examine changes in the content of maternal and child care as a proxy for healthcare quality, to better evaluate the effectiveness of an HSS intervention in a rural district of Madagascar. The intervention aimed at improving system readiness at all levels of care (community health, primary health centers, district hospital) through facility renovations, staffing, equipment, and training, while removing logistical and financial barriers to medical care (e.g., ambulance network and user-fee exemptions).

METHODS AND FINDINGS

We carried out a district-representative open longitudinal cohort study, with surveys administered to 1,522 households in the Ifanadiana district of Madagascar at the start of the HSS intervention in 2014, and again to 1,514 households in 2016. We examined changes in healthcare seeking behavior and outputs for sick-child care among children <5 years old, as well as for antenatal care and perinatal care among women aged 15-49. We used a difference-in-differences (DiD) analysis to compare trends between the intervention group (i.e., people living inside the HSS catchment area) and the non-intervention comparison group (i.e., the rest of the district). In addition, we used health facility-based surveys, monitoring service availability and readiness, to assess changes in the operational capacities of facilities supported by the intervention. The cohort study included 657 and 411 children (mean age = 2 years) reported to be ill in the 2014 and 2016 surveys, respectively (27.8% and 23.8% in the intervention group for each survey), as well as 552 and 524 women (mean age = 28 years) reported to have a live birth within the previous two years in the 2014 and 2016 surveys, respectively (31.5% and 29.6% in the intervention group for each survey). Over the two-year study period, the proportion of people who reported seeking care at health facilities experienced a relative change of +51.2% (from 41.4% in 2014 to 62.5% in 2016) and -7.1% (from 30.0% to 27.9%) in the intervention and non-intervention groups, respectively, for sick-child care (DiD p-value = 0.01); +11.4% (from 78.3% to 87.2%), and +10.3% (from 67.3% to 74.2%) for antenatal care (p-value = 0.75); and +66.2% (from 23.1% to 38.3%) and +28.9% (from 13.9% to 17.9%) for perinatal care (p-value = 0.13). Most indicators of care content, including rates of medication prescription and diagnostic test administration, appeared to increase more in the intervention compared to in the non-intervention group for the three areas of care we assessed. The reported prescription rate for oral rehydration therapy among children with diarrhea changed by +68.5% (from 29.6% to 49.9%) and -23.2% (from 17.8% to 13.7%) in the intervention and non-intervention groups, respectively (p-value = 0.05). However, trends observed in the care content varied widely by indicator and did not always match the large apparent increases observed in care seeking behavior, particularly for antenatal care, reflecting important gaps in the provision of essential health services for individuals who sought care. The main limitation of this study is that the intervention catchment was not randomly allocated, and some demographic indicators were better for this group at baseline than for the rest of the district, which could have impacted the trends observed.

CONCLUSION

Using a district-representative longitudinal cohort to assess the content of care delivered to the population, we found a substantial increase over the two-year study period in the prescription rate for ill children and in all World Health Organization (WHO)-recommended perinatal care outputs assessed in the intervention group, with more modest changes observed in the non-intervention group. Despite improvements associated with the HSS intervention, this study highlights the need for further quality improvement in certain areas of the district's healthcare system. We show how content of care, measured through standard population-based surveys, can be used as a component of HSS impact evaluations, enabling healthcare leaders to track progress as well as identify and address specific gaps in the provision of services that extend beyond care access.

Advancing research on emergency care systems in low-income and middle-income countries: ensuring high-quality care delivery systems

Emergency care systems (ECS) address a wide range of acute conditions, including emergent conditions from communicable diseases, non-communicable diseases, pregnancy and injury. Together, ECS represent an area of great potential for reducing morbidity and mortality in low-income and middle-income countries (LMICs). It is estimated that up to 54% of annual deaths in LMICs could be addressed by improved prehospital and facility-based emergency care. Research is needed to identify strategies for enhancing ECS to optimise prevention and treatment of conditions presenting in this context, yet significant gaps persist in defining critical research questions for ECS studies in LMICs. The Collaborative on Enhancing Emergency Care Research in LMICs seeks to promote research that improves immediate and long-term outcomes for clients and populations with emergent conditions. The objective of this paper is to describe systems approaches and research strategies for ECS in LMICs, elucidate priority research questions and methodology, and present a selection of studies addressing the operational, implementation, policy and health systems domains of health systems research as an approach to studying ECS. Finally, we briefly discuss limitations and the next steps in developing ECS-oriented interventions and research.

Quality of maternal obstetric and neonatal care in low-income countries: development of a composite index

BACKGROUND

In low-income countries, studies demonstrate greater access and utilization of maternal and neonatal health services, yet mortality rates remain high with poor quality increasingly scrutinized as a potential point of failure in achieving expected goals. Comprehensive measures reflecting the multi-dimensional nature of quality of care could prove useful to quality improvement. However, existing tools often lack a systematic approach reflecting all aspects of quality considered relevant to maternal and newborn care. We aim to address this gap by illustrating the development of a composite index using a step-wise approach to evaluate the quality of maternal obstetric and neonatal healthcare in low-income countries.

METHODS

The following steps were employed in creating a composite index: 1) developing a theoretical framework; 2) metric selection; 3) imputation of missing data; 4) initial data analysis 5) normalization 6) weighting and aggregating; 7) uncertainty and sensitivity analysis of resulting composite score; 8) and deconstruction of the index into its components. Based on this approach, we developed a base composite index and tested alternatives by altering the decisions taken at different stages of the construction process to account for missing values, normalization, and aggregation. The resulting single composite scores representing overall maternal obstetric and neonatal healthcare quality were used to create facility rankings and further disaggregated into sub-composites of quality of care.

RESULTS

The resulting composite scores varied considerably in absolute values and ranges based on method choice. However, the respective coefficients produced by the Spearman rank correlations comparing facility rankings by method choice showed a high degree of correlation. Differences in method of aggregation had the greatest amount of variation in facility rankings compared to the base case. Z-score standardization most closely aligned with the base case, but limited comparability at disaggregated levels.

CONCLUSIONS

This paper illustrates development of a composite index reflecting the multi-dimensional nature of maternal obstetric and neonatal healthcare. We employ a step-wise process applicable to a wide range of obstetric quality of care assessment programs in low-income countries which is adaptable to setting and context. In exploring alternative approaches, certain decisions influencing the interpretation of a given index are highlighted.

A health system framework for perinatal care in South African district hospitals: a Delphi technique

Background

The majority of perinatal deaths occurring in low- and middle- income countries are preventable. South Africa is a middle-income country with consistently high perinatal mortality rates and most factors contributing to preventable deaths are linked to the functioning of the health system. Particularly of concern in South Africa is the high perinatal mortality in district hospitals, where most births occur and where intrapartum care is provided to women of low and intermediate risk. Therefore, it is crucial to strengthen the health system for perinatal care in district hospitals. There is currently no consolidated documented framework outlining contextual health system domains and indicators that are key to providing effective perinatal care in district hospitals. The purpose of this study was to derive key health system domains and indicators necessary to measure the performance of the health system for perinatal care in South African district hospitals.

Methods

The Delphi technique was used in collecting data from a panel with experts drawn from disciplines connected with the functioning of the health system for perinatal care in South Africa. The study enrolled thirteen experts from whom data on key health system domains and indicators for perinatal care were derived. The project reference group gave guidance to the development of the framework and ascertained its relevance to the South African setting.

Results

The Facility Based Health System Framework for Perinatal Care comprising domains and indicators necessary to measure health system performance in South African district hospitals was derived from data. The broad structure of the proposed framework aligns with the WHO Health Systems Framework. Each critical building block has detailed domains and indicators that illuminate essential facility-level and programme-specific elements that require attention for strengthening the health system for perinatal care.

Conclusion

The proposed framework can enable district hospital management teams to identify gaps in the health system for perinatal care, which need to be strengthened in order to alleviate the burden of perinatal deaths in district hospitals.

Assessing associational strength of 23 correlates of child anthropometric failure: An econometric analysis of the 2015-2016 National Family Health Survey, India

Despite the broad consensus that investments in nutrition-sensitive programmes are required to reduce child undernutrition, in practice empirical studies and interventions tend to focus on few nutrition-specific risk factors in isolation. The 2015-16 National Family Health Survey provides the first opportunity in more than a decade to conduct an up-to-date comprehensive evaluation of the relative importance of various maternal and child health and nutrition (MCHN) factors in respect to child anthropometric failures in India. The primary analysis included 140,444 children aged 6-59 months with complete data on 20 MCHN factors, and the secondary analysis included a subset of 25,603 children with additional paternal data. Outcome variables were stunting, underweight and wasting. We conducted logistic regression models to first evaluate each correlate separately in age- and sex-adjusted models, and then jointly in a mutually adjusted model. For all anthropometric failures, indicators of past and present socioeconomic conditions showed the most robust associations. The strongest correlates for stunting were short maternal stature (OR: 4.39; 95%CI: 4.00, 4.81), lack of maternal education (OR: 1.74; 95%CI: 1.60, 1.89), low maternal BMI (OR: 1.64; 95%CI: 1.54, 1.75), poor household wealth (OR: 1.25; 95%CI: 1.15, 1.35) and poor household air quality (OR: 1.22; 95%CI: 1.16, 1.29). Weaker associations were found for other correlates, including dietary diversity, vitamin A supplementation and breastfeeding initiation. Paternal factors were also important predictors of anthropometric failures, but to a lesser degree than maternal factors. The results remained consistent when stratified by children's age (6-23 vs 24-59 months) and sex (girls vs boys), and when low birth weight was additionally considered. Our findings indicate the limitation of nutrition-specific interventions. Breaking multi-generational poverty and improving environmental factors are promising investments to prevent anthropometric failures in early childhood.

Conceptual framework of equity-focused implementation research for health programs (EquIR)

BACKGROUND

Implementation research is increasingly used to identify common implementation problems and key barriers and facilitators influencing efficient access to health interventions.

OBJECTIVE

To develop and propose an equity-based framework for Implementation Research (EquIR) of health programs, policies and systems.

METHODS

A systematic search of models and conceptual frameworks involving equity in the implementation of health programs, policies and systems was conducted in Medline (PubMed), Embase, LILACS, Scopus and grey literature. Key characteristics of models and conceptual frameworks were summarized. We identified key aspects of equity in the context of seven Latin American countries-focused health programs We gathered information related to the awareness of inequalities in health policy, systems and programs, the potential negative impact of increasing inequalities in disadvantaged populations, and the strategies used to reduce them.

RESULTS

A conceptual framework of EquIR was developed. It includes elements of equity-focused implementation research, but it also links the population health status before and after the implementation, including relevant aspects of health equity before, during and after the implementation. Additionally, health sectors were included, linked with social determinants of health through the "health in all policies" proposal affecting universal health and the potential impact of the public health and public policies.

CONCLUSION

EquIR is a conceptual framework that is proposed for use by decision makers and researchers during the implementation of programs, policies or health interventions, with a focus on equity, which aims to reduce or prevent the increase of existing inequalities during implementation.

Advancing the health of women and newborns: predictors of patient satisfaction among women attending antenatal and maternity care in rural Rwanda

Objective

Identify predictors of patient satisfaction with antenatal care (ANC) and maternity services in rural Rwanda.

Design

Cross-sectional.

Setting

Twenty-six health facilities in Southern Kayonza (SK) and Kirehe districts.

Participants

Sample of women ≥ 16 years old receiving antenatal and delivery care between November and December 2013.

Intervention

Survey of patient satisfaction with antenatal and delivery care to inform quality improvement (QI) initiatives aimed at reducing neonatal mortality.

Main Outcome Measure

Overall satisfaction with antenatal and delivery care (reported as excellent or very good).

Results

In multivariate logistic regression analysis, high perceived quality [odds ratio (OR) = 3.03, 95% confidence intervals (CI): 1.565.88], respect [OR = 4.13, 95% CI: 2.16-7.89], and confidentiality [SK: OR = 7.50, 95% CI: 2.16-26.01], [Kirehe: OR = 1.54, 95% CI: 0.60-3.94] were associated with higher overall satisfaction with ANC, while having ≥1 child compared to none [OR = 0.46, 95% CI: 0.25-0.84] was associated with lower satisfaction. For maternity services, <5 years of school versus ≥5 years [OR = 0.13, 95% CI: 0.026-0.69] and higher cleanliness [OR = 19.23, 95% CI: 2.22-166.83], self-reported quality [OR = 10.52, 95% CI: 1.81-61.22], communication [OR = 8.78, 95%CI: 1.95-39.59], and confidentiality [OR = 8.66, 95% CI: 1.20-62.64] were all positively associated with high satisfaction. Higher comfort [OR: 0.050, 95% CI: 0.0034-0.71] and Kirehe vs. SK district [OR: 0.21, 95% CI: 0.042-1.01] were associated with lower satisfaction.

Conclusions

Patient-centeredness (including interpersonal relationships), organizational factors, and location are important individual determinants of satisfaction for women seeking maternal care at study facilities. Understanding variation in these factors should inform QI efforts in maternal and newborn health programs.

Assessing global preparedness for the next pandemic: development and application of an Epidemic Preparedness Index

Introduction

Robust metrics for national-level preparedness are critical for assessing global resilience to epidemic and pandemic outbreaks. However, existing preparedness assessments focus primarily on public health systems or specific legislative frameworks, and do not measure other essential capacities that enable and support public health preparedness and response.

Methods

We developed an Epidemic Preparedness Index (EPI) to assess national-level preparedness. The EPI is global, covering 188 countries. It consists of five subindices measuring each country’s economic resources, public health communications, infrastructure, public health systems and institutional capacity. To evaluate the construct validity of the EPI, we tested its correlation with proxy measures for preparedness and response capacity, including the timeliness of outbreak detection and reporting, as well as vaccination rates during the 2009 H1N1 influenza pandemic.

Results

The most prepared countries were concentrated in Europe and North America, while the least prepared countries clustered in Central and West Africa and Southeast Asia. Better prepared countries were found to report infectious disease outbreaks more quickly and to have vaccinated a larger proportion of their population during the 2009 pandemic.

Conclusion

The EPI measures a country’s capacity to detect and respond to infectious disease events. Existing tools, such as the Joint External Evaluation (JEE), have been designed to measure preparedness within a country over time. The EPI complements the JEE by providing a holistic view of preparedness and is constructed to support comparative risk assessment between countries. The index can be updated rapidly to generate global estimates of pandemic preparedness that can inform strategy and resource allocation.

Indicators to guide health equity work in local public health agencies: a locally driven collaborative project in Ontario

INTRODUCTION

Funded by a Public Health Ontario 'Locally Driven Collaborative Project' grant, a team led by public health practitioners set out to develop and test a comprehensive set of indicators to guide health equity work in local public health agencies (LPHAs).

METHODS

The project began with a scoping review, consultation with content experts, and development of a face-validated set of indicators aligned with the four public health roles to address health inequities (NCCDH, 2014), plus a fifth set of indicators related to an organizational and system development role. We report here on the field testing of the indicators for feasibility, face validity (clarity, relevance), reliability, and comparability in four Ontario LPHAs. Data were collected by two separate individuals or groups at each site, during two consecutive periods. These individuals participated in separate focus groups at the end of each test period, which further examined indicator clarity, data source availability and relevance. A third focus group explored anticipated indicator uses.

RESULTS

Field testing showed that indicators addressed important issues in all public health roles. Although the capacity for indicator use varied, all test sites found the indicators useful. Suggestions for improved clarity were used to refine the final set of indicators, and to develop a Health Equity Indicator User Guide with background information and recommended resources.

CONCLUSION

The process of evaluating health equity-related activity within LPHAs is still in its early stages. This project provides Ontario LPHAs with a tool to guide health equity work that may be adaptable to other Canadian jurisdictions.

The Effectiveness of Home Services in Taiwan: A People-Centered Approach

Among available home and community-based services in Taiwan, there should be a focus on providing people with people-centered, value-based services. This study aims to follow up the people-centered health outcomes of care recipients and to examine the factors associated with to feedback for policy and practice in long-term care. A total of 9889 persons from the long-term care dataset were followed up for two years (T0–T4). The Cox Proportional Hazard Regression analyses to analyze mortality and the mixed effect models for health outcomes were used. Three classes among the care recipients were identified. Health profiles (HR = 1.46 and 2.56 for FI and FD compared with RI, p < 0.001), subsidy gap (HR = 1.01), and living status (HR = 0.88 for those living with spouse only) had a significant impact on mortality. The overall dropout rate was 52.3% at two years, and the health profiles at baseline significantly influenced the health outcome’s change. The health heterogeneity matters and influences subsequent outcomes. To reach the goal of the HCBS, regular and exact monitoring of care recipients is crucial, while feedback regarding health outcomes and a greater focus on providing person-centered and responsive services in the community are also required.

Do the more educated utilize more health care services? Evidence from Vietnam using a regression discontinuity design

In 1991, Vietnam implemented a compulsory primary schooling reform that provides this study a natural experiment to estimate the causal effect of education on health care utilization with a regression discontinuity design. This paper finds that education causes statistically significant impacts on health care utilization, although the signs of the impacts change with specific types of health care services examined. In particular, education increases the inpatient utilization of the public health sector, but it reduces the outpatient utilization of both the public and private health sectors. The estimates are strongly robust to various windows of the sample choice. The paper also discovers that the links between education and the probability of health insurance and income play essential roles as potential mechanisms to explain the causal impact of education on health care utilization in Vietnam.

Primary health Centres' performance assessment measures in developing countries: review of the empirical literature

Background

It is universally accepted that primary healthcare is essential for achieving public health and that assessment of its performance is critical for continuous improvement. The World Health Organization’s (WHO’s) framework for performance assessment is a comprehensive global standard, but difficult to apply in developing countries because of financial and data constraints. This study aims to review the empirical literature on measures for Primary Health Centre (PHC) performance assessment in developing countries, and compare them for comprehensiveness with the aspects described by the WHO Framework.

Methods

Research articles published in English scientific journals between January 1979 and October 2016 were reviewed systematically. The reporting quality of the article and the quality of the measures were assessed with instruments adapted for the purpose of this study. Data was categorized and described.

Results

Fifteen articles were included in the study out of 4359 articles reviewed. Nine articles used quantitative methods, one article used qualitative methods exclusively and five used mixed methods. Fourteen articles had a good description of the measurement properties. None of the articles presented validity tests of the measures but eleven articles presented measures that were well established. Mostly studies included components of personnel competencies (skilled/ non-skilled) and centre performance (patient satisfaction/cost /efficiency).

Conclusions

In comparison to the WHO framework, the measures in the articles were limited in scope as they did not represent all service components of PHCs. Hence, PHC performance assessment should include system components along with relevant measures of personnel performance beyond knowledge of protocols. Existing measures for PHC performance assessment in developing countries need to be validated and concise measures for neglected aspects need to be developed.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3423-0) contains supplementary material, which is available to authorized users.

Multiple policy approaches in improving community pharmacy practice: the case in Indonesia

BACKGROUND

Health reform has been an ongoing agenda in many countries with community pharmacy increasingly gaining attention for contributing to healthcare improvement. Likewise, multiple policy approaches have been introduced to improve community pharmacy practice in Indonesia yet no studies have evaluated their effectiveness. Therefore, this study aimed to identify and collate information on approaches intended to improve practice in Indonesian community pharmacy and subsequently examine the perceptions of key stakeholders in healthcare and community pharmacy about these approaches and the extent to which they have affected community pharmacists as a profession.

METHODS

This study reviewed the grey literature related to community pharmacy policies published by government and pharmacy organisations in Indonesia since 2009 and broadened the search to other relevant databases. In-depth semi structured interviews were conducted with a wide range of key stakeholders in pharmacy and healthcare between February and August 2016 to evaluate these policy approaches.

RESULTS

Seventeen policy documents were identified with the majority published by the Indonesian Pharmacists' Association (8 documents) and Ministry of Health of Indonesia (6 documents). Most documents (15 documents), either the updated version or new policy, were published since 2014 indicating the recent enthusiasm of pharmacy stakeholders to improve community pharmacy practice. Twenty-nine key stakeholders participated in the study, and highlighted three main themes regarding the policy approaches: barriers to effective policy implementation, need for policy changes and strategies to cope with policy challenges. Poor policy enforcement was commonly expressed by participants as a major challenge, with participants anticipating the need for a unified stakeholder vision to improve the current situation. Participants also mentioned several local initiatives which they claimed were improving practice but evidence was lacking.

CONCLUSION

The introduction of policy initiatives within the past ten years has highlighted the enthusiasm of policy makers and pharmacy stakeholders to improve community pharmacy practice in Indonesia. However, some of the initiatives were conceived and enacted in a piecemeal, sometimes conflicting and uncoordinated way. Overall, fundamental and entrenched barriers to practice need to be overcome to create a more professional climate for the practice of pharmacy in Indonesia.

A critique of the Uganda district league table using a normative health system performance assessment framework

Background

In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality.

Methods

A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis.

Results

Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range.

Conclusions

The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks.

Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.

Health Systems and Their Assessment: A Methodological Proposal of the Synthetic Outcome Measure

The effectiveness of health systems is an area of constant interest for public health researchers and practitioners. The varied approach to effectiveness itself has resulted in numerous methodological proposals related to its measurement. The limitations of the currently used methods lead to a constant search for better tools for the assessment of health systems. This article shows the possibilities of using the health system synthetic outcome measure (SOM) for this purpose. It is an original tool using 41 indicators referring to the epidemiological situation, health behaviors, and factors related to the health-care system, which allows a relatively quick and easy assessment of the health system in terms of its effectiveness. Construction of the measure of health system functioning in such a way allowed its presentation in dynamic perspective, i.e., assessing not only the health system itself in a given moment of time but also changes in the value of the effectiveness measures. In order to demonstrate the cognitive value of the SOM, the analysis of the effectiveness of health systems in 21 countries of Central and Eastern Europe during the transformation period was carried out. The mean SOM values calculated on the basis of the component measures allowed to differentiate countries in terms of the effectiveness of their health systems. Considering the whole period, a similar level of health system effects can be observed in Slovenia, Croatia, Czech Republic, Slovakia, Poland, Macedonia, and Albania. In the middle group, Hungary, Romania, Latvia, Lithuania, Georgia, Estonia, Bulgaria, Belarus, and Armenia were found. The third group, weakest in terms of achieved effects, was formed by health systems in countries like Ukraine, Moldova, and Russia. The presented method allows for the analysis of the health system outcomes from a comparative angle, eliminating arbitrariness of pinpointing a model solution as a potential reference point in the assessment of the systems. The measure, with the use of additional statistical tools to establish correlations with elements of the external and internal environment of a health system, allows for conducting analyses of conditions for differences in the effects of health system operation and circumstances for the effectiveness of reform processes.

An evaluation of governance capacity of the specialized component of pharmaceutical services in Brazil

This paper presents application of an indicator protocol to assessment of current levels of governance capacity of the Specialized Component of Pharmaceutical Services (CEAF) in a state of the South of Brazil. We chose the theoretical referential of 'governance capacity' proposed by Carlos Matus, which reflects in the concepts of management capacity and pharmaceutical service management, due to the perception of a need to overcome the fragmentation and technicist reductionism that we believe has been imposed on the area of pharmaceutical services. Data was collected using the protocol in 74 municipal or state units. The results of the analysis indicate that the currently existing governance capacity needs improvement in all three dimensions that were evaluated, principally in relation to the aspects that seek sustainability of the governance. The model and the protocol used indicate a way forward for governance of pharmaceutical service by proposing a change from the technicist-logistical focus to an emphasis on strategic and political actions, or ones which foster greater participation and autonomy. With these results in hand, it will be possible to develop strategies for improvement of access to medicines in the SUS, in the sense that the CEAF becomes able to guarantee integrality of medicines treatments.

Provider perspectives on PrEP for adolescent girls and young women in Tanzania: The role of provider biases and quality of care

BACKGROUND

Oral pre-exposure prophylaxis (PrEP) has the potential to reduce HIV acquisition among adolescent girls and young women (AGYW) in sub-Saharan Africa. However, health care providers' (HCPs) perspectives and interactions with potential clients can substantially influence effective provision of quality health services. We examine if HCPs' knowledge, attitude, and skills, as well as their perceptions of facility readiness to provide PrEP are associated with their willingness to provide PrEP to AGYW at high risk of HIV in Tanzania.

METHODS

A self-administered questionnaire was given to 316 HCPs from 74 clinics in two districts and 24 HCPs participated in follow-up in-depth interviews (IDIs). We conducted bivariate and multivariable Poisson regression to assess factors associated with willingness to provide PrEP to AGYW. Thematic content analysis was used to analyze the IDIs, which expanded upon the quantitative results.

RESULTS

Few HCPs (3.5%) had prior PrEP knowledge, but once informed, 61.1% were willing to prescribe PrEP to AGYW. Higher negative attitudes toward adolescent sexuality and greater concerns about behavioral disinhibition due to PrEP use were associated with lower willingness to prescribe PrEP. Qualitatively, HCPs acknowledged that biases, rooted in cultural norms, often result in stigmatizing and discriminatory care toward AGYW, a potential barrier for PrEP provision. However, better training to provide HIV services was associated with greater willingness to prescribe PrEP. Conversely, HCPs feared the potential negative impact of PrEP on the provision of existing HIV services (e.g., overburdened staff), and suggested the integration of PrEP into non-HIV services and the use of paramedical professionals to facilitate PrEP provision.

CONCLUSIONS

Preparing for PrEP introduction requires more than solely training HCPs on the clinical aspects of providing PrEP. It requires a two-pronged strategy: addressing HCPs' biases regarding sexual health services to AGYW; and preparing the health system infrastructure for the introduction of PrEP.

HIV and early hospital readmission: evaluation of a tertiary medical facility in Lilongwe, Malawi

BACKGROUND

Delivery of quality healthcare in resource-limited settings is an important, understudied public health priority. Thirty-day (early) hospital readmission is often avoidable and an important indicator of healthcare quality.

METHODS

We investigated the prevalence of all-cause early readmission and its associated factors using age and sex adjusted risk ratios (RR) and 95% confidence intervals (CI). A retrospective review of the medical ward database at Kamuzu Central Hospital in Lilongwe, Malawi was conducted between February and December 2013.

RESULTS

There were 3547 patients with an index admission of which 2776 (74.4%) survived and were eligible for readmission. Among these patients: 49.7% were male, mean age was 39.7 years, 36.1% were HIV-positive, 34.6% were HIV-negative, and 29.3% were HIV-unknown. The prevalence of early hospital readmission was 5.5%. Diagnoses associated with 30-day readmission were HIV-positive status (RR = 2.41; 95% CI: 1.64-3.53) and malaria (RR = 0.45; 95% CI: 0.22-0.91). Other factors associated with readmission were multiple diagnoses (excluding HIV) (RR = 1.52; 95% CI: 1.11-2.06), and prolonged length of stay (≥ 16 days) at the index hospitalization (RR = 3.63; 95% CI: 1.72-7.67).

CONCLUSION

Targeting HIV-infected inpatients with multiple diagnoses and longer index hospitalizations may prevent early readmission and improve quality of care.

Snakebites as cause of deaths in the Western Brazilian Amazon: Why and who dies? Deaths from snakebites in the Amazon

Snake envenoming represents a major burden for public health worldwide. In the Amazon, the official number of cases and deaths detected is probably underestimated because of the difficulty riverine and indigenous populations have reaching health centers in order to receive medical assistance. Thus, integrated analysis of health information systems must be used in order to improve adequate health policies. The aim of this work is to describe a series of deaths and identify risk factors for lethality from snakebites in the state of Amazonas, Brazil. All deaths from snakebites reported to the Brazilian Notifiable Diseases Surveillance System (SINAN) and to the Mortality Information System (SIM; ICD10-10th revision, X.29), from 2007 to 2015, were included. Variables were assessed by blocks with distal (ecological variables), intermediate (demographics) and proximal (clinical variables) components to identify predictors of case fatality. A total of 127 deaths from snakebites were recorded, with 58 pairs found through linkage of the SINAN and SIM databases (45.7%), 37 (29.1%) deaths found only in SINAN and 32 (25.2%) found only in the SIM. Deaths occurred mostly in males (95 cases; 74.8%) living in rural areas (78.6%). The most affected age group was the ≥61 years old (36 cases; 28.4%). Snakebites were presumably due to Bothrops snakes in 68.5% of the cases and Lachesis in 29.5% based on clinico-epidemiological diagnosis. A proportion of 26.2% of the cases received treatment over 24 h after the bite ocurred. On admission, cases were mostly classified as severe (65.6%). Overall, 28 patients (22.0%). Deceased without any medical assistance Antivenom was given to 53.5%. In the multivariate analysis, a distance from Manaus >300 km [OR = 3.40 (95%CI = 1.99-5.79); (p < 0.001)]; age ≥61 years [OR = 4.31 (95%CI = 1.22-15.21); (p = 0.023)] and Indigenous status [OR = 5.47 (95%CI = 2.37-12.66); (p < 0.001)] were independently associated with case fatality from snakebites. Severe snakebites [OR = 16.24 (95%CI = 4.37-60.39); (p < 0.001)] and a lack of antivenom administration [OR = 4.21 (95%CI = 1.30-13.19); (p = 0.014)] were also independently associated with case fatality. Respiratory failure/dyspnea, systemic bleeding, sepsis and shock were recorded only among fatal cases. In conclusion, i) death from snakebites was underreported in the mortality surveillance system; ii) older age groups living in remote municipalities and indigenous peoples were the population groups most prone to death; iii) lack or underdosage of antivenom resulted in higher case fatality and iv) systemic bleeding, circulatory shock, sepsis and acute respiratory failure were strongly associated to fatal outcome.