Exploring models for the roles of health systems' responsiveness and social determinants in explaining universal health coverage and health outcomes

Health system responsiveness: comparison of different levels of medical institutions in Kunshan City, China

BACKGROUND

Evaluation of health system responsiveness (HSR) can improve patient satisfaction, promote health equity and enhance the quality of health services.

OBJECTIVES

To explore the differences in HSR among medical institutions at different levels and in various domains.

METHODS

A multi-stage stratified sampling method was used to select 820 participants aged 18 years and older from Kunshan City, China. Analysis of variance was used for univariate analysis. Linear regression and ordinal logistics were applied to explore the relationship between different hospital levels and HSR. Forest plots were used to illustrate the relationship between each domain and the hospital level.

RESULTS

The relationship between hospital level and HSR remained significant (p < 0.05). Compared with primary healthcare institutions, secondary hospitals had lower HSR scores (β = -1.47, 95%CI = [-2.15, -0.79], p < 0.001). Similarly, tertiary hospitals had lower HSR scores compared with primary healthcare institutions (β = -1.54, 95%CI = [-2.39, -0.70], p < 0.001). The study found that attention, communication, basic amenities, social support, and the choice of healthcare providers were lower in secondary hospitals compared to primary healthcare institutions (OR < 1; p < 0.05). In tertiary hospitals, attention, communication, autonomy, basic amenities, social support, and the choice of healthcare provider were lower compared to primary healthcare institutions (OR < 1; p < 0.05).

CONCLUSIONS

By comparing the HSR of hospitals at different levels, the study identified areas for improvement. Particularly, urgent improvements are needed in prompt attention, communication, basic amenities, social support and the choice of healthcare providers.

Health systems responsiveness towards needs of pregnant women in Vietnam

BACKGROUND

Health systems that are responsive to maternal mental health recognise the importance of integrating mental health services into maternal care. Studies from Vietnam have reported particularly high rates of common perinatal mental health disorders (CPMDs) in both rural and urban areas of the country. Despite the increasing burden of maternal mental health conditions, there is currently no guidance on the screening for CPMDs within maternal care, both antenatal and postnatal. In this paper, we report the findings from a survey that examined health systems responsiveness to the needs of pregnant women at the primary care-level in Vietnam, utilising the WHO's validated responsiveness questionnaire.

METHODS

Cluster sampling was used in two districts, in Bac Giang Province. Data were collected using the WHO responsiveness tool, including questions on the domains of responsiveness relating to pregnant women's last antenatal visit. SPSS (version 24) software was used for data entry and analysis, respectively. Bivariate and multivariable logistic regression were computed to identify the associated factors of health system responsiveness in maternity care at 95% CI.

RESULTS

We found that the overall mean health systems responsiveness score was 2.86 (out of maximum 4), with 30.4% pregnant women rating responsiveness as "poor" for maternal health care (based on the cutoff point of 60 for overall score). The three highest scoring domains were "social support", "trust", and "dignity" and lowest scoring domains were "choice of providers", "prompt attention", and "communication". There is a strong preference for seeking maternal health care at private facilities which meet women's needs of "confidentiality" and "basic amenities". Household income was found to have a significant impact on the six responsiveness domains. Finally, only a small proportion of pregnant women self-reported having CPMDs and accessed mental health facilities.

CONCLUSIONS

These findings highlight the need to improve the responsiveness of the Vietnamese health system to meet pregnant women's expectations, mainly in relation to prompt attention and communication. This study also highlights the importance of specifically targeting efforts towards improving the responsiveness of the public health sector. Integrating maternal and mental health at the primary care-level can be one approach to tackle the mental health treatment gap experienced by pregnant women in Vietnam. This can promote early detection and intervention of CPMDs, but may also contribute towards reducing mental health-related stigma.

Health systems responsiveness towards the Mentor Mother Program for preventing mother-to-child transmission of HIV in military hospitals

AIM

This study explored health systems responsiveness towards the Mentor Mother Program for PMTCT in the Nigeria Department of Defence hospitals. Factors affecting quality service were also highlighted, which gave helpful insights into the strategies employed by stakeholders to ensure that health systems responsiveness was propagated responsibly.

DESIGN

An exploratory qualitative interview study.

METHODS

Six semistructured interviews were conducted with six key informants (three doctors and three nurses) and one focus group session with six Mentor Mothers. Open coding of data was done to formulate themes and subthemes. Thematic analysis was adopted for analysis.

RESULTS

Four themes emerged-Service Quality, Basic Amenities, Patient-oriented Strategies and Factors affecting service Quality. These showcased the nonmedical components of health systems responsiveness and accentuated how well they were utilized to achieve health systems responsiveness.

Drivers of patient perceptions of health system responsiveness in Germany

BACKGROUND

Health system responsiveness (HSR)-the ability of a health system to meet the non-medical legitimate expectations of patients-is a key to patient-centred health systems. Although responsiveness is essential to provide equitable and accountable health care, little is known about patient-side drivers of HSR. This study aims to narrow this gap.

METHODS

A survey among 20,000 Germans with substitutive private health insurance included questions on HSR and patient characteristics such as health literacy (HL), experienced discrimination, and sociodemographic information. Survey data were linked to patient-level claims data. Logistic regression was applied to assess the association between HSR and patient characteristics.

RESULTS

The sample (age 54.0 ± 16.1; 60.5% male) contains 2951 respondents with outpatient physician care in the past year. Of the nine HSR items, eight are rated as (very) good (74.4%-94.3%), except for coordination between providers (60.2%). Patient characteristics highly influence HSR: patients with high HL, for instance, are more likely to assess responsiveness as (very) good (e.g., clear explanations from physicians: OR 4.17). Poor assessment of responsiveness is seen among users who experienced discrimination.

CONCLUSION

This study revealed new associations between HSR and patient characteristics. Incorporating this knowledge in practice would help strengthen patient-centred health services by considering patient experiences and expectations. This highlights that HSR can be used as a tool to evaluate and promote patient-centred health services. Future research should investigate additional drivers of HSR, both on the patient and the provider sides.

Bisoborwa G, Sillah JS, W. Muriithi A, Nirina Razakasoa H, Bigirimana F. High impact health service interventions for attainment of UHC in Africa: A systematic review

African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.

Assessment of the level and distribution of health system responsiveness in Oyo State, Nigeria

BACKGROUND

Health systems need to be evaluated to ascertain if they are meeting their objectives. There is an increased interest in health system responsiveness (HSR) as a means to appraise health systems. This becomes vital as we put people at the centre of integrated health systems and put a premium on their rights and perspectives. Thus, this study assessed the levels, distribution and factors associated with HSR in Oyo State.

METHODS

The study was a cross-sectional study with 717 adults, who had used an out-patient health facility in the preceding 12 months, interviewed using a semi-structured, interviewer-administered questionnaire. HSR was measured on a multi-domain and multi-item (7 domains and 20 items) 5-point Likert scale that was developed by the WHO to measure HSR globally. Summary scores were computed for level, distribution and the most important domains of HSR. Determinants of poor HSR were determined using binomial logistic regression. The level of statistical significance was set at 5%.

RESULTS

The overall level of HSR was 47%. The highest-rated domains were confidentiality (72%), dignity (64%) and choice (60%), while the least rated were prompt attention (43%) and communication (52%). The overall distribution of HSR was 0.228 (range of 0 to 1) with the domains of prompt attention (0.595) and choice (0.506) being the most unequally distributed. The most important domains were communication, prompt attention and dignity. The least important domains were choice and confidentiality. The factors associated with poor HSR (overall) were no formal education, (OR = 2.81; 95% CI: 1.35-5.86), primary education as the highest level of education (OR = 2.19; 95% CI: 1.28-3.75), poor socioeconomic class (OR = 1.86; 95% CI: 1.23-2.80), using a government-owned facility (OR = 1.56; 95% CI: 1.11-2.19) and not using the usual health facility (OR = 1.69; 95% CI: 1.13-2.53).

CONCLUSIONS

The overall level of HSR in Oyo State was low with the domains of prompt attention, communication and autonomy being the least rated domains. Therefore, concerted efforts should be targeted at improving HSR as this will improve wellbeing, health system utilization, and the overall health system.

Sex and age as determinants of the seroprevalence of anti-measles IgG among European healthcare workers: A systematic review and meta-analysis

INTRODUCTION

The international literature shows good evidence of a significant rate of measles susceptibility among healthcare workers (HCWs). As such, they are an important public health issue.

METHODS

We conducted a systematic review and meta-analysis to estimate the prevalence of susceptible HCWs in EU/EEA countries and in the UK and to explore the characteristics (sex and age differences) and management of those found to be susceptible.

RESULTS

Nineteen studies were included in the meta-analysis. The prevalence of measles-susceptible HCWs was 13.3% (95 %CI: 10.0-17.0%). In a comparison of serosusceptible female vs. male HCWs, the RR was 0.92 (95 %CI = 0.83-1.03), and in a comparison of age classes (born after vs. before 1980) the RR was 2.78 (95 %CI = 2.20-3.50). The most recent studies proposed the mandatory vaccination of HCWs.

DISCUSSION

According to our meta-analysis, the prevalence of serosusceptible European HCWs is 13%; HCWs born in the post-vaccination era seem to be at higher risk. Healthcare professionals susceptible to measles are a serious epidemiological concern. Greater efforts should therefore be made to identify those who have yet to be vaccinated and actively encourage their vaccination.

How do policy levers shape the quality of a national health system?

Poor quality of care may have a detrimental effect on access and take-up and can become a serious barrier to the universality of health services. This consideration is of particular interest in view of the fact that health systems in many countries must address a growing public-sector deficit and respond to increasing pressures due to COVID-19 and aging population, among other factors. In line with a rapidly emerging literature, we focus on patient satisfaction as a proxy for quality of health care. Drawing on rich longitudinal and cross-sectional data for Spain and multilevel estimation techniques, we show that in addition to individual level differences, policy levers (such as public health spending and the patient-doctor ratio, in particular) exert a considerable influence on the quality of a health care system. Our results suggest that policymakers seeking to enhance the quality of care should be cautious when compromising the level of health resources, and in particular, health personnel, as a response to economic downturns in a sector that traditionally had insufficient human resources in many countries, which have become even more evident in the light of the current health crisis. Additionally, we provide evidence that the increasing reliance on the private health sector may be indicative of inefficiencies in the public system and/or the existence of features of private insurance which are deemed important by patients.

Protocol for a realist synthesis of health systems responsiveness in low-income and middle-income countries

INTRODUCTION

Health systems responsiveness is a key objective of any health system, yet it is the least studied of all objectives particularly in low-income and middle-income countries. Research on health systems responsiveness highlights its multiple elements, for example, dignity and confidentiality. Little is known, however, about underlying theories of health systems responsiveness, and the mechanisms through which responsiveness works. This realist synthesis contributes to bridging these two knowledge gaps.

METHODS AND ANALYSIS

In this realist synthesis, we will use a four-step process, comprising: mapping of theoretical bases, formulation of programme theories, theory refinement and testing of programme theories using literature and empirical data from Ghana and Vietnam. We will include theoretical and conceptual pieces, reviews, empirical studies and grey literature, alongside the primary data. We will explore responsiveness as entailing external and internal interactions within health systems. The search strategy will be purposive and iterative, with continuous screening and refinement of theories. Data extraction will be combined with quality appraisal, using appropriate tools. Each fragment of evidence will be appraised as it is being extracted, for its relevance to the emerging programme theories and methodological rigour. The extracted data pertaining to contexts, mechanisms and outcomes will be synthesised to identify patterns and contradictions. Results will be reported using narrative explanations, following established guidance on realist syntheses.

ETHICS AND DISSEMINATION

Ethics approvals for the wider RESPONSE (Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam) study, of which this review is one part, were obtained from the ethics committees of the following institutions: London School of Hygiene and Tropical Medicine (ref: 22981), University of Leeds, School of Medicine (ref: MREC19-051), Ghana Health Service (ref: GHS-ERC 012/03/20) and Hanoi University of Public Health (ref: 020-149/DD-YTCC).We will disseminate results through academic papers, conference presentations and stakeholder workshops in Ghana and Vietnam.

PROSPERO REGISTRATION NUMBER

CRD42020200353. Full record: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200353.

Building health system responsiveness to noncommunicable diseases for Gweru District adults, Zimbabwe: a case study

Purpose

Gweru District, Zimbabwe faces a major challenge of noncommunicable diseases (NCDs). Globally, health systems have not responded successfully to problems in prevention and management of NCDs. Despite numerous initiatives, reorienting health services has been slow in many countries. Gweru District has similar challenges. The purpose of this paper is to explore what the health systems in Zimbabwe have done, and are doing to respond to increasing numbers of NCD cases in adults in the nation, especially in the district of Gweru

Design/methodology/approach

The study employed a descriptive narrative review of the academic and grey literature, supplemented by semi-structured key informant interviews with 14 health care staff and 30 adults living with a disease or caring for an adult with a disease in Gweru District.

Findings

Respondents identified many limitations to the response in Gweru. Respondents said that screening and diagnosis cease to be helpful when it is difficult securing medications. Nearly all community respondents reported not understanding why they are not freed of the diseases, showing poor understanding of NCDs. The escalating costs and scarcity of medications have led people to lose trust in services. Government and NGO activities include diagnosis and screening, provision of health education and some medication. Health personnel mentioned gaps in transport, medication shortages, poor equipment and poor community engagement. Suggestions include: training of nurses for a greater role in screening and management of NCDs, greater resourcing, outreach activities/satellite clinics and better integration of diverse NCD policies.

Research limitations/implications

Participant responses were greatly influenced by the current political and economic situation in Zimbabwe, so responses may reflect short-term crises rather than long-term trends.

Originality/value

This research offers an understanding of NCD strategies and their limitations from the bottom-up, lived experience perspective of local health care workers and community members.

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol

BACKGROUND

Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam.

METHODS

We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance.

DISCUSSION

The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

Unmet Needs of Healthcare Services and Associated Factors among a Cohort of Ghanaian Adults: A Nationally Stratified Cross-Sectional Study Design

We estimated the prevalence of unmet needs of healthcare services (UNHS) and its associated factors among a cohort of older Ghanaian adults. World Health Organization (WHO) Study on Global AGEing and Adult Health for Ghana was used with a total of 4735 participants. Logistics regression analysis was performed using Stata 16 to assess associated factors. The overall UNHS was 3.7% (95% CI = 2.7-4.8) and the prevalence was significantly high amongst older adults aged 60 to 69 years (5.9%). Could not afford the healthcare (56.4%) was the main contender for UNHS. UNHS was influenced by; those aged 60 to 69 years [OR (95% CI) = 1.86 (1.19-2.91)]; no formal educational [aOR (95% CI) = 4.71 (1.27-17.38)], and no NHIS [OR (95% CI) = 1.78 (1.03-3.09)]. Participants needed care for joint pain (25.4%), and communicable diseases (19.1%). The inability to access healthcare was relatively higher for older adults more advanced in age, with low education, and for those without health insurance. Health system strengthening including financial protection by expanding the National Health Insurance Scheme to all Ghanaians in line with Ghana's Universal Health Coverage Roadmap would reduce the unmet healthcare needs of older adults.

Improving the validity, relevance and feasibility of the continuum of care framework for maternal health in South Africa: a thematic analysis of experts' perspectives

BACKGROUND

The continuum of care is a key strategy for ensuring comprehensive service delivery for maternal health, while acknowledging the role of the social determinants of health. However, there is little research on the operationalisation of the framework by decision-makers and implementers to address maternal health challenges. The framework should be measurable and feasible for implementation in low- and middle-income country contexts. In this study, we explore experts' perspective on monitoring indicators for continuum of care and key issues related to their use in the South African context.

METHODS

We conducted key informant interviews with a range of experts in decision-making and programme implementation roles in the health system and relevant sectors. Key informants provided their perspectives on systematically selected, nationally representative monitoring indicators in terms of validity, relevance and feasibility. We interviewed 13 key informants and conducted a thematic analysis of their responses using multi-stage coding techniques in Atlas.ti 8.4.

RESULTS

Experts believed that the continuum of care framework and monitoring indicators offer a multisectoral perspective for maternal health intervention missing in current programmes. To improve validity of monitoring indicators, experts suggested reflection on the use of proxy indicators and improvement of data to allow for equity analysis. In terms of relevance and feasibility, experts believe there was potential to foster co-accountability using continuum of care indicators. However, as experts stated, new indicators should be integrated that directly measure intersectoral collaboration for maternal health. In addition, experts recommended that the framework and indicators should evolve over time to reflect evolving policy priorities and public health challenges.

CONCLUSION

Experts, as decision-makers and implementers, helped identify key issues in the application of the continuum of care framework and its indicators. The use of local indicators can bring the continuum of care framework from an under-utilised strategy to a useful tool for action and decision-making in maternal health. Our findings point to measurement issues and systematic changes needed to improve comprehensive monitoring of maternal health interventions in South Africa. Our methods can be applied to other low- and middle-income countries using the continuum of care framework and locally available indicators.

Understanding the implications of the Sustainable Development Goals for health policy and systems research: results of a research priority setting exercise

BACKGROUND

Given the paradigmatic shift represented by the Sustainable Development Goals (SDGs) as compared to the Millennium Development Goals - in particular their broad and interconnected nature - a new set of health policy and systems research (HPSR) priorities are needed to inform strategies to address these interconnected goals.

OBJECTIVES

To identify high priority HPSR questions linked to the achievement of the Sustainable Development Goals.

METHODS

We focused on three themes that we considered to be central to achieving the health related SDGs: (i) Protecting and promoting access to health services through systems of social protection (ii) Strengthening multisectoral collaborations for health and (iii) Developing more participatory and accountable institutions. We conducted 54 semi-structured interviews and two focus group discussions to investigate policy-maker perspectives on evidence needs. We also conducted an overview of literature reviews in each theme. Information from these sub-studies was extracted into a matrix of possible research questions and developed into three domain-specific lists of 30-36 potential priority questions. Topic experts from the global research community then refined and ranked the proposed questions through an online platform. A final webinar on each theme sought feedback on findings.

RESULTS

Policy-makers continue to demand HPSR for many well-established issues such as health financing, human resources for health, and service delivery. In terms of service delivery, policy-makers wanted to know how best to strengthen primary health care and community-based systems. In the themes of social protection and multisectoral collaboration, prioritized questions had a strong emphasis on issues of practical implementation. For participatory and accountable institutions, the two priority questions focused on political factors affecting the adoption of accountability measures, as well as health worker reactions to such measures.

CONCLUSIONS

To achieve the SDGs, there is a continuing need for research in some already well established areas of HPSR as well as key areas highlighted by decision-makers. Identifying appropriate conceptual frameworks as well as typologies of examples may be a prerequisite for answering some of the substantive policymaker questions. In addition, implementation research engaging non-traditional stakeholders outside of the health sector will be critical.

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.

A Hybrid Decision-Making Approach for the Service and Financial-Based Measurement of Universal Health Coverage for the E7 Economies

The aim of this study is to measure universal health coverage in Emerging 7 (E7) economies. Within this framework, five different dimensions and 14 different criteria are selected by considering the explanations of World Health Organization and United Nations regarding universal health coverage. While weighting the dimensions and criteria, the Decision-making Trial and Evaluation Laboratory (DEMATEL) is considered with the triangular fuzzy numbers. Additionally, Multi-Objective Optimization on the basis of Ratio Analysis (MOORA) approach is used to rank E7 economies regarding Universal Health Coverage (UHC) performance. The novelty of this study is that both service and financial based factors are taken into consideration at the same time. Additionally, fuzzy DEMATEL and MOORA methodologies are firstly used in this study with respect to the evaluation of universal health coverage. The findings show that catastrophic out of pocket health spending, pushed below an international poverty line and annual growth rate of real Gross Domestic Product (GDP) per capita are the most significant criteria for universal health coverage performance. Moreover, it is also concluded that Russia is the country that has the highest universal health coverage performance whereas China, India and Brazil are in the last ranks. It can be understood that macroeconomic conditions play a very significant role on the performance of universal health coverage. Hence, economic conditions should be improved in these countries to have better universal health coverage performance. Furthermore, it is necessary to establish programs that provide exemptions or lower out-of-pocket expenditures which will not prevent the use of health services. This situation can protect people against the financial risks related to health expenditures. In addition to them, it is also obvious that high population has also negative influence on the countries such as, China and India. It indicates that it would be appropriate for these countries to make population planning for this purpose.

A Model for Sustaining Health at the Primary Care Level

As the healthcare industry in USA is changing from a fee-for-service to a value-based system, the need for a shift in how patients are treated is evident. Healthcare organizations are reimbursed based on value and quality of service. The system shift recognizes that each patient possesses differing medical needs moving care from generalized medical treatments to individualistic care. To deal with this change and attempt to increase quality and value, many healthcare organizations are adopting a team care approach through the development of Patient-Centered Medical Homes (PCMH). In many examples of the team approach, the Primary Care Practitioner (PCP) is viewed as the main coordinator of care. Having this responsibility can create added stress for practitioners, which can lead to a decrease in the quality of care. The proposed model, in this article, outlines an example of how individualistic care can be achieved and assembled in the PCMH with the PCP as the main coordinator of care to sustain patient health.

Towards a universal concept of vulnerability: Broadening the evidence from the elderly to perinatal health using a Delphi approach

BACKGROUND

The concept 'vulnerability' is prevalent in the public domain, health care, social institutions and multidisciplinary research. Conceptual heterogeneity is present, hampering the creation of a common evidence-base of research achievements and successful policies. Recently an international expert group combined a specific literature review with a 2-stage Delphi procedure, arriving at a seemingly universal concept of vulnerability for the elderly with applications for research instruments. We replicated and extended this study, to generalize this result to health in general, and perinatal health in particular.

METHODS

Two independent expert panels (general health, perinatal health) repeated the Delphi-procedure, using an extended and updated literature review to derive statements on the concept and defining pathways of vulnerability. Additional views were collected on research tools. Consensus-by-design was explicitly avoided. Data collection and processing was independent.

RESULTS

Both panels showed surprising convergence on the pathways of vulnerability to health/ill-health, and their interaction. The agreed conceptual model describes a dynamic relation between health and ill-health and vulnerability. The 2 key pathways that link to vulnerability, are complementary, but not symmetrical as biological processes of maintaining health or obtaining better health are not reciprocal to recovery, so also not in terms of vulnerability impacts. An individual's degree of vulnerability is the net balance of risk effects and protective and healing factors (socially, biologically and in terms of health literacy and health care access). These factors can for measurement purposes (according to the panels: interview for exploration, checklists for population research) be grouped into 'material resources', 'taking responsibility for one's own health', 'risky activities and behaviors', and 'social support'. Supportive and transforming action can thus be undertaken.

CONCLUSION

A universal concept of vulnerability in the context of health was successfully derived after careful replication and extension of an international Delphi study on vulnerability among the elderly.

Public Hospitals in China: Is There a Variation in Patient Experience with Inpatient Care

In China, public hospitals are the main provider of inpatient service. The Chinese public hospital reform has recently shifted towards health care organizations and delivery to improve health care quality. This study analyzes the variation of one of the dimensions of health care quality, patient-centeredness, among inpatients with different socioeconomic status and geographical residency in China. 1471 respondents who received inpatient care in public hospitals were included in our analysis. Patient-centeredness performance was assessed on the dimensions of Communication, Autonomy, Dignity, and Confidentiality. Variations of inpatient experience were estimated using binary logistic regression models according to: residency, region, age, gender, education, income quintile, self-rated health, and number of hospital admissions. Our results indicate that older patients, and patients living in rural areas and Eastern China are more likely to report positive experience of their public hospital stay according to the care aspects of Dignity, Communication, Confidentiality and Autonomy. However, there remains a gap between China and other countries in relation to inpatient experience. Noticeable disparities in inpatient experience also persist between different geographical regions in China. These variations of patient experience pose a challenge that China's health policy makers would need to consider in their future reform efforts.

Patients' perceptions of health system responsiveness in ambulatory care in Germany

OBJECTIVE

To identify overall levels of health system responsiveness and the associations with social determinants for ambulatory health care in Germany from a user perspective.

METHODS

This analysis drew on a 2016 health survey sample of 6113 adults in Germany. Responsiveness was measured for general practitioners (GPs) and specialists (SPs) along the domains trust, dignity, confidentiality, autonomy and communication. Bivariate and multivariate logistic regression techniques were applied.

RESULTS

Over 90% of all patients assessed their last GP and SP visit as good regarding trust, dignity, autonomy and communication, but only half for confidentiality in the doctor office (GP visits: 50.3%; SP visits: 52.4%). For GP visits, patients' young age of 18-34 years showed most associations with poor assessment of the domains, for SP visits a current health problem as the reason for the last consultation.

CONCLUSION

While overall responsiveness levels for ambulatory care are high, ratings of confidentiality are distressing. Particularly patients' young age and bad health are associated with a poor assessment of responsiveness.

PRACTICE IMPLICATIONS

Measures to improve doctor office infrastructure and to enhance responsiveness towards patients under the age of 35 years and those with health problems are vital to increase responsiveness.

Uveitis and health disparities: results from the National Inpatient Sample

PURPOSE

Health disparities exist when the prevalence or outcome of the disease are influenced by age, race, sex or income. Health disparities are prevalent in autoimmune diseases. However, there is a lack of national US data regarding health disparities in uveitis. The primary aim of our study is to evaluate health disparities for uveitis in the USA.

METHODS

We performed a retrospective, observational, cross-sectional study to ascertain health disparities for uveitis and its complications in the USA using the National Inpatient Sample (NIS) for the years 2002-2013. We used the International Classification of Disease, ninth revision, codes to identify uveitis cases and ocular complications. Uveitis was divided into total, infectious and non-infectious uveitis. We collected information on age, sex, race, income quartile and ocular complications. We preformed statistical analysis using SAS V.9.4. A logistic regression model was used to predict the odds of developing uveitis and its complications.

RESULTS

There were a total of 94 143 978 discharges including 15 296 total uveitis, 4538 infectious and 10 758 non-infectious uveitis patients. Compared with the total NIS population, patients with uveitis were younger (mean age 45±18 vs 48±28 years, p value ≤0.0001, African-Americans (23% vs 10%, p value ≤0.0001), in the lowest income quartile (<$38 999; 29% vs 26%, p value ≤0.0001) and were insured by Medicaid (25% vs 20%, p value ≤0.0001).

CONCLUSION

African-American patients have a higher prevalence of uveitis. Patients insured by Medicare and Medicaid have more frequent ocular complications. This knowledge may guide future research on disparity and shape healthcare decision making.

Research on subgroups is not research on equity attributes: Evidence from an overview of systematic reviews on vaccination

BACKGROUND

Equity remains a priority in the international health development agenda. However, major inequities in vaccination coverage jeopardise the achievement of the Sustainable Development Goals. We aim at comprehensively describing how research has addressed equity issues related to vaccination.

METHODS

We carried out an overview of systematic reviews (SRs) that explicitly explored the effects of interventions to improve vaccination in any context; for any vaccine and, in any language. We followed standard research synthesis methods to systematically search for SR, assess them for inclusion and extracting relevant data, particularly on vaccination related outcomes. To gather evidence on equity issues addressed in the SR, we used the PROGRESS-plus framework.

FINDINGS

Our search obtained 2,003 hits which resulted in 54 included SRs, published between 1994 and 2014. The quality of SRs was generally poor, with less than half complying with most of the quality criteria. Reported vaccines included, by order of frequency, influenza and Expanded Programme on Immunisation vaccines. The types of interventions more frequently reported were related to vaccination delivery strategies, financial support and information, education and communication. Most of the SRs suggested effects favouring intervention groups as opposed to comparison groups. The most frequently reported equity attribute was 'place of residence' and the least reported equity attributes were sexual orientation and religion. Very few estimates of effects actually measured differences or changes between groups having those attributes and all of them referred to the place of residence. No data was found about reducing equity gaps for vulnerable groups or minorities, or attributes such as sexual orientation, education or specific religious groups.

CONCLUSIONS

Although research on vulnerable populations as a subgroup is abundant, it fails to report on the interventions that will actually reduce inequities and consider how redistribution of health care resources could shrink the gap between the privileged and most vulnerable groups including minorities. Research, if aiming at being responsive to global health policy trends, needs to report not only on specific attributes but also on how a better redistribution of health care resources could contribute to alleviating the unjust situation of the most vulnerable populations.

Squaring the circle: health as a bridge to global solidarity in the Sustainable Development Goals

The Sustainable Development Goals (SDGs), launched in September 2015 to follow on from the Millennium Development Goals, require action by all countries. The new goals range from traditional areas of health and education to a newer focus on global trade and environmental protection. We discuss how all countries can be incentivised to engage and commit and argue that thoughtful target-setting and benchmarking, a more aggressive focus on equity and an emphasis on the interdependence of health and non-health development goals are key to meaningful progress. Fundamental shared values and aspirations around health, and in particular child health, within SDG3 may, we argue, offer a platform on which to build genuine global solidarity.