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Alam A, Kaur H, Bhatnagar S. Awareness among Pediatricians Regarding National Telemedicine Guidelines during the COVID-19 Pandemic: A Survey. Indian J Community Med 2024; 49:539-543. [PMID: 38933790 PMCID: PMC11198522 DOI: 10.4103/ijcm.ijcm_644_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 02/26/2024] [Indexed: 06/28/2024] Open
Abstract
The success of telemedicine depends on awareness among doctors on how to implement it. We aimed to assess knowledge about national telemedicine guidelines in pediatricians during the coronavirus disease 2019 (COVID-19) pandemic. A cross-sectional study of pediatricians across India was conducted through a structured online questionnaire containing 16 marks. The mean knowledge score (KS) was calculated. Participants were divided into two groups: poor KS (KS <8) and good KS (KS ≥8). The association between factors and KS was assessed using univariate analysis. A total of 503 pediatricians participated (private sector: 80.7% and public sector: 19.3%). Most (61%) belonged to the age group of 31-50 years and were males (75%). The minimum educational qualification was a Doctor of Medicine (MD) in 57% of cases. Despite work experience of more than 5 years in most (70%) of the cases, very few had provided teleconsultation before the pandemic (13.9%). The mean KS was 10.60 ± 2.8, that is, 66.25%. The minimum KS was 1 (6.25%), and the maximum was 16 (100%). Assam, Chandigarh, Himachal Pradesh, Jharkhand, Odisha, Sikkim, and Tamil Nadu showed higher knowledge than other states, although no significant difference was found. The majority (89.1%) had good KS, which is significantly higher among private practitioners as compared to public practitioners. There was no association between KS and age, gender, qualification, and work experience. Pediatricians have good information regarding telemedicine guidelines in India; however, training programs will further empower doctors working in the public sector.
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Affiliation(s)
- Areesha Alam
- Department of Pediatrics, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Harpreet Kaur
- Department of Pediatrics, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Shrish Bhatnagar
- Department of Pediatrics, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
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Morris G, Maliqi B, Lattof SR, Strong J, Yaqub N. Private sector quality of care for maternal, new-born, and child health in low-and-middle-income countries: a secondary review. Front Glob Womens Health 2024; 5:1369792. [PMID: 38707636 PMCID: PMC11066217 DOI: 10.3389/fgwh.2024.1369792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/21/2024] [Indexed: 05/07/2024] Open
Abstract
The private sector has emerged as a crucial source of maternal, newborn, and child health (MNCH) care in many low- and middle-income countries (LMICs). Quality within the MNCH private sector varies and has not been established systematically. This study systematically reviews findings on private-sector delivery of quality MNCH care in LMICs through the six domains of quality care (QoC) (i.e., efficiency, equity, effectiveness, people-centered care, safety, and timeliness). We registered the systematic review with PROSPERO international prospective register of systematic reviews (registration number CRD42019143383) and followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) Statement for clear and transparent reporting of systematic reviews and meta-analyses. Searches were conducted in eight electronic databases and two websites. For inclusion, studies in LMICs must have examined at least one of the following outcomes using qualitative, quantitative, and/or mixed-methods: maternal morbidity, maternal mortality, newborn morbidity, newborn mortality, child morbidity, child mortality, service utilization, quality of care, and/or experience of care including respectful care. Outcome data was extracted for descriptive statistics and thematic analysis. Of the 139 included studies, 110 studies reported data on QoC. Most studies reporting on QoC occurred in India (19.3%), Uganda (12.3%), and Bangladesh (8.8%). Effectiveness was the most widely measured quality domain with 55 data points, followed by people-centered care (n = 52), safety (n = 47), timeliness (n = 31), equity (n = 24), and efficiency (n = 4). The review showed inconsistencies in care quality across private and public facilities, with quality varying across the six domains. Factors such as training, guidelines, and technical competence influenced the quality. There were also variations in how domains like "people-centered care" have been understood and measured over time. The review underscores the need for clearer definitions of "quality" and practical QoC measures, central to the success of Sustainable Development Goals (SDGs) and equitable health outcomes. This research addresses how quality MNCH care has been defined and operationalized to understand how quality is delivered across the private health sector and the larger health system. Numerous variables and metrics under each QoC domain highlight the difficulty in systematizing QoC. These findings have practical significance to both researchers and policymakers. Systematic Review Registration https://bmjopen.bmj.com/content/10/2/e033141.long, Identifier [CRD42019143383].
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Affiliation(s)
- Georgina Morris
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Blerta Maliqi
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Joe Strong
- Department of Maternal, Newborn, Child, Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Nuhu Yaqub
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
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Wagner Z, Mohanan M, Zutshi R, Mukherji A, Sood N. What drives poor quality of care for child diarrhea? Experimental evidence from India. Science 2024; 383:eadj9986. [PMID: 38330118 DOI: 10.1126/science.adj9986] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/08/2023] [Indexed: 02/10/2024]
Abstract
Most health care providers in developing countries know that oral rehydration salts (ORS) are a lifesaving and inexpensive treatment for child diarrhea, yet few prescribe it. This know-do gap has puzzled experts for decades. Using randomized experiments in India, we estimated the extent to which ORS underprescription is driven by perceptions that patients do not want ORS, provider's financial incentives, and ORS stock-outs (out-of-stock events). Patients expressing a preference for ORS increased ORS prescribing by 27 percentage points. Eliminating stock-outs increased ORS provision by 7 percentage points. Removing financial incentives did not affect ORS prescribing on average but did increase ORS prescribing at pharmacies. We estimate that perceptions that patients do not want ORS explain 42% of underprescribing, whereas stock-outs and financial incentives explain only 6 and 5%, respectively.
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Affiliation(s)
- Zachary Wagner
- Department of Economics, Sociology and Statistics, RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Rushil Zutshi
- Department of Economics, Sociology and Statistics, RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Arnab Mukherji
- Center for Public Policy, Indian Institute of Management Bangalore, Bangalore, Karnataka, India
| | - Neeraj Sood
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA
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Garg R, Walecha A, Goyal V, Mehra A, Badkur M, Gaur R, Choudhary IS, Talwar Y. A 12-Month Randomized Controlled Trial to Assess the Impact of Telemedicine on Patient Experience and Care Continuity. Cureus 2024; 16:e53201. [PMID: 38425584 PMCID: PMC10902609 DOI: 10.7759/cureus.53201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Telemedicine is the use of electronic information to communicate technologies to provide and support healthcare when distance separates the participants. Satisfaction and engagement of patients are key resource indicators for any healthcare setup and healthcare provider for evolving the care continuum (a system that provides a comprehensive range of health services so that care can evolve with the patient over time) and ensuring continuous quality improvement in the systems. As the latest remarkable strategy to connect with patients for consultations and follow-up, telemedicine has been of pivotal importance, especially during the coronavirus disease 2019 (COVID-19), where medicinal services utilize digital sound, video, and information interchanges to remotely access and provide care. MATERIALS AND METHODS A cross-sectional study was planned during the second wave of the COVID-19 pandemic from April 2021 to April 2022 to assess the impact of telemedicine in essential healthcare delivery by super specialty tertiary care healthcare setup, which is also a medical college, by three consultants and a physiotherapist. RESULTS There was a significant improvement in satisfaction scores and an improvement in the approach of patients towards telemedicine was observed. Various other parameters, like readmission compliance with medications and a reduction in ED times, were also observed. Finally, clinical endpoints were captured, and the correlation between readmission and medicine adherence was found to be strongly correlated (r = 0.9). A p-value of the reduction in utilization times of ED (emergency department), readmission, and medicine adherence was found to be highly significant Conclusions: Telemedicine is the need of the hour and is now an essential part of healthcare. Its acceptance post-COVID-19 pandemic and adaptability into existing healthcare setups would deliver fruitful results.
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Affiliation(s)
- Ruchi Garg
- Hospital Administration, All India Institute of Medical Sciences, Jodhpur, IND
| | - Akshi Walecha
- Anesthesia, All India Institute of Medical Sciences, Jodhpur, IND
| | - Vinay Goyal
- Physical Medicine and Rehabilitation, All India Institute of Physical Medicine and Rehabilitation, Mumbai, IND
| | - Aditi Mehra
- Hospital Administration, Government Medical College & Hospital, Chandigarh, IND
| | - Mayank Badkur
- General Surgery, All India Institute of Medical Sciences, Jodhpur, IND
| | - Ravi Gaur
- Physical Medicine and Rehabilitation, All India Institute of Medical Sciences, Jodhpur, IND
| | | | - Yatin Talwar
- Hospital Administration, All India Institute of Medical Sciences, Jodhpur, IND
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Wagner Z, Banerjee S, Mohanan M, Sood N. Does the market reward quality? Evidence from India. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2023; 23:467-505. [PMID: 36477343 DOI: 10.1007/s10754-022-09341-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
There are two salient facts about health care in low and middle-income countries; (1) the private sector plays an important role and (2) the care provided is often of poor quality. Despite these facts we know little about what drives quality of care in the private sector and why patients seek care from poor quality providers. We use two field studies in India that provide insight into this issue. First, we use a discrete choice experiment to show that patients strongly value technical quality. Second, we use standardized patients to show that better quality providers are not able to charge higher prices. Instead providers are able to charge higher prices for elements of quality that the patient can observe, which are less important for health outcomes. Future research should explore whether accessible information on technical quality of local providers can shift demand to higher quality providers and improve health outcomes.
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Affiliation(s)
| | | | - Manoj Mohanan
- Sanford School of Public Policy, Duke University, Durham, NC, USA
| | - Neeraj Sood
- Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
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Ghosh K, Chakraborty AS, SenGupta S. Identifying spatial clustering of diarrhoea among children under 5 years across 707 districts in India: a cross sectional study. BMC Pediatr 2023; 23:272. [PMID: 37254063 DOI: 10.1186/s12887-023-04073-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 05/16/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Diarrhoea is one of the leading reasons for under-five child mortality and morbidity across the globe and especially in low- and middle-income countries like India. The present study aims to investigate and identify the spatial clustering and the factors associated with diarrhoea across 707 districts of different states in India. METHODS This study used National Family Health Survey-4 & 5 (2015-16 & 2019-21) data in India. Spatial analysis software i.e., ArcGIS and GeoDa including Moran's statistics have been applied to detect the spatial prevalence and auto-correlation of diarrhoea among neighbourhood districts. Bivariate analysis with a chi-square test and logistic regression has been performed to identify the factors associated with the morbidity condition. RESULTS The result shows out of 2,23,785 children, 7.3 percent children suffer from diarrhoea in India. The prevalence is highest in Bihar (13.7%) and lowest in Lakshadweep (2.3%). Around 33 percent of districts have reported more than the national average level of diarrhoea prevalence. The study also found a medium to high level of autocorrelation with 0.41 Moran's Index value and detected 69 hot-spots districts mostly from Maharashtra, Bihar, Odisha, and Gujarat. The study has also found, with an increase in children's age as well as mother's age the prevalence of the disease decreases. The prevalence is more among male children than females. Underweight [OR = 1.08, 95% CI (1.03-1.13)] children have a greater risk of suffering from diarrhoeal diseases. The odds of children living in a pucca house [OR = 0.89, 95% CI (0.68-1.16)] are less likely to suffer from diarrhoea. On the other hand, rich economic status [OR = 0.91, 95% CI (0.86-0.97)], reduce the risk of such morbid conditions. CONCLUSION The study recommends targeting the hot-spot districts with high prevalence areas, and district-level interventions by improving housing type and child nutrition status, which can help to prevent diarrhoeal diseases among children in India. Thus, the identification of hotspot districts and suggested policy interventions by the current study can help to prevent childhood mortality and morbidity, as well as to achieve the target given by Sustainable development Goals 3.2.
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Affiliation(s)
- Koustav Ghosh
- Gokhale Institute of Politics and Economics, Pune, India.
- Population Research Centre Baroda, Gujarat, India.
| | | | - Shoummo SenGupta
- International Institute for Population Sciences (IIPS), Mumbai, India
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Kushniruk A, Lehmann H, Alam AA, Yazdi Y, Acharya S. Development of a Digital Assistant to Support Teleconsultations Between Remote Physicians and Frontline Health Workers in India: User-Centered Design Approach. JMIR Hum Factors 2023; 10:e25361. [PMID: 36729578 PMCID: PMC9936362 DOI: 10.2196/25361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 05/31/2021] [Accepted: 09/10/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Many low- and middle-income countries have adopted telemedicine programs that connect frontline health workers (FHWs) such as nurses, midwives, or community health workers in rural and remote areas with physicians in urban areas to deliver care to patients. By leveraging technology to reduce temporal, financial, and geographical barriers, these health worker-to-physician telemedicine programs have the potential to increase health care quality, expand the specialties available to patients, and reduce the time and cost required to deliver care. OBJECTIVE We aimed to identify, validate, and prioritize unmet needs in the health care space of health worker-to-physician telemedicine programs and develop and refine a solution that addresses those needs. METHODS We collected information regarding user needs through ethnographic research, direct observation, and semistructured interviews with 37 stakeholders (n=5, 14% physicians; n=1, 3% public health program manager; n=12, 32% community health workers; and n=19, 51% patients) at 2 telemedicine clinics in rural West Bengal, India. We used the Spiral-Iterative Innovation Model to design and develop a prototype solution to meet these needs. RESULTS We identified 74 unmet needs through our immersion in health worker-to-physician telemedicine programs. We identified a critical unmet need that achieving optimal teleconsultations in low- and middle-income countries often requires shifting tasks such as history taking and physical examination from high-skilled remote physicians to FHWs. To meet this need, we developed a prototype digital assistant that would allow FHWs to assume some of the tasks carried out by remote clinicians. The user needs of multiple stakeholder groups (patients, FHWs, physicians, and health organizations) were incorporated into the design and features of the task-shifting tool. The final prototype was shared with the health workers, physicians, and public health program managers who expressed that the tool would be useful and valuable. CONCLUSIONS The final prototype that was developed was released as an open-source digital public good and may improve the quality and efficiency of care delivery in health worker-to-physician telemedicine programs.
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Affiliation(s)
| | - Harold Lehmann
- Division of Health Sciences Informatics, Johns Hopkins University, Baltimore, MD, United States
| | | | - Youseph Yazdi
- Division of Health Sciences Informatics, Johns Hopkins University, Baltimore, MD, United States
| | - Soumyadipta Acharya
- Division of Health Sciences Informatics, Johns Hopkins University, Baltimore, MD, United States
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Participatory user requirements elicitation, validation, and prioritization for tele-otology app in deprived populations. Int J Med Inform 2022; 167:104869. [PMID: 36174414 DOI: 10.1016/j.ijmedinf.2022.104869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 09/04/2022] [Accepted: 09/11/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The timely and accurate diagnosis of ENT (Ear, Nose, and throat) diseases in deprived areas is very important due to the increased burden of the disease in high-risk populations. Therefore, the purpose of this study is to identify, validate and prioritize the information needs of stakeholders of a tele-otology system for diagnosing ear diseases and to provide a solution. MATERIAL AND METHODS In this study, to identify the information need of the stakeholders and prioritize them, the spiral-iterative model was used. Data were obtained through direct observation, interviews with 23 stakeholders (6 ENT specialist doctors, 3 health center managers, 2 patients, and 12 health facilitators), and a survey among all ENT specialists and residents (n = 49), working in Kerman province, Iran. Finally, based on the study findings, the important information needs of the stakeholders were considered as the input for developing the tele-otology software. RESULTS In the observation phase, the workflow of the tele-otology system was developed. In the interview phase, 4 main themes including patient information; Technology and communication; Policy, guidelines, and requirements; Facilitator skills and knowledge were determined. In total, the four categories of the iterative-spiral model including strategic, patient information, commercial and technical with 8, 9, 3, and 9 sub-categories, respectively, were prioritized by specialists which were considered as input for system development. CONCLUSION By applying the spiral-iterative model, the prototype included a mobile app and server system was developed. In the final solution, the possibility of capturing patient history and video images was provided for facilitators to help physicians in effective diagnosis. The results of this study, while identifying the workflow of service providers and determining their information needs can help telemedicine system developers to have an optimal design when designing systems for the diagnosis of ear disease.
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Vyas V, Singh K, Pareek P, Garg MK, Didel S, Priyanka P, Goel AD, Misra S. Guardian-Reported Impact of the COVID-19 Pandemic on the Lifestyle of Children with Diabetes Mellitus. J Trop Pediatr 2022; 68:6523956. [PMID: 35137217 PMCID: PMC8903385 DOI: 10.1093/tropej/fmac013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The coronavirus disease-2019 (COVID-19) pandemic has had an unprecedented impact on the lives and lifestyles of people of all ages worldwide. Lifestyle has an essential role in the management of diabetes mellitus in children. METHODS The study was carried out at a tertiary care centre in India. A telehealth survey was conducted among the parents/guardians of children with diabetes to study the impact of the COVID-19 pandemic. The survey evaluated the effects on lifestyle, diabetes management and challenges in connecting to a new telemedicine programme. RESULTS The survey was completed by guardians of 91 patients. The mean age of the patients was 13.0 ± 3.8 years in boys and 11.9 ± 4.5 years in girls. Fifty-seven per cent of them were boys, and 63.7% stayed in rural areas. The pandemic has resulted in a significant increase in screen time and sleep duration. The median non-educational screen time has gone up from 1.00 (0.5-2.0) to 2.50 (1.0-4.0) h. The mean sleep duration in children increased from 9.1 ± 1.4 to 9.7 ± 1.4 h. Telemedicine services have been established with minimum resources, but they have limitations, and awareness about them is also limited. CONCLUSION The COVID-19 pandemic has made the lifestyle of children with diabetes more sedentary. Some of them have also faced challenges with regard to diabetes-related supplies and management. It would be fair to anticipate more complications related to this sedentary lifestyle in the future and work towards identifying and treating them.
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Affiliation(s)
- Varuna Vyas
- Associate Professor, Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, India,Corresponding Author: Dr Varuna Vyas, , Department of Pediatrics, Room number 3147, Academic Block, All India Institute of Medical Sciences, Jodhpur, Jodhpur, Rajasthan, India 342005, Telephone number: + 91 9810508477
| | - Kuldeep Singh
- Professor and Head, Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, India
| | - Puneet Pareek
- Additional Professor, Department of Radio- Therapy, All India Institute of Medical Sciences, Jodhpur, India
| | - Mahendra Kumar Garg
- Professor and Head, Department of Endocrinology, All India Institute of Medical Sciences, Jodhpur, India
| | - Siyaram Didel
- Assistant Professor, Department of Pediatrics, All India Institute of Medical Sciences, Jodhpur, India
| | - Priyanka Priyanka
- Senior Resident, Department of Pediatrics, All India Institute of Medical Sciences, Patna, India
| | - Akhil Dhanesh Goel
- Associate Professor, Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Sanjeev Misra
- Director, Professor and Head, Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, India
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Iloka CB, Ekpo IA, Rjoub H, Iyiola K, Odugbesan JAA. Investigating the Receptiveness Attitude of the Patient With Diabetes Retinopathy Towards the Use of Teleophthalmology. INTERNATIONAL JOURNAL OF E-HEALTH AND MEDICAL COMMUNICATIONS 2022. [DOI: 10.4018/ijehmc.309685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Research on the attitude of diabetes retinopathy's (DR) patients towards teleophthalmology as a branch of telemedicine has not been examined in developing countries. This article examines the receptiveness attitude of the patients with DR towards the use of teleophthalmology using 400 questionnaires to examine patients in Calabar DR screening center in Cross River State, Nigeria. The hypotheses were tested using multiple indicators multiple causes (MIMIC) as a special case of the structural equation modeling (SEM). The findings in this study indicated high cost and excess time negatively affects patient attitude, information, knowledge, and experience significantly and positively predict patients attitude towards teleophthalmology. Furthermore, the result of the paper shows that convenience and knowledge for 35.7 percent of the receptiveness of patients towards teleophthalmology. This study contributes by identifying that among other factors positive factors to enhance patient's receptive attitude to being diagnosis with diabetes retinopathy through telemedicine.
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Affiliation(s)
| | | | - Husam Rjoub
- Department of Accounting and Finance, College of Administrative Sciences and Informatics, Palestine Polytechnic University, Hebron City, West Bank, Palestine
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King JJC, Powell-Jackson T, Makungu C, Spieker N, Risha P, Mkopi A, Goodman C. Effect of a multifaceted intervention to improve clinical quality of care through stepwise certification (SafeCare) in health-care facilities in Tanzania: a cluster-randomised controlled trial. Lancet Glob Health 2021; 9:e1262-e1272. [PMID: 34363766 PMCID: PMC8370880 DOI: 10.1016/s2214-109x(21)00228-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Quality of care is consistently shown to be inadequate in health-care settings in many low-income and middle-income countries, including in private facilities, which are rapidly growing in number but often do not have effective quality stewardship mechanisms. The SafeCare programme aims to address this gap in quality of care, using a standards-based approach adapted to low-resource settings, involving assessments, mentoring, training, and access to loans, to improve clinical quality and facility business performance. We assessed the effect of the SafeCare programme on quality of patient care in faith-based and private for-profit facilities in Tanzania. METHODS In this cluster-randomised controlled trial, health facilities were eligible if they were dispensaries, health centres, or hospitals in the faith-based or private for-profit sectors in Tanzania. We randomly assigned facilities (1:1) using computer-generated stratified randomisation to receive the full SafeCare package (intervention) or an assessment only (control). Implementing staff and participants were masked to outcome measurement and the primary outcomes were measured by fieldworkers who had no knowledge of the study group allocation. The primary outcomes were health worker compliance with infection prevention and control (IPC) practices as measured by observation of provider-patient interactions, and correct case management of undercover standardised patients at endline (after a minimum of 18 months). Analyses were by modified intention to treat. The trial is registered with ISRCTN, ISRCTN93644888. FINDINGS Between March 7 and Nov 30, 2016, we enrolled and randomly assigned 237 health facilities to the intervention (n=118) or control (n=119). Nine facilities (seven intervention facilities and two control facilities) closed during the trial and were not included in the analysis. We observed 29 608 IPC indications in 5425 provider-patient interactions between Feb 7 and April 5, 2018. Health facilities received visits from 909 standardised patients between May 3 and June 12, 2018. Intervention facilities had a 4·4 percentage point (95% CI 0·9-7·7; p=0.015) higher mean SafeCare standards assessment score at endline than control facilities. However, there was no evidence of a difference in clinical quality between intervention and control groups at endline. Compliance with IPC practices was observed in 8181 (56·9%) of 14 366 indications in intervention facilities and 8336 (54·7%) of 15 242 indications in control facilities (absolute difference 2·2 percentage points, 95% CI -0·2 to -4·7; p=0·071). Correct management occurred in 120 (27·0%) of 444 standardised patients in the intervention group and in 136 (29·2%) of 465 in the control group (absolute difference -2·8 percentage points, 95% CI -8·6 to -3·1; p=0·36). INTERPRETATION SafeCare did not improve clinical quality as assessed by compliance with IPC practices and correct case management. The absence of effect on clinical quality could reflect a combination of insufficient intervention intensity, insufficient links between structural quality and care processes, scarcity of resources for quality improvement, and inadequate financial and regulatory incentives for improvement. FUNDING UK Health Systems Research Initiative (Medical Research Council, Economic and Social Research Council, UK Department for International Development, Global Challenges Research Fund, and Wellcome Trust).
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Affiliation(s)
| | | | | | | | - Peter Risha
- PharmAccess Tanzania, Dar es Salaam, Tanzania
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Gautham M, Spicer N, Chatterjee S, Goodman C. What are the challenges for antibiotic stewardship at the community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural India. Soc Sci Med 2021; 275:113813. [PMID: 33721743 PMCID: PMC8164106 DOI: 10.1016/j.socscimed.2021.113813] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/08/2021] [Accepted: 03/01/2021] [Indexed: 12/15/2022]
Abstract
In many low- and middle-income countries, providers without formal training are an important source of antibiotics, but may provide these inappropriately, contributing to the rising burden of drug resistant infections. Informal providers (IPs) who practise allopathic medicine are part of India's pluralistic health system legacy. They outnumber formal providers but operate in a policy environment of unclear legitimacy, creating unique challenges for antibiotic stewardship. Using a systems approach we analysed the multiple intrinsic (provider specific) and extrinsic (community, health and regulatory system and pharmaceutical industry) drivers of antibiotic provision by IPs in rural West Bengal, to inform the design of community stewardship interventions. We surveyed 291 IPs in randomly selected village clusters in two contrasting districts and conducted in-depth interviews with 30 IPs and 17 key informants including pharmaceutical sales representatives, managers and wholesalers/retailers; medically qualified private and public doctors and health and regulatory officials. Eight focus group discussions were conducted with community members. We found a mosaic or bricolage of informal practices conducted by IPs, qualified doctors and industry stakeholders that sustained private enterprise and supplemented the weak public health sector. IPs' intrinsic drivers included misconceptions about the therapeutic necessity of antibiotics, and direct and indirect economic benefits, though antibiotics were not the most profitable category of drug sales. Private doctors were a key source of IPs' learning, often in exchange for referrals. IPs constituted a substantial market for local and global pharmaceutical companies that adopted aggressive business strategies to exploit less-saturated rural markets. Paradoxically, the top-down nature of regulations produced a regulatory impasse wherein regulators were reluctant to enforce heavy sanctions for illegal sales, fearing an adverse impact on rural healthcare, but could not implement enabling strategies to improve antibiotic provision due to legal barriers. We discuss the implications for a multi-stakeholder antibiotic stewardship strategy in this setting.
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Affiliation(s)
- Meenakshi Gautham
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17, Tavistock Place, London, WC1H 9SH, UK.
| | - Neil Spicer
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17, Tavistock Place, London, WC1H 9SH, UK.
| | | | - Catherine Goodman
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, 15-17, Tavistock Place, London, WC1H 9SH, UK.
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Agarwal D, Roy N, Panwar V, Basil A, Agarwal PM. Bringing Health Care Closer to People - A Review of Various Telemedicine Models under the National Health Mission in India. Indian J Community Med 2020; 45:274-277. [PMID: 33354000 PMCID: PMC7745827 DOI: 10.4103/ijcm.ijcm_334_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 05/18/2020] [Indexed: 11/09/2022] Open
Abstract
Telemedicine is an alliance between technology and medicine. It is a prevalent practice in developed countries; it has been widely used in developing countries to address the issues of access to medical care. India has been experimenting with telemedicine since long to address the issues of access and availability of specialist care and in recent years, with the rapid advancement of information technology, telemedicine has become a popular concept across the country. In this article, we have reviewed the various aspects of different government-funded telemedicine models functional in 12 states across India. We have also attempted to explore the levels of care delivery and services at facilities provided through telemedicine and challenges being faced in the implementation of the models. As a way forward, the health-care community needs to realize the full potential of telemedicine facility and utilize it to their benefit. Telemedicine will work best when it is one component of a well-functioning health system and not as an isolated gap-filling application.
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Affiliation(s)
- Disha Agarwal
- National Health Systems Resource Centre, New Delhi, India
| | - Nobhojit Roy
- National Health Systems Resource Centre, New Delhi, India
| | - Vivek Panwar
- National Health Systems Resource Centre, New Delhi, India
| | - Ajay Basil
- National Health Systems Resource Centre, New Delhi, India
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14
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Darmstadt GL, Pepper KT, Ward VC, Srikantiah S, Mahapatra T, Tarigopula UK, Bhattacharya D, Irani L, Schooley J, Chaudhuri I, Dutt P, Sastry P, Mitra R, Chamberlain S, Monaghan S, Nanda P, Atmavilas Y, Saggurti N, Borkum E, Rangarajan A, Mehta KM, Abdalla S, Wilhelm J, Weng Y, Carmichael SL, Raheel H, Bentley J, Munar WA, Creanga A, Trehan S, Walker D, Shah H. Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya. J Glob Health 2020; 10:021001. [PMID: 33414906 PMCID: PMC7757841 DOI: 10.7189/jogh.10.021001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
In 2010, the Bill and Melinda Gates Foundation (BMGF) partnered with the Government of Bihar (GoB), India to launch the Ananya program to improve reproductive, maternal, newborn and child health and nutrition (RMNCHN) outcomes. The program sought to address supply- and demand-side barriers to the adoption, coverage, quality, equity and health impact of select RMNCHN interventions. Approaches included strengthening frontline worker service delivery; social and behavior change communications; layering of health, nutrition and sanitation into women's self-help groups (SHGs); and quality improvement in maternal and newborn care at primary health care facilities. Ananya program interventions were piloted in approximately 28 million population in eight innovation districts from 2011-2013, and then beginning in 2014, were scaled up by the GoB across the rest of the state's population of 104 million. A Bihar Technical Support Program provided techno-managerial support to governmental Health as well as Integrated Child Development Services, and the JEEViKA Technical Support Program supported health layering and scale-up of the GoB's SHG program. The level of support at the block level during statewide scale-up in 2014 onwards was approximately one-fourth that provided in the pilot phase of Ananya in 2011-2013. This paper - the first manuscript in an 11-manuscript and 2-viewpoint collection on Learning from Ananya: Lessons for primary health care performance improvement - seeks to provide a broad description of Ananya and subsequent statewide adaptation and scale-up, and capture the background and context, key objectives, interventions, delivery approaches and evaluation methods of this expansive program. Subsequent papers in this collection focus on specific intervention delivery platforms. For the analyses in this series, Stanford University held key informant interviews and worked with the technical support and evaluation grantees of the Ananya program, as well as leadership from the India Country Office of the BMGF, to analyse and synthesise data from multiple sources. Capturing lessons from the Ananya pilot program and statewide scale-up will assist program managers and policymakers to more effectively design and implement RMNCHN programs at scale through technical assistance to governments.
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Affiliation(s)
- Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Kevin T Pepper
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Victoria C Ward
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | | | | | | | | | | | - Janine Schooley
- Project Concern International, Delhi, India, and San Diego, California, USA
| | - Indrajit Chaudhuri
- Project Concern International, Delhi, India, and San Diego, California, USA
| | | | | | | | | | - Sophia Monaghan
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Priya Nanda
- Bill and Melinda Gates Foundation, Delhi, India
| | | | | | | | | | - Kala M Mehta
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Safa Abdalla
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jess Wilhelm
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yingjie Weng
- Quantitaitve Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Suzan L Carmichael
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Hina Raheel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Jason Bentley
- Quantitaitve Sciences Unit, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wolfgang A Munar
- George Washington University Milken Institute School of Public Health, Washington DC, USA
| | - Andreea Creanga
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shamik Trehan
- CARE India, Patna, India
- Dr Reddy's Foundation, Hyderabad, India
| | - Dilys Walker
- Department of Obstetrics and Gynecology and Reproductive Services, University of California San Francisco, San Francisco, California, USA
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15
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Darmstadt GL, Pepper KT, Ward VC, Srikantiah S, Mahapatra T, Tarigopula UK, Bhattacharya D, Irani L, Schooley J, Chaudhuri I, Dutt P, Sastry P, Mitra R, Chamberlain S, Monaghan S, Nanda P, Atmavilas Y, Saggurti N, Borkum E, Rangarajan A, Mehta KM, Abdalla S, Wilhelm J, Weng Y, Carmichael SL, Raheel H, Bentley J, Munar WA, Creanga A, Trehan S, Walker D, Shah H. Improving primary health care delivery in Bihar, India: Learning from piloting and statewide scale-up of Ananya. J Glob Health 2020. [DOI: 10.7189/jogh.10.0201001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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16
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Abstract
Telemedicine has the potential to deliver high-quality, affordable health care to underserved populations that otherwise would not have adequate access to care. The authors provide a snapshot of several telemedicine initiatives that have used information and communication technologies to connect patients with health care providers across various Asian countries with differing socioeconomic statuses. They highlight several factors thought to contribute to the success of telemedicine programs, such as financial sustainability, ease of use, and utilization of existing resources. Challenges these programs have faced include lack of technological infrastructure, limitations in funding, and conflicting health system priorities.
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17
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Kwan A, Daniels B, Bergkvist S, Das V, Pai M, Das J. Use of standardised patients for healthcare quality research in low- and middle-income countries. BMJ Glob Health 2019; 4:e001669. [PMID: 31565413 PMCID: PMC6747906 DOI: 10.1136/bmjgh-2019-001669] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/28/2019] [Accepted: 07/20/2019] [Indexed: 02/05/2023] Open
Abstract
The use of standardised patients (SPs)-people recruited from the local community to present the same case to multiple providers in a blinded fashion-is increasingly used to measure the quality of care in low-income and middle-income countries. Encouraged by the growing interest in the SP method, and based on our experience of conducting SP studies, we present a conceptual framework for research designs and surveys that use this methodology. We accompany the conceptual framework with specific examples, drawn from our experience with SP studies in low-income and middle-income contexts, including China, India, Kenya and South Africa, to highlight the versatility of the method and illustrate the ongoing challenges. A toolkit and manual for implementing SP studies is included as a companion piece in the online supplement.
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Affiliation(s)
- Ada Kwan
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Benjamin Daniels
- McCourt School of Public Policy and School of Foreign Service, Georgetown University, Washington, District of Columbia, USA
| | - Sofi Bergkvist
- ACCESS Health International, New York City, New York, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Madhukar Pai
- Department of Epidemiology & Biostatistics, and McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Jishnu Das
- McCourt School of Public Policy and School of Foreign Service, Georgetown University, Washington, District of Columbia, USA
- Center for Policy Research, Delhi, India
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18
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Lam F, Pro G, Agrawal S, Shastri VD, Wentworth L, Stanley M, Beri N, Tupe A, Mishra A, Subramaniam H, Schroder K, Prescott MR, Trikha N. Effect of enhanced detailing and mass media on community use of oral rehydration salts and zinc during a scale-up program in Gujarat and Uttar Pradesh. J Glob Health 2018; 9:010501. [PMID: 30546870 PMCID: PMC6287208 DOI: 10.7189/jogh.09.010501] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The Clinton Health Access Initiative implemented a program from 2012-2016 to increase use of oral rehydration salts (ORS) and zinc to treat diarrhea in children under five in three states in India: Gujarat, Madhya Pradesh, and Uttar Pradesh. The program interventions included detailing and development of a rural supply chain to reach private rural health care providers, training of Accredited Social Health Activists (ASHAs), technical support to the state governments, and a mass media campaign targeted at caregivers. In Gujarat and Uttar Pradesh, some of the program activities, such as detailing and ASHA trainings, were targeted to high-burden focal districts, thus providing an opportunity to study their effect compared to statewide activities that covered all districts, such as the mass media campaign. Our study aimed to estimate the effect of activities on ORS and zinc use. Methods Household surveys were conducted at two points during the program and in both focal and non-focal districts. We used a difference-in-difference quasi-experimental approach to estimate the effect of the enhanced activities in focal districts and mass media campaign on the odds of a child being treated with ORS and zinc. Findings Focal district interventions were associated with a significant increase in the odds of a diarrhea episode receiving ORS in Gujarat and Uttar Pradesh. Living in focal districts increased the odds of receiving ORS in Gujarat and Uttar Pradesh by factors of 3.42 (95% CI = 1.39-8.33) and 2.29 (95% CI = 1.19-4.39), respectively. Focal district interventions were also associated with 15.02 (95% CI = 2.97-75.19) greater odds of receiving both ORS and zinc in Gujarat. In Uttar Pradesh, where the mass media campaign was focused, exposure to the campaign further modified the odds of receiving ORS and combined ORS and zinc by 1.38 (95% CI = 1.04-1.84) and 1.57 (95% CI = 1.01-2.46), respectively. Conclusion Comprehensive public and private provider interventions combined with mass media are effective strategies for increasing ORS and zinc use.
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Affiliation(s)
- Felix Lam
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - George Pro
- Northern Arizona University, Center for Health Equity, Flagstaff, Arizona, USA
| | | | | | | | - Melinda Stanley
- Clinton Health Access Initiative, Boston, Massachusetts, USA
| | - Nitin Beri
- Clinton Health Access Initiative, New Delhi, India
| | | | | | - Hamsa Subramaniam
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Kate Schroder
- Clinton Health Access Initiative, Boston, Massachusetts, USA
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Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, Adeyi O, Barker P, Daelmans B, Doubova SV, English M, García-Elorrio E, Guanais F, Gureje O, Hirschhorn LR, Jiang L, Kelley E, Lemango ET, Liljestrand J, Malata A, Marchant T, Matsoso MP, Meara JG, Mohanan M, Ndiaye Y, Norheim OF, Reddy KS, Rowe AK, Salomon JA, Thapa G, Twum-Danso NAY, Pate M. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health 2018; 6:e1196-e1252. [PMID: 30196093 PMCID: PMC7734391 DOI: 10.1016/s2214-109x(18)30386-3] [Citation(s) in RCA: 1528] [Impact Index Per Article: 254.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/16/2018] [Accepted: 08/10/2018] [Indexed: 12/19/2022]
Affiliation(s)
| | - Anna D Gage
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Keely Jordan
- New York University College of Global Public Health, New York, NY, USA
| | | | | | | | - Pierre Barker
- Institute for Healthcare Improvement, Cambridge, MA, USA
| | | | | | - Mike English
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Oye Gureje
- WHO Collaborating Centre for Research and Training in Mental Health, Neuroscience, Drug and Alcohol Abuse, University of Ibadan, Ibadan, Nigeria
| | - Lisa R Hirschhorn
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lixin Jiang
- National Centre for Cardiovascular Disease, Beijing, China
| | | | | | | | - Address Malata
- Malawi University of Science and Technology, Limbe, Malawi
| | - Tanya Marchant
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - John G Meara
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Manoj Mohanan
- Duke University Sanford School of Public Policy, Durham, NC, USA
| | - Youssoupha Ndiaye
- Ministry of Health and Social Action of the Republic of Senegal, Dakar, Senegal
| | - Ole F Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Alexander K Rowe
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Gagan Thapa
- Legislature Parliament of Nepal, Kathmandu, Nepal
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20
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Penn-Kekana L, Powell-Jackson T, Haemmerli M, Dutt V, Lange IL, Mahapatra A, Sharma G, Singh K, Singh S, Shukla V, Goodman C. Process evaluation of a social franchising model to improve maternal health: evidence from a multi-methods study in Uttar Pradesh, India. Implement Sci 2018; 13:124. [PMID: 30249294 PMCID: PMC6154932 DOI: 10.1186/s13012-018-0813-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 09/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A prominent strategy to engage private sector health providers in low- and middle-income countries is clinical social franchising, an organisational model that applies the principles of commercial franchising for socially beneficial goals. The Matrika programme, a multi-faceted social franchise model to improve maternal health, was implemented in three districts of Uttar Pradesh, India, between 2013 and 2016. Previous research indicates that the intervention was not effective in improving the quality and coverage of maternal health services at the population level. This paper reports findings from an independent external process evaluation, conducted alongside the impact evaluation, with the aim of explaining the impact findings. It focuses on the main component of the programme, the "Sky" social franchise. METHODS We first developed a theory of change, mapping the key mechanisms through which the programme was hypothesised to have impact. We then undertook a multi-methods study, drawing on both quantitative and qualitative primary data from a wide range of sources to assess the extent of implementation and to understand mechanisms of impact and the role of contextual factors. We analysed the quantitative data descriptively to generate indicators of implementation. We undertook a thematic analysis of the qualitative data before holding reflective meetings to triangulate across data sources, synthesise evidence, and identify the main findings. Finally, we used the framework provided by the theory of change to organise and interpret our findings. RESULTS We report six key findings. First, despite the franchisor achieving its recruitment targets, the competitive nature of the market for antenatal care meant social franchise providers achieved very low market share. Second, all Sky health providers were branded but community awareness of the franchise remained low. Third, using lower-level providers and community health volunteers to encourage women to attend franchised antenatal care services was ineffective. Fourth, referral linkages were not sufficiently strong between antenatal care providers in the franchise network and delivery care providers. Fifth, Sky health providers had better knowledge and self-reported practice than comparable health providers, but overall, the evidence pointed to poor quality of care across the board. Finally, telemedicine was perceived by clients as an attractive feature, but problems in the implementation of the technology meant its effect on quality of antenatal care was likely limited. CONCLUSIONS These findings point towards the importance of designing programmes based on a strong theory of change, understanding market conditions and what patients value, and rigorously testing new technologies. The design of future social franchising programmes should take account of the challenges documented in this and other evaluations.
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Affiliation(s)
- Loveday Penn-Kekana
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Timothy Powell-Jackson
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Manon Haemmerli
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Varun Dutt
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Isabelle L. Lange
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | | | - Gaurav Sharma
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
| | - Kultar Singh
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | | | - Vasudha Shukla
- Sambodhi Research and Communications, Noida, Uttar Pradesh India
| | - Catherine Goodman
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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21
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Mumtaz Z. Setting the record straight on social franchising – Author's reply. THE LANCET GLOBAL HEALTH 2018; 6:e612. [DOI: 10.1016/s2214-109x(18)30191-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 03/14/2018] [Indexed: 10/16/2022] Open
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23
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Kitutu FE, Mayora C, Johansson EW, Peterson S, Wamani H, Bigdeli M, Shroff ZC. Health system effects of implementing integrated community case management (iCCM) intervention in private retail drug shops in South Western Uganda: a qualitative study. BMJ Glob Health 2017; 2:e000334. [PMID: 29259824 PMCID: PMC5717929 DOI: 10.1136/bmjgh-2017-000334] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/27/2017] [Accepted: 06/30/2017] [Indexed: 11/04/2022] Open
Abstract
Background Intervening in private drug shops to improve quality of care and enhance regulatory oversight may have health system effects that need to be understood before scaling up any such interventions. We examine the processes through which a drug shop intervention culminated in positive unintended effects and other dynamic interactions within the underlying health system. Methods A multifaceted intervention consisting of drug seller training, supply of diagnostics and subsidised medicines, use of treatment algorithms, monthly supervision and community sensitisation was implemented in drug shops in South Western Uganda, to improve paediatric fever management. Focus group discussions and in-depth interviews were conducted with stakeholders (drug sellers, government officials and community health workers) at baseline, midpoint and end-line between September 2013 and September 2015. Using a health market and systems lens, transcripts from the interviews were analysed to identify health system effects associated with the apparent success of the intervention. Findings Stakeholders initially expressed caution and fears about the intervention's implications for quality, equity and interface with the regulatory framework. Over time, these stakeholders embraced the intervention. Most respondents noted that the intervention had improved drug shop standards, enabled drug shops to embrace patient record keeping, parasite-based treatment of malaria and appropriate medicine use. There was also improved supportive supervision, and better compliance to licensing and other regulatory requirements. Drug seller legitimacy was enhanced from the community and client perspective, leading to improved trust in drug shops. Conclusion The study showed how effectively using health technologies and the perceived efficacy of medicines contributed to improved legitimacy and trust in drug shops among stakeholders. The study also demonstrated that using a combination of appropriate incentives and consumer empowerment strategies can help harmonise common practices with medicine regulations and safeguard public health, especially in mixed health market contexts.
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Affiliation(s)
- Freddy Eric Kitutu
- Department of Pharmacy, Makerere University College of Health Sciences, Kampala, Uganda.,School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Women's and Children's Health, International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden
| | - Chrispus Mayora
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,University of Witwatersrand, School of Public Health, Johannesburg, South Africa
| | - Emily White Johansson
- Department of Women's and Children's Health, International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden
| | - Stefan Peterson
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Women's and Children's Health, International Maternal and Child Health Unit, Uppsala University, Uppsala, Sweden.,UNICEF, Health Section, New York, USA
| | - Henry Wamani
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maryam Bigdeli
- Department of Health System Governance and Financing, Health System Governance, Policy and Aid Effectiveness, WHO, Geneva, Switzerland
| | - Zubin Cyrus Shroff
- WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland
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