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Huang A, Zhao Y, Cao C, Lyu M, Tang K. Development assistance, donor-recipient dynamic, and domestic policy: a case study of two health interventions supported by World Bank-UK and Global Fund in China. Glob Health Res Policy 2024; 9:7. [PMID: 38310321 PMCID: PMC10838425 DOI: 10.1186/s41256-024-00344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/04/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND This study views sustainability after the exit of development assistance for health (DAH) as a shared responsibility between donors and recipients and sees transitioning DAH-supported interventions into domestic health policy as a pathway to this sustainability. It aims to uncover and understand the reemergent aspects of the donor-recipient dynamic in DAH and how they contribute to formulating domestic health policy and post-DAH sustainability. METHODS We conducted a case study on two DAH-supported interventions: medical financial assistance in the Basic Health Services Project supported by the World Bank and UK (1998-2007) and civil society engagement in the HIV/AIDS Rolling Continuation Channel supported by the Global Fund (2010-2013) in China. From December 2021 to December 2022, we analyzed 129 documents and interviewed 46 key informants. Our data collection and coding were guided by a conceptual framework based on Walt and Gilson's health policy analysis model and the World Health Organization's health system building blocks. We used process tracing for analysis. RESULTS According to the collected data, our case study identified three reemergent, interrelated aspects of donor-recipient dynamics: different preferences and compromise, partnership dialogues, and responsiveness to the changing context. In the case of medical financial assistance, the dynamic was characterized by long-term commitment to addressing local needs, on-site mutual learning and understanding, and local expertise cultivation and knowledge generation, enabling proactive responses to the changing context. In contrast, the dynamic in the case of HIV/AIDS civil society engagement marginalized genuine civil society engagement, lacked sufficient dialogue, and exhibited a passive response to the context. These differences led to varying outcomes in transnational policy diffusion and sustainability of DAH-supported interventions between the cases. CONCLUSIONS Given the similarities in potential alternative factors observed in the two cases, we emphasize the significance of the donor-recipient dynamic in transnational policy diffusion through DAH. The study implies that achieving post-DAH sustainability requires a balance between donor priorities and recipient ownership to address local needs, partnership dialogues for mutual understanding and learning, and collaborative international-domestic expert partnerships to identify and respond to contextual enablers and barriers.
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Affiliation(s)
- Aidan Huang
- Vanke School of Public Health, Tsinghua University, No. 30 Shuangqing Road, Beijing, 100084, China
- Institute for International and Area Studies, Tsinghua University, Beijing, China
| | - Yingxi Zhao
- Vanke School of Public Health, Tsinghua University, No. 30 Shuangqing Road, Beijing, 100084, China
- Department of Medicine, University of Oxford, Nuffield Oxford, UK
| | - Chunkai Cao
- Vanke School of Public Health, Tsinghua University, No. 30 Shuangqing Road, Beijing, 100084, China
| | - Mohan Lyu
- Vanke School of Public Health, Tsinghua University, No. 30 Shuangqing Road, Beijing, 100084, China
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Kun Tang
- Vanke School of Public Health, Tsinghua University, No. 30 Shuangqing Road, Beijing, 100084, China.
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Chikovani I, Soselia G, Huang A, Uchaneishvili M, Zhao Y, Cao C, Lyu M, Tang K, Gotsadze G. Adapting national data systems for donor transition: comparative analysis of experience from Georgia and China. Health Policy Plan 2024; 39:i9-i20. [PMID: 38253442 PMCID: PMC10803199 DOI: 10.1093/heapol/czad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/06/2023] [Accepted: 10/24/2023] [Indexed: 01/24/2024] Open
Abstract
Health management information systems (HMISs) are essential in programme planning, budgeting, monitoring and evidence-informed decision-making. This paper focuses on donor transitions in two upper-middle-income countries, China and Georgia, and explores how national HMIS adaptations were made and what facilitated or limited successful and sustainable transitions. This comparative analytical case study uses a policy triangle framework and a mixed-methods approach to explore how and why adaptations in the HMIS occurred under the Gavi Alliance and the Global Fund-supported programmes in China and Georgia. A review of published and grey literature, key informant interviews and administrative data analysis informed the study findings. Contextual factors such as the global and country context, and health system and programme needs drove HMIS developments. Other factors included accountability on a national and international level; improvements in HMIS governance by establishing national regulations for clear mandates of data collection and reporting rules and creating institutional spaces for data use; investing in hardware, software and human resources to ensure regular and reliable data generation; and capacitating national players to use data in evidence-based decision-making for programme and transition planning, budgeting and outcome monitoring. Not all the HMIS initiatives supported by donors were sustained and transitioned. For the successful adaptation and sustainable transition, five interlinked and closely coordinated support areas need to be considered: (1) coupling programme design with a good understanding of the country context while considering domestic and external demands for information, (2) regulating appropriate governance and management arrangements enhancing country ownership, (3) avoiding silo HMIS solutions and taking integrative approach, (4) ensuring the transition of funding onto domestic budget and enforcing fulfilment of the government's financial commitments and finally (5) investing in technologies and skilled human resources for the HMIS throughout all levels of the health system. Neglecting any of these elements risks not delivering sustainable outcomes.
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Affiliation(s)
- Ivdity Chikovani
- Curatio International Foundation, 3 Kavsadze St., Office 5, Tbilisi 0179, Georgia
| | - Giorgi Soselia
- Curatio International Foundation, 3 Kavsadze St., Office 5, Tbilisi 0179, Georgia
- Medecins Du Monde (France) South Caucasus Regional Program, 3 Elene Akhvlediani Khevi, Tbilisi 0102, Georgia
| | - Aidan Huang
- Department: Institute for International and Area Studies, Tsinghua University, 30 Shuangqing Road, Beijing 100084, China
| | - Maia Uchaneishvili
- Curatio International Foundation, 3 Kavsadze St., Office 5, Tbilisi 0179, Georgia
| | - Yingxi Zhao
- Vanke School of Public Health, Tsinghua University, 30 Shuangqing Road, Beijing 100084, China
- NDM Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, South Parks Road, Oxford OX1 3SY, UK
| | - Chunkai Cao
- Vanke School of Public Health, Tsinghua University, 30 Shuangqing Road, Beijing 100084, China
| | - Mohan Lyu
- Vanke School of Public Health, Tsinghua University, 30 Shuangqing Road, Beijing 100084, China
- Duke Global Health Institute, Duke University, 310 Trent Drive, Durham, NC 27708, USA
| | - Kun Tang
- Vanke School of Public Health, Tsinghua University, 30 Shuangqing Road, Beijing 100084, China
| | - George Gotsadze
- Curatio International Foundation, 3 Kavsadze St., Office 5, Tbilisi 0179, Georgia
- School of Natural Sciences and Medicine, Ilia State University, 32 Chavchavadze Av., Tbilisi 0179, Georgia
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Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21). Health Policy Plan 2024; 39:i21-i32. [PMID: 38253438 PMCID: PMC10803197 DOI: 10.1093/heapol/czad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/19/2023] [Accepted: 10/20/2023] [Indexed: 01/24/2024] Open
Abstract
Although donor transitions from HIV programmes are increasingly common in low-and middle-income countries, there are limited analyses of long-term impacts on HIV services. We examined the impact of changes in President's Emergency Plan for AIDS Relief (PEPFAR) funding policy on HIV services in Eastern Uganda between 2015 and 2021.We conducted a qualitative case study of two districts in Eastern Uganda (Luuka and Bulambuli), which were affected by shifts in PEPFAR funding policy. In-depth interviews were conducted with PEPFAR officials at national and sub-national levels (n = 46) as well as with district health officers (n = 8). Data were collected between May and November 2017 (Round 1) and February and June 2022 (Round 2). We identified four significant donor policy transition milestones: (1) between 2015 and 2017, site-level support was withdrawn from 241 facilities following the categorization of case study districts as having a 'low HIV burden'. Following the implementation of this policy, participants perceived a decline in the quality of HIV services and more frequent commodity stock-outs. (2) From 2018 to 2020, HIV clinic managers in transitioned districts reported drastic drops in investments in HIV programming, resulting in increased patient attrition, declining viral load suppression rates and increased reports of patient deaths. (3) District officials reported a resumption of site-level PEPFAR support in October 2020 with stringent targets to reverse declines in HIV indicators. However, PEPFAR declared less HIV-specific funding. (4) In December 2021, district health officers reported shifts by PEPFAR of routing aid away from international to local implementing partner organizations. We found that, unlike districts that retained PEPFAR support, the transitioned districts (Luuka and Bulambuli) fell behind the rest of the country in implementing changes to the national HIV treatment guidelines adopted between 2017 and 2020. Our study highlights the heavy dependence on PEPFAR and the need for increasing domestic financial responsibility for the national HIV response.
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Affiliation(s)
- Henry Zakumumpa
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Ligia Paina
- Bloomberg School of Public Health, Johns Hopkins University, P O Box 7062, Kampala, Uganda
| | - Eric Ssegujja
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - Justin Namakula
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, School of Public Health, Makerere University, P O Box 7061, Kampala, Uganda
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Lewin S, Langlois EV, Tunçalp Ö, Portela A. Assessing unConventional Evidence (ACE) tool: development and content of a tool to assess the strengths and limitations of 'unconventional' source materials. Health Res Policy Syst 2024; 22:2. [PMID: 38167048 PMCID: PMC10759469 DOI: 10.1186/s12961-023-01080-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 11/23/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND When deciding whether to implement an intervention, decision-makers typically have questions on feasibility and acceptability and on factors affecting implementation. Descriptions of programme implementation and of policies and systems are rich sources of information for these questions. However, this information is often not based on empirical data collected using explicit methods. To use the information in unconventional source materials in syntheses or other decision support products, we need methods of assessing their strengths and limitations. This paper describes the development and content of the Assessing unConventional Evidence (ACE) tool, a new tool to assess the strengths and limitations of these sources. METHODS We developed the ACE tool in four stages: first, we examined existing tools to identify potentially relevant assessment criteria. Second, we drew on these criteria and team discussions to create a first draft of the tool. Third, we obtained feedback on the draft from potential users and methodologists, and through piloting the tool in evidence syntheses. Finally, we used this feedback to iteratively refine the assessment criteria and to improve our guidance for undertaking the assessment. RESULTS The tool is made up of 11 criteria including the purpose and context of the source; the completeness of the information presented; and the extent to which evidence is provided to support the findings made. Users are asked to indicate whether each of the criteria have been addressed. On the basis of their judgements for each criterion, users then make an overall assessment of the limitations of the source, ranging from no or very minor concerns to serious concerns. These assessments can then facilitate appropriate use of the evidence in decision support products. CONCLUSIONS Through focussing on unconventional source materials, the ACE tool fills an important gap in the range of tools for assessing the strengths and limitations of policy-relevant evidence and supporting evidence-informed decision-making.
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Affiliation(s)
- Simon Lewin
- Department of Health Sciences Ålesund, Norwegian University of Science and Technology, Ålesund, Norway.
- Centre for Epidemic Interventions Research (CEIR), Norwegian Institute of Public Health, Oslo, Norway.
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Etienne V Langlois
- Partnership for Maternal, Newborn & Child Health (PMNCH), World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
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Lapidaire W, Proaño A, Blumenberg C, Loret de Mola C, Delgado CA, del Castillo D, Wehrmeister FC, Gonçalves H, Gilman RH, Oberhelman RA, Lewandowski AJ, Wells JCK, Miranda JJ. Effect of preterm birth on growth and blood pressure in adulthood in the Pelotas 1993 cohort. Int J Epidemiol 2023; 52:1870-1877. [PMID: 37354551 PMCID: PMC10749774 DOI: 10.1093/ije/dyad084] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 06/01/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Preterm birth has been associated with increased risk of hypertension and cardiovascular disease later in adulthood, attributed to cardiovascular and metabolic alterations in early life. However, there is paucity of evidence from low- and middle-income countries (LMICs). METHODS We investigated the differences between preterm (<37 weeks gestational age) and term-born individuals in birth length and weight as well as adult (18 and 20 years) height, weight and blood pressure in the Brazilian 1993 Pelotas birth cohort using linear regressions. Analyses were adjusted for the maternal weight at the beginning of pregnancy and maternal education and family income at childbirth. Additional models were adjusted for body mass index (BMI) and birthweight. Separate analyses were run for males and females. The complete sample was analysed with an interaction term for sex. RESULTS Of the 3585 babies included at birth, 3010 were followed up in adulthood at 22 years. Preterm participants had lower length and weight at birth. This difference remained for male participants in adulthood, but female participants were no shorter than their term counterparts by 18 years of age. At 22 years, females born preterm had lower blood pressures (systolic blood pressure -1.00 mmHg, 95%CI -2.7, 0.7 mmHg; diastolic blood pressure -1.1 mmHg, 95%CI -2.4, 0.3 mmHg) than females born at term. These differences were not found in male participants. CONCLUSIONS In this Brazilian cohort we found contrasting results regarding the association of preterm birth with blood pressure in young adulthood, which may be unique to an LMIC.
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Affiliation(s)
- Winok Lapidaire
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Alvaro Proaño
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cauane Blumenberg
- Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
- Causale Consultoria, Pelotas, Brazil
- Grupo de Pesquisa e Inovação em Saúde, Programa de Pós-Graduação em Saúde Pública, FURG, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brasil
| | - Christian Loret de Mola
- Grupo de Pesquisa e Inovação em Saúde, Programa de Pós-Graduação em Saúde Pública, FURG, Universidade Federal do Rio Grande (FURG), Rio Grande, RS, Brasil
- Universidad Científica del Sur, Lima, Peru
| | - Carlos A Delgado
- Faculty of Medicine, Department of Pediatrics, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Neonatal Intensive Care Unit, Instituto Nacional de Salud del Niño, Lima, Peru
| | - Darwin del Castillo
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Helen Gonçalves
- Post-Graduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - Robert H Gilman
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Richard A Oberhelman
- Department of Tropical Medicine, Tulane School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Adam J Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jonathan C K Wells
- Population, Policy and Practice Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- George Institute for Global Health, UNSW, Sydney, NSW, Australia
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Whyle EB, Olivier J. A socio-political history of South Africa's National Health Insurance. Int J Equity Health 2023; 22:247. [PMID: 38037083 PMCID: PMC10691113 DOI: 10.1186/s12939-023-02058-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/12/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Spurred by the WHO's endorsement of universal health coverage as a goal of all health systems, many countries are undertaking health financing reforms. The nature of these reforms, and the policy processes by which they are achieved, will depend on context-specific factors, including the history of reform efforts and the political imperatives driving reforms. South Africa's pursuit of universal health coverage through a National Health Insurance is the latest in a nearly 100-year history of health system reform efforts shaped by social and political realities. METHODS We conducted an interdisciplinary, retrospective literature review to explore how these reform efforts have unfolded, and been shaped by the contextual realities of the moment. We began the review by identifying peer-reviewed literature on health system reform in South Africa, and iteratively expanded the search through author tracking, citation tracking and purposeful searches for material on particular events or processes referenced in the initial body of evidence. Data was extracted and organised chronologically into nine periods. RESULTS The analysis suggests that in South Africa politics; the power of the private sector; competing policy priorities and budgetary constraints; and ideas, values and ideologies have been particularly important in constraining, and sometimes spurring, health system reform efforts. Political transitions and pressures - including the introduction of apartheid in 1948, anti-apartheid opposition, the transition to democracy, and corruption and governance failures - have alternately created political imperatives for reform, and constrained reform efforts. In addition, the country's political history has given rise to dominant ideas, values and ideologies that imbue health system reform with a particular social meaning. While these ideas and values increase opposition and complicate reform efforts, they also help to expose the inequities of the current system as problematic and re-emphasise the need for reform. CONCLUSION Ultimately, this analysis demonstrates the context-specific nature of health system reform processes and the influence of history on what sorts of reforms are politically feasible and socially acceptable, even in the context of a global push for universal health coverage.
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Affiliation(s)
- Eleanor Beth Whyle
- Health Policy and Systems Division, School of Public Health, University of Cape Town, Cape Town, South Africa.
| | - Jill Olivier
- Health Policy and Systems Division, School of Public Health, University of Cape Town, Cape Town, South Africa
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Erku D, Yigzaw N, Tegegn HG, Gartner CE, Scuffham PA, Garedew YT, Shambel E. Framing, moral foundations and health taxes: interpretive analysis of Ethiopia's tobacco excise tax policy passage. BMJ Glob Health 2023; 8:e012058. [PMID: 37813449 PMCID: PMC10565163 DOI: 10.1136/bmjgh-2023-012058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/17/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND In 2019-2020, the Ethiopian government ratified a suite of legislative measures that includes levying a tax on tobacco products. This study aims to examine stakeholders' involvement, position, power and perception regarding the Ethiopian Food and Drug Authority (EFDA) bill (Proclamation No.1112/2019). This includes their meaning-making and interaction with each other during the bill's formulation, adoption and implementation stages. METHODS We employed a mixed-methods design drawing on three sources of data: (1) policy documents and media articles from government and/or civil society groups (n=27), (2) audio and video transcripts of parliamentary debates and (3) qualitative stakeholder interviews. RESULTS Policy actors in both the public health camp and tobacco industry employed several framing moves, engaged in distinctive patterns of moral rhetoric, and strategically invoked moral languages to galvanise support for their policy objectives. Central to this framing debate are issues of public health and the danger of tobacco, and the protection of 'the economy and personal freedom'. The public health camp's arguments and persuasiveness-which led to the passage of the EFDA bill-centred around discrediting tobacco industry's cost-benefit assessments through frame disconnection, or by polarising their own position that the financial, psychological and lost productivity costs incurred by tobacco use outweighs any tax revenue. CONCLUSIONS A successful cultivation of an epistemic community and engagement of policy entrepreneurs-both from government agencies and civil society organisations-was critical in creating a united front and a compelling affirmative policy narrative, thereby influence excise tax policy outcomes.
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Affiliation(s)
- Daniel Erku
- Centre for Applied Health Economics, Griffith University, Southport, Queensland, Australia
- Menzies Health Research Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Nigusse Yigzaw
- Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Henok Getachew Tegegn
- Centre for Applied Health Economics, Griffith University, Southport, Queensland, Australia
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Coral E Gartner
- School of Public Health, University of Queensland, Herston, Queensland, Australia
| | - Paul A Scuffham
- Centre for Applied Health Economics, Griffith University, Southport, Queensland, Australia
- Menzies Health Research Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Yordanos Tegene Garedew
- Health Policy and Systems Research, EPIC Research and Training Institute, Addis Ababa, Ethiopia
| | - Ehetemariam Shambel
- Pharmaceutical and Medical Equipment Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
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Zuleta M, Perez-Leon S, Mialon M, Delgado-Zegarra J. Political and socioeconomic factors that shaped health taxes implementation in Peru. BMJ Glob Health 2023; 8:e012024. [PMID: 37813443 PMCID: PMC10565308 DOI: 10.1136/bmjgh-2023-012024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 06/10/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND In 2016 and 2018, the Peruvian Ministry of Economy and Finance (MoEF) significantly reformulated taxes on tobacco products, alcohol and sugar-sweetened beverages (SSBs). During these processes, different actors advanced arguments supporting or opposing the taxes. This study examines Peru's political and socioeconomic factors, the role of other actors and framing strategies, shaping health taxes introduction. METHODS We conducted qualitative analysis by collecting information from three sources, such as: (1) media material (n=343 documents), (2) government documents (n=34) and (3) semistructured interviews (n=11). That data allowed us to identify and characterise the actors involved in implementing health taxes in Peru. We combined the data from these sources, synthesised our findings and conducted a stakeholder analysis. RESULTS Key actors supporting taxes were the MoEF and civil society organisations, while trade associations and the alcohol, SSBs and tobacco industries opposed them using economic, trade-related arguments and criticised the policy process. The supporting group used arguments related to the economy and health to legitimate its narrative. The framing strategies employed by these stakeholders shaped and determined the outcome of the policy process. CONCLUSION Peruvian stakeholders against health taxes demonstrated a strong capacity to convey their messages to the media and high-level policy-makers. Despite these efforts, attempts to interfere with health taxes were unsuccessful in 2016 and 2018 and failed to overcome state institutions, particularly the MoEF. Strong institutions and individual decision-makers in Peru also contributed to the successful implementation of health taxes in Peru in 2016 and 2018.
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Affiliation(s)
- Mario Zuleta
- Centre for Food Policy, City University, London, UK
| | - Silvana Perez-Leon
- CRONICAS Center of Excellence in Chronic Disease, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Melissa Mialon
- Trinity Business School, Trinity College Dublin, Dublin, Ireland
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Ahsan A, Amalia N, Rahmayanti KP, Adani N, Wiyono NH, Endawansa A, Utami MG, Yuniar AM. Health taxes in Indonesia: a review of policy debates on the tobacco, alcoholic beverages and sugar-sweetened beverage taxes in the media. BMJ Glob Health 2023; 8:e012042. [PMID: 37813444 PMCID: PMC10565181 DOI: 10.1136/bmjgh-2023-012042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/14/2023] [Indexed: 10/13/2023] Open
Abstract
INTRODUCTION One of the WHO's 'best buys' in controlling non-communicable diseases and their risk factors is to impose health taxes. While the Indonesian political process inhibits the implementation of health tax policy, studies to discuss the issue remain limited. METHODS We employed media analysis to document health tax policy dynamics, for example, the changes in policy timeline and key actors' statements. We conducted an article search in the Open-Source Intelligence database using appropriate terminology on three commodities, for example, tobacco, alcoholic beverages and sugar-sweetened beverages (SSB). RESULTS Throughout the 15 years of implementation (2007-2022), tobacco has received the most policy attention compared with the other two commodities. This is mainly related to the increasing tariff and reforming the tax structure. As Indonesia is a Muslim-majority country, alcohol consumption is low, and a tax on alcoholic beverages was nearly unchanging and lacked media coverage. Ministry of Finance (MoF) officials are key opinion leaders often cited in the media for health taxes. MoF's support for health taxes is important to pass and implement health taxes. While SSB taxation is emerging, key opinion leaders' media statements imply policy contestation, leading to delayed implementation. The policy debates on tobacco taxation implied election years as a major challenge for health tax passages. During the political years, anti-health tax arguments emerged from politicians. While the political contestation on SSB concluded that accentuating the health tax arguments in favour of public health generates the strongest opposition against taxation from the industry. CONCLUSIONS Politics of tobacco tax implementation are complex-compared with the other two commodities. The political context drives the divided views among policy-makers. Policy recommendations include generating public allies with key religious opinion leaders, continuing capacity building for politicians and Ministry of Health, and generating evidence-based arguments in favour of public health for MoF.
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Affiliation(s)
- Abdillah Ahsan
- Department of Economics, Faculty of Economics and Business, University of Indonesia, Depok, West Java, Indonesia
- Demographic Institute, Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
| | - Nadira Amalia
- Demographic Institute, Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
| | - Krisna Puji Rahmayanti
- Department of Public Administration, Faculty of Administrative Science, University of Indonesia, Depok, Indonesia
| | - Nadhila Adani
- Center for Research in Islamic Economics and Business, Universitas Indonesia Faculty of Economics and Business, Depok, West Java, Indonesia
| | - Nur Hadi Wiyono
- Demographic Institute, Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
| | - Althof Endawansa
- Demographic Institute, Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
| | - Maulida Gadis Utami
- Demographic Institute, Faculty of Economics and Business, University of Indonesia, Depok, Indonesia
| | - Adela Miranti Yuniar
- Center for Research in Islamic Economics and Business, Universitas Indonesia Faculty of Economics and Business, Depok, West Java, Indonesia
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Mirza Z, Munir D. Conflicting interests, institutional fragmentation and opportunity structures: an analysis of political institutions and the health taxes regime in Pakistan. BMJ Glob Health 2023; 8:e012045. [PMID: 37844957 PMCID: PMC10583104 DOI: 10.1136/bmjgh-2023-012045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/14/2023] [Indexed: 10/18/2023] Open
Abstract
Pakistan is the world's fifth most populous country, with large segments of its population at risk from non-communicable diseases caused by consumption of harmful products, including tobacco and sugar-sweetened beverages. Even though evidence exists that increased taxes on harmful products leads to consumption reductions as well as increased revenues, Pakistan's health taxes remain low. We seek to understand the reasons for the deficient health tax regime. Much of the existing literature emphasises industry tactics, resources and motivations. We take a different approach and instead focus on political institutions in Pakistan which could help explain deficiencies in the health taxes regime. We employed a mixed method design. We conducted: (1) a detailed analysis of media content, (2) semistructured interviews with key stakeholders (and attended relevant meetings) and (3) an analysis of primary and secondary literature, including legal and policy documents. We identify two key aspects of Pakistan's political institutions which may help explain deficiencies in health taxes. First, we identified structural issues in the design and functioning of key institutions responsible for health taxes, including with respect to federalism, intraelite conflict, interagency coordination and intra-agency fragmentation. Second, we found evidence of an entrenchment of industry interests within governmental institutions, which are characterised by weak frameworks for regulating conflicts of interest. We conclude that gaps and conflict within political institutions, owing to weak design, instability and fragmentation, create political opportunity for industry actors to influence the system to advance their interests. The findings of this research indicate towards needed interventions.
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Affiliation(s)
- Zafar Mirza
- Professor of Health System and Population Health, School of Universal Health Coverage (Global Institute of Human Development), Shifa Tameer-e-Millat University, Islamabad, Pakistan
- Onto Global Ltd (A Global Development Consultancy Firm), Vancouver, British Columbia, Canada
| | - Daud Munir
- Partner, Axis Law Chambers, Islamabad, Pakistan
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Acharya Y, Karmacharya V, Paudel U, Joshi S, Ghimire R, Adhikari SR. Perceptions of key stakeholders on taxes on tobacco and alcohol products in Nepal. BMJ Glob Health 2023; 8:e012040. [PMID: 37813451 PMCID: PMC10565236 DOI: 10.1136/bmjgh-2023-012040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/05/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) are on the rise in Nepal. Consumption of alcohol and tobacco products remains high. Taxes on these products are significantly below the rate recommended by the WHO. In an effort to understand the reasons behind the slow progress towards the adoption of higher health taxes to curb NCDs, we documented the perceptions of key stakeholders on health taxes, including perceived barriers and facilitators to adopting higher health taxes. METHODS We conducted 45 in-depth interviews with individuals comprising government officials; producers, wholesale distributors and sellers of alcohol and tobacco products; and consumers and representatives from civil society organisations. We conducted a thematic analysis of the resulting data. RESULTS Respondents from alcohol and tobacco industries are not supportive of higher health taxes. They argued that higher taxes can increase illicit trade and worsen inequality. Strikingly, several government officials shared the industries' concerns, arguing that health taxes have limited potential to reduce consumption of alcohol and tobacco products to help curb NCDs. In terms of barriers to adoption of higher health taxes, several local government representatives opined that close ties between industries and politicians at the federal level is a major hindrance. CONCLUSIONS In order to adopt higher health taxes, the government will need to counter the false narrative pushed by alcohol and tobacco industries on the negative economic effects of such taxes. Health taxes earmarked for NCDs need to reflect the amount of revenue raised, reoriented towards prevention efforts and communicated clearly to the public.
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Affiliation(s)
- Yubraj Acharya
- Department of Health Policy and Administration, Pennsylvania State University, State College, Pennsylvania, USA
| | | | | | - Supriya Joshi
- Pennsylvania State University, University Park, Pennsylvania, USA
| | | | - Shiva Raj Adhikari
- Central Department of Economics, Tribhuvan University, Kathmandu, Nepal
- Nepal Health Economics Association, Kathmandu, Nepal
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Mukanu MM, Mchiza ZJR, Delobelle P, Thow AM. Nutrition policy reforms to address the double burden of malnutrition in Zambia: a prospective policy analysis. Health Policy Plan 2023; 38:926-938. [PMID: 37452507 PMCID: PMC10506529 DOI: 10.1093/heapol/czad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 05/31/2023] [Accepted: 07/13/2023] [Indexed: 07/18/2023] Open
Abstract
The evolution of nutrition patterns in Zambia has resulted in the coexistence of undernutrition and overnutrition in the same population, the double burden of malnutrition. While Zambia has strong policies addressing undernutrition and stunting, these do not adequately address food environment drivers of the double burden of malnutrition and the adolescent age group and hence the need for nutrition policy reforms. We conducted a theory-based qualitative prospective policy analysis involving in-depth interviews with nutrition policy stakeholders and policy document review to examine the feasibility of introducing nutrition policy options that address the double burden of malnutrition among adolescents to identify barriers and facilitators to such policy reforms. Using the multiple streams theory, we categorized the barriers and facilitators to prospective policy reforms into those related to the problem, policy solutions and politics stream. The use of a life-course approach in nutrition programming could facilitate policy reforms, as adolescence is one of the critical invention points in a person's lifecycle. Another key facilitator of policy reform was the availability of institutional infrastructure that could be leveraged to deliver adolescent-focused policies. However, the lack of evidence on the burden and long-term impacts of adolescent nutrition problems, the food industry's strong influence over governments' policy agenda setting and the lack of public awareness to demand better nutrition were perceived as critical barriers to policy reforms. In addition, the use of the individual responsibility framing for nutrition problems was dominant among stakeholders. As a result, stakeholders did not perceive legislative nutrition policy options that effectively address food environment drivers of the double burden of malnutrition to be feasible for the Zambian context. Policy entrepreneurs are required to broker policy reforms that will get legislative policy options on the government's agenda as they can help raise public support and re-engineer the framing of nutrition problems and their solutions in Zambia.
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Affiliation(s)
- Mulenga Mary Mukanu
- School of Public Health, University of the Western Cape, Bellville, Cape Town 7535, South Africa
| | - Zandile June-Rose Mchiza
- School of Public Health, University of the Western Cape, Bellville, Cape Town 7535, South Africa
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town 7505, South Africa
| | - Peter Delobelle
- Chronic Disease Initiative for Africa, University of Cape Town, Cape Town 7700, South Africa
- Department of Public Health, Vrije Universiteit Brussel, Brussels, Belgium
| | - Anne Marie Thow
- Menzies Centre for Health Policy and Economics, University of Sydney, Camperdown, NSW 2006, Australia
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Mosadeghrad AM, Isfahani P, Eslambolchi L, Zahmatkesh M, Afshari M. Strategies to strengthen a climate-resilient health system: a scoping review. Global Health 2023; 19:62. [PMID: 37641052 PMCID: PMC10463427 DOI: 10.1186/s12992-023-00965-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Climate change is a major global threat to human health and puts tremendous pressure on health systems. Therefore, a resilient health system is crucial to enhance, maintain, and restore the population's health. This study aimed to identify interventions and actions to strengthen a climate-resilient health system to deal with the adverse health effects of climate change. METHOD This study was a scoping review. Five databases and Google Scholar search engine were searched using relevant keywords. Initially, 4945 documents were identified, and 105 were included in the review. Content thematic analysis method was applied using MAXQDA 10 software. RESULTS Overall, 87 actions were identified for building a climate-resilient health system and were classified into six themes (i.e., governance and leadership; financing; health workforce; essential medical products and technologies; health information systems; and service delivery). The most commonly reported actions were formulating a national health and climate change adaptation plan, developing plans for essential services (electricity, heating, cooling, ventilation, and water supply), assessing the vulnerabilities and capacities of the health system, and enhancing surveillance systems targeting climate-sensitive diseases and their risk sources. CONCLUSIONS A holistic and systemic approach is needed to build a climate-resilient health system owing to its complex adaptive nature. Strong governance and leadership, raising public awareness, strategic resource allocation, climate change mitigation, emergency preparedness, robust health services delivery, and supporting research, are essential to building a climate-resilient health system.
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Affiliation(s)
- Ali Mohammad Mosadeghrad
- Professor of Health policy and management, Health Economics and Management Department, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Parvaneh Isfahani
- School of Public Health, Zabol University of Medical Sciences, Zabol, Iran
| | - Leila Eslambolchi
- PhD in Health management, Health Economics and Management Department, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Maryam Zahmatkesh
- School of Business and Management, Royal Holloway University of London, Egham, England
| | - Mahnaz Afshari
- School of Nursing and Midwifery, Saveh University of Medical Sciences, Saveh, Iran.
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Okonofua F, Ntoimo LF, Ekezue B, Ohenhen V, Agholor K, Imongan W, Ogu R, Galadanci H. Outcome of interventions to improve the quality of intrapartum care in Nigeria's referral hospitals: a quasi-experimental research design. BMC Pregnancy Childbirth 2023; 23:614. [PMID: 37633892 PMCID: PMC10464082 DOI: 10.1186/s12884-023-05893-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 08/02/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Evidence indicates that Nigeria's high maternal mortality rate is attributable primarily to events that occur during the intrapartum period. This study determines the effectiveness of multifaceted interventions in improving the quality of intrapartum care in Nigeria's referral hospitals. METHODS Data collected through an exit interview with 752 women who received intrapartum care in intervention and control hospitals were analyzed. The interventions were designed to improve the quality indicators in the WHO recommendations for positive childbirth and assessed using 12 quality indicators. Univariate, bivariate, Poisson, and logistic regression analyses were used to compare twelve quality indicators at intervention and control hospitals. RESULTS The interventions showed a 6% increase in composite score of quality of care indicators at intervention compared with control hospitals. Five signal functions of intrapartum care assessed were significantly (< 0.001) better at intervention hospitals. Quality scores for segments of intervention periods compared to baseline were higher at intervention than in control hospitals. CONCLUSIONS We conclude that multiple interventions that address various components of the quality of intrapartum care in Nigeria's referral hospitals have demonstrated effectiveness. The interventions improved five of ten quality indicators. We believe that this approach to developing interventions based on formative research is important, but a process of integrating the implementation activities with the normal maternal health delivery processes in the hospitals will enhance the effectiveness of this approach. TRIAL REGISTRATION The study was registered at the Nigeria Clinical Trials Registry. Trial Registration Number NCTR No: 91,540,209 (14/04/2016) http://www.nctr.nhrec.net/ and retrospectively with the ISRCTN. Trial Registration Number 64 ISRCTN17985403 (14/08/2020) https://doi.org/10.1186/ISRCTN17985403 .
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Affiliation(s)
- Friday Okonofua
- Centre Leader, Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin City, Nigeria.
- Department of Obstetrics and Gynaecology, University of Benin, University of Benin Teaching Hospital, Benin City, Nigeria.
- Women's Health and Action Research Centre (WHARC), Benin City, Nigeria.
| | - Lorretta Favour Ntoimo
- Women's Health and Action Research Centre (WHARC), Benin City, Nigeria
- Department of Demography and Social Statistics, Federal University Oye-Ekiti, Ekiti, Nigeria
| | - Bola Ekezue
- Fayetteville State University, Fayetteville, USA
| | - Victor Ohenhen
- Department of Obstetrics and Gynaecology, Central Hospital Benin City, Benin City, Nigeria
| | - Kingsley Agholor
- Department of Obstetrics and Gynaecology/Anti-Retroviral Therapy Centre, Central Hospital, Warri, Delta State, Nigeria
| | - Wilson Imongan
- Women's Health and Action Research Centre (WHARC), Benin City, Nigeria
| | - Rosemary Ogu
- Department of Obstetrics and Gynaecology, University of Port Harcourt, Choba, Rivers State, Nigeria
| | - Hadiza Galadanci
- Department of Obstetrics and Gynaecology, Bayero University, Kano, Nigeria
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Ssegujja E, Namakula J, Kabagenyi A, Kyozira C, Musila T, Zakumumpa H, Ssengooba F. The impact of donor transition on continuity of maternal and newborn health service delivery in Rwenzori sub-region of Uganda: a qualitative country case study analysis. Global Health 2023; 19:48. [PMID: 37430280 DOI: 10.1186/s12992-023-00945-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND The transition of donor-supported health programmes to country ownership is gaining increasing attention due to reduced development assistance for health globally. It is further accelerated by the ineligibility of previously Low-Income Countries' elevation into Middle-income status. Despite the increased attention, little is known about the long-term impact of this transition on the continuity of maternal and child health service provision. Hence, we conducted this study to explore the impact of donor transition on the continuity of maternal and newborn health service provision at the sub-national level in Uganda between 2012 and 2021. METHODS We conducted a qualitative case study of the Rwenzori sub-region in mid-western Uganda which benefited from a USAID project to reduce maternal and newborn deaths between 2012 and 2016. We purposively sampled three districts. Data were collected between January and May 2022 among subnational key informants (n = 26), national level key informants at the Ministry of Health [3], national level donor representatives [3] and subnational level donor representatives [4] giving a total of 36 respondents. Thematic analysis was deductively conducted with findings structured along the WHO's health systems building blocks (Governance, Human resources for health, Health financing, Health information systems, medical products, Vaccines and Technologies and service delivery) framework. RESULTS Overall, continuity of maternal and newborn health service provision was to a greater extent maintained post-donor support. The process was characterised by a phased implementation approach. The embedded learning offered the opportunity to plough back lessons into intervention modification which reflected contextual adaptation. The availability of successor grants from other donors (such as Belgian ENABEL), counterpart funding from the government to bridge the gaps left behind, absorption of USAID-project salaried workforce (such as midwives) onto the public sector payroll, harmonisation of salary structures, the continued use of infrastructure (such as newborn intensive care units), and support for MCH services under PEPFAR support post-transition contributed to the maintenance of coverage. The demand creation for MCH services pre-transition ensured patient demand post-transition. Challenges to the maintenance of coverage were drug stockouts and sustainability of the private sector component among others. CONCLUSION A general perception of the continuity of maternal and newborn health service provision post-donor transition was observed with internal (government counterpart funding) and external enablers (successor donor funding) contributing to this performance. Opportunities for the continuity of maternal and newborn service delivery performance post-transition exist when harnessed well within the prevailing context. The ability to learn and adapt, the presence of government counterpart funding and commitment to carry on with implementation were major ingredients signalling a crucial role of government in the continuity of service provision post-transition.
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Affiliation(s)
- Eric Ssegujja
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University- Kampala, Kampala, Uganda.
| | - Justine Namakula
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University- Kampala, Kampala, Uganda
| | - Allen Kabagenyi
- Department of Statistics and Population Studies, College of Business and Management Studies, Makerere University- Kampala, Kampala, Uganda
| | | | | | - Henry Zakumumpa
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University- Kampala, Kampala, Uganda
| | - Freddie Ssengooba
- Department of Health Policy Planning and Management, School of Public Health, College of Health Sciences, Makerere University- Kampala, Kampala, Uganda
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Okonofua F, Ekezue BF, Ntoimo LF, Ohenhen V, Agholor K, Imongan W, Ogu R, Galadanci H. Outcomes of a multifaceted intervention to prevent eclampsia and eclampsia-related deaths in Nigerian referral facilities. Int Health 2023:ihad044. [PMID: 37386659 DOI: 10.1093/inthealth/ihad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/01/2023] [Accepted: 06/07/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Eclampsia causes maternal mortality in Nigeria. This study presents the effectiveness of multifaceted interventions that addressed institutional barriers in reducing the incidence and case fatality rates associated with eclampsia. METHODS The design was quasi-experimental and the activities implemented at intervention hospitals included a new strategic plan, retraining health providers on eclampsia management protocols, clinical reviews of delivery care and educating pregnant women and their partners. Prospective data were collected monthly on eclampsia and related indicators from study sites over 2 y. The results were analysed by univariate, bivariate and multivariable logistic regression. RESULTS The results show a higher eclampsia rate (5.88% vs 2.45%) and a lower use of partograph and antenatal care (ANC; 17.99% vs 23.42%) in control compared with intervention hospitals, but similar case fatality rates of <1%. Overall, adjusted analysis shows a 63% decrease in the odds of eclampsia at intervention compared with control hospitals. Factors associated with eclampsia were ANC, referral for care from other facilities and older maternal age. CONCLUSION We conclude that multifaceted interventions that address challenges associated with managing pre-eclampsia and eclampsia in health facilities can reduce eclampsia occurrence in referral facilities in Nigeria and potential eclampsia death in resource-poor African countries.
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Affiliation(s)
- Friday Okonofua
- Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin City, Nigeria
- Department of Obstetrics and Gynaecology, University of Benin and University of Benin Teaching Hospital, Benin City, Nigeria
- Women's Health and Action Research Centre, Benin City, Nigeria
| | - Bola F Ekezue
- Broadwell College of Business and Economics, Fayetteville State University, Fayetteville, NC, USA
| | - Lorretta Favour Ntoimo
- Women's Health and Action Research Centre, Benin City, Nigeria
- Department of Demography and Social Statistics, Federal University Oye-Ekiti, Nigeria
| | - Victor Ohenhen
- Department of Obstetrics and Gynaecology, Central Hospital Benin City, Benin City, Nigeria
| | - Kingsley Agholor
- Department of Obstetrics and Gynaecology/Anti-Retroviral Therapy Centre, Central Hospital, Warri, Delta State, Nigeria
| | - Wilson Imongan
- Women's Health and Action Research Centre, Benin City, Nigeria
| | - Rosemary Ogu
- Department of Obstetrics and Gynaecology, University of Port Harcourt, Rivers State, Nigeria
| | - Hadiza Galadanci
- Department of Obstetrics and Gynaecology, Bayero University, Kano, Nigeria
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Alvarado Ascencio NP, Castro Montoya AP, Mendoza Salguero GS. [Information systems and regulatory documentation in El Salvador related to migration and healthSistemas de informação e documentação regulatória de El Salvador referentes a migração e saúde]. Rev Panam Salud Publica 2023; 47:e102. [PMID: 37363622 PMCID: PMC10289473 DOI: 10.26633/rpsp.2023.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 04/25/2023] [Indexed: 06/28/2023] Open
Abstract
Objective Analyze, from the perspective of international health, data on migration and health contained in El Salvador's information systems and regulatory documentation. Method The information and documentation systems of the Virtual Center for Regulatory Documentation of the Ministry of Health of El Salvador were reviewed in detail. Regulatory documentation on migration and health from the websites of the Central American Integration System (SICA), the Mesoamerican Initiative, and the Plan of the Alliance for Prosperity in the Northern Triangle was also studied. Results None of the six information systems of the Ministry of Health of El Salvador captures either immigration status or access to and use of health services. Of the 52 national documents studied, 50 do not specify actions on migration and health. Conclusions Not all the information systems provide data on access to and use of health services, nor information on pro-health behaviors or early warnings that are useful for decision-making by health authorities. The guidelines contained in the Salvadoran regulatory framework do not address actions related to migration and health.
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Affiliation(s)
- Nelly Patricia Alvarado Ascencio
- Universidad Católica de El SalvadorFacultad de Ciencias de la SaludSan SalvadorEl SalvadorUniversidad Católica de El Salvador, Facultad de Ciencias de la Salud, San Salvador, El Salvador.
| | - Ana Patricia Castro Montoya
- Universidad Católica de El SalvadorFacultad de Ciencias de la SaludSan SalvadorEl SalvadorUniversidad Católica de El Salvador, Facultad de Ciencias de la Salud, San Salvador, El Salvador.
| | - Guillermo Salvador Mendoza Salguero
- Universidad Católica de El SalvadorFacultad de Ciencias de la SaludSan SalvadorEl SalvadorUniversidad Católica de El Salvador, Facultad de Ciencias de la Salud, San Salvador, El Salvador.
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Robson RC, Thomas SM, Langlois ÉV, Mijumbi R, Kawooya I, Antony J, Courvoisier M, Amog K, Marten R, Chikovani I, Nambiar D, Ved RR, Bhaumik S, Balqis-Ali NZ, Sararaks S, Md. Sharif S, Kangwende RA, Munatsi R, Straus SE, Tricco AC. Embedding rapid reviews in health policy and systems decision-making: Impacts and lessons learned from four low- and middle-income countries. Health Res Policy Syst 2023; 21:45. [PMID: 37280697 PMCID: PMC10243686 DOI: 10.1186/s12961-023-00992-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/09/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Demand for rapid evidence-based syntheses to inform health policy and systems decision-making has increased worldwide, including in low- and middle-income countries (LMICs). To promote use of rapid syntheses in LMICs, the WHO's Alliance for Health Policy and Systems Research (AHPSR) created the Embedding Rapid Reviews in Health Systems Decision-Making (ERA) Initiative. Following a call for proposals, four LMICs were selected (Georgia, India, Malaysia and Zimbabwe) and supported for 1 year to embed rapid response platforms within a public institution with a health policy or systems decision-making mandate. METHODS While the selected platforms had experience in health policy and systems research and evidence syntheses, platforms were less confident conducting rapid evidence syntheses. A technical assistance centre (TAC) was created from the outset to develop and lead a capacity-strengthening program for rapid syntheses, tailored to the platforms based on their original proposals and needs as assessed in a baseline questionnaire. The program included training in rapid synthesis methods, as well as generating synthesis demand, engaging knowledge users and ensuring knowledge uptake. Modalities included live training webinars, in-country workshops and support through phone, email and an online platform. LMICs provided regular updates on policy-makers' requests and the rapid products provided, as well as barriers, facilitators and impacts. Post-initiative, platforms were surveyed. RESULTS Platforms provided rapid syntheses across a range of AHPSR themes, and successfully engaged national- and state-level policy-makers. Examples of substantial policy impact were observed, including for COVID-19. Although the post-initiative survey response rate was low, three quarters of those responding felt confident in their ability to conduct a rapid evidence synthesis. Lessons learned coalesced around three themes - the importance of context-specific expertise in conducting reviews, facilitating cross-platform learning, and planning for platform sustainability. CONCLUSIONS The ERA initiative successfully established rapid response platforms in four LMICs. The short timeframe limited the number of rapid products produced, but there were examples of substantial impact and growing demand. We emphasize that LMICs can and should be involved not only in identifying and articulating needs but as co-designers in their own capacity-strengthening programs. More time is required to assess whether these platforms will be sustained for the long-term.
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Affiliation(s)
- Reid C. Robson
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, 7th Floor, East Building, Toronto, ON M5B 1T8 Canada
| | - Sonia M. Thomas
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, 7th Floor, East Building, Toronto, ON M5B 1T8 Canada
| | - Étienne V. Langlois
- Partnership for Maternal, Newborn and Child Health (PMNCH), World Health Organization, Geneva, Switzerland
- Alliance for Health Policy and Systems Research, Science Division, World Health Organization (WHO), Geneva, Switzerland
| | - Rhona Mijumbi
- The Center for Rapid Evidence Synthesis (ACRES), Regional East African Policy Initiative, Uganda Node, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ismael Kawooya
- The Center for Rapid Evidence Synthesis (ACRES), Regional East African Policy Initiative, Uganda Node, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jesmin Antony
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, 7th Floor, East Building, Toronto, ON M5B 1T8 Canada
| | - Melissa Courvoisier
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, 7th Floor, East Building, Toronto, ON M5B 1T8 Canada
| | - Krystle Amog
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, 7th Floor, East Building, Toronto, ON M5B 1T8 Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
| | - Robert Marten
- Alliance for Health Policy and Systems Research, Science Division, World Health Organization (WHO), Geneva, Switzerland
| | - Ivdity Chikovani
- Research Department, Curatio International Foundation, Tbilisi, Georgia
| | - Devaki Nambiar
- The George Institute for Global Health, New Delhi, India
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | | | - Soumyadeep Bhaumik
- Meta-Research & Evidence Synthesis Unit, The George Institute for Global Health, New Delhi, India
| | - Nur Zahirah Balqis-Ali
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Putrajaya, Malaysia
| | - Sondi Sararaks
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Putrajaya, Malaysia
| | - Shakirah Md. Sharif
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Putrajaya, Malaysia
| | | | - Ronald Munatsi
- Zimbabwe Evidence-Informed Policy Network (ZeipNET), Harare, Zimbabwe
| | - Sharon E. Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, 7th Floor, East Building, Toronto, ON M5B 1T8 Canada
- Department of Geriatric Medicine, University of Toronto, Toronto, ON Canada
| | - Andrea C. Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, 209 Victoria Street, 7th Floor, East Building, Toronto, ON M5B 1T8 Canada
- Epidemiology Division and Institute for Health, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
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Uneke CJ, Okedo-Alex IN, Akamike IC, Uneke BI, Eze II, Chukwu OE, Otubo KI, Urochukwu HC. Institutional roles, structures, funding and research partnerships towards evidence-informed policy-making: a multisector survey among policy-makers in Nigeria. Health Res Policy Syst 2023; 21:36. [PMID: 37237324 DOI: 10.1186/s12961-023-00971-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/27/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Evidence-informed policy-making aims to ensure that the best and most relevant evidence is systematically generated and used for policy-making. The aim of this study was to assess institutional structures, funding, policy-maker perspectives on researcher-policy-maker interactions and the use of research evidence in policy-making in five states in Nigeria. METHODS This was a cross-sectional study carried out among 209 participants from two geopolitical zones in Nigeria. Study participants included programme officers/secretaries, managers/department/facility heads and state coordinators/directors/presidents/chairpersons in various ministries and the National Assembly. A pretested semi-structured self-administered questionnaire on a five-point Likert scale was used to collect information on institutional structures for policy and policy-making in participants' organizations, the use of research evidence in policy and policy-making processes, and the status of funding for policy-relevant research in the participants' organizations. Data were analysed using IBM SPSS version 20 software. RESULTS The majority of the respondents were older than 45 years (73.2%), were male (63.2) and had spent 5 years or less (74.6%) in their present position. The majority of the respondents' organizations had a policy in place on research involving all key stakeholders (63.6%), integration of stakeholders' views within the policy on research (58.9%) and a forum to coordinate the setting of research priorities (61.2%). A high mean score of 3.26 was found for the use of routine data generated from within the participants' organizations. Funding for policy-relevant research was captured in the budget (mean = 3.47) but was inadequate (mean = 2.53) and mostly donor-driven (mean = 3.64). Funding approval and release/access processes were also reported to be cumbersome, with mean scores of 3.74 and 3.89, respectively. The results showed that capacity existed among career policy-makers and the Department of Planning, Research and Statistics to advocate for internal funds (mean = 3.55) and to attract external funds such as grants (3.76) for policy-relevant research. Interaction as part of the priority-setting process (mean = 3.01) was the most highly rated form of policy-maker-researcher interaction, while long-term partnerships with researchers (mean = 2.61) had the lower mean score. The agreement that involving policy-makers in the planning and execution of programmes could enhance the evidence-to-policy process had the highest score (mean = 4.40). CONCLUSION The study revealed that although institutional structures such as institutional policies, fora and stakeholder engagement existed in the organizations studied, there was suboptimal use of evidence obtained from research initiated by both internal and external researchers. Organizations surveyed had budget lines for research, but this funding was depicted as inadequate. There was suboptimal actual participation of policy-makers in the co-creation, production and dissemination of evidence. The implementation of contextually relevant and sustained mutual institutional policy-maker-researcher engagement approaches is needed to promote evidence-informed policy-making. Thus there is a need for institutional prioritization and commitment to research evidence generation.
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Affiliation(s)
- Chigozie Jesse Uneke
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria.
| | - Ijeoma Nkem Okedo-Alex
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria
| | - Ifeyinwa Chizoba Akamike
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria
| | - Bilikis Iyabo Uneke
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria
| | - Irene Ifeyinwa Eze
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria
| | - Onyekachi Echefu Chukwu
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria
| | - Kingsley Igboji Otubo
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria
| | - Henry C Urochukwu
- African Institute for Health Policy and Health Systems, Ebonyi State University (EBSU), Abakaliki, Nigeria
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Singh A, Smith K, Hellowell M, Logo DD, Marten R, Suu K, Owusu-Dabo E. An exploration of stakeholder views and perceptions on taxing tobacco, alcohol and sugar-sweetened beverages in Ghana. BMJ Glob Health 2023; 8:e012054. [PMID: 37257939 PMCID: PMC10255295 DOI: 10.1136/bmjgh-2023-012054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/14/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND Non-communicable diseases (NCDs) account for nearly 43% of Ghana's all-cause mortality. Unhealthy commodities (such as alcohol, sugar and tobacco) are an important factor in the growing NCD burden in the region of sub-Saharan Africa (SSA). Despite health taxes on tobacco, alcohol and sugar-sweetened beverages (SSBs) gaining renewed attention, adoption and implementation in SSA remain limited. This study aims to unpack the contextual politics and to examine current perceptions of opportunities and barriers for health taxes in Ghana. METHODS Semistructured qualitative interviews (n=19) conducted with purposively sampled stakeholders representing four sectors: government, civil society, media and international organisations, and two group interviews with nine industry stakeholders, informed by a review of relevant literature and policy/advocacy documents. RESULTS Stakeholders had a general belief that such taxes are primarily useful for revenue generation (for health spending) rather than for reducing consumption and improving health. There do appear to be opportunities for health taxes with stakeholders broadly supportive of taxing SSBs. This support could be strengthened via 'health' framing of any new tax proposals, the generation of Ghana-specific evidence about the potential impacts of such taxes and greater public awareness. Industry actors and some government representatives opposed health taxes, citing concerns about the potential to increase illicit trade and economic harm. Some stakeholders also believed that links between politicians and affected industries represent an important barrier. CONCLUSION These findings identify opportunities to introduce health taxes but also underline the potential resistance from affected industry stakeholders. Nevertheless, a strategic approach that focuses on achieving policy coherence (between central government, health and economic ministries), combined with efforts to strengthen stakeholder and public support, may weaken the lobbying position of industry. Such efforts could be supported by research to help demonstrate the value of different designs of health taxes for achieving Ghana's health goals and to better understand industry-political links.
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Affiliation(s)
- Arti Singh
- School of Public Health, KNUST, Kumasi, Ghana
| | - Katherine Smith
- School of Social Work and Social Policy, University of Strathclyde, Glasgow, UK
| | - Mark Hellowell
- School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | | | - Robert Marten
- WHO Alliance for Health Policy and Systems Research, Geneva, Switzerland
| | - Kaung Suu
- Alliance For Health Policy and System Research, Geneva, Switzerland
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Kentikelenis A, Ghaffar A, McKee M, Dal Zennaro L, Stuckler D. Global financing for health policy and systems research: a review of funding opportunities. Health Policy Plan 2023; 38:409-416. [PMID: 36546732 PMCID: PMC10019567 DOI: 10.1093/heapol/czac109] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/21/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Health policy and systems research (HPSR) is a neglected area in global health financing. Despite repeated calls for greater investment, it seems that there has been little growth. We analysed trends in reported funding and activity between 2015 and 2021 using a novel real-time source of global health data, the Devex.com database, the world's largest source of funding opportunities related to international development. We performed a systematic search of the Devex.com database for HPSR-related terms with a focus on low- and middle-income countries. We included 'programs', 'tenders & grants' and 'contract awards', covering all call statuses (open, closed or forecast). Such funding opportunities were included if they were related specifically to HPSR funding or had an HPSR component; pure biomedical funding was excluded. Our findings reveal a relative neglect of HPSR, as only ∼2% of all global health funding calls included a discernible HPSR component. Despite increases in funding calls until 2019, this situation reversed in 2020, likely reflecting the redirection of resources to rapid assessments of the impacts of the coronavirus disease 2019 (COVID-19) pandemic. Most identified projects represented small-scale opportunities-commonly for consultancies or technical assistance. To the extent that new data were generated, these projects were either tied to a specific large intervention or were narrow in scope to meet a specific challenge-with many examples informing policy responses to the Covid-19 pandemic. Nearly half of advertised funding opportunities were multi-country projects, usually addressing global policy priorities like health systems strengthening or development of coordinated public health policies at a regional level. The Covid-19 pandemic has shown why investing in HPSR is more important than ever to enable the delivery of effective health interventions and avoid costly implementation failures. The evidence presented here highlights the need to scale up efforts to convince global health funders to institutionalize the inclusion of HPSR components in all funding calls.
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Affiliation(s)
- Alexander Kentikelenis
- Department of Social and Political Sciences, Bocconi University, via Roentgen 1, Milan 20136, Italy
| | | | - Martin McKee
- *Corresponding author. Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK. E-mail:
| | - Livia Dal Zennaro
- Alliance for Health Policy and Systems Research, World Health Organization, 20 Avenue Appia, Geneva 1211, Switzerland
| | - David Stuckler
- Department of Social and Political Sciences, Bocconi University, via Roentgen 1, Milan 20136, Italy
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Srivastava S, Nambiar D. Pivoting from systems “thinking” to systems “doing” in health systems—Documenting stakeholder perspectives from Southeast Asia. Front Public Health 2022; 10:910055. [PMID: 35991011 PMCID: PMC9386283 DOI: 10.3389/fpubh.2022.910055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Applications of systems thinking in the context of Health Policy and Systems Research have been scarce, particularly in Low- and Middle-Income Countries (LMICs). Given the urgent need for addressing implementation challenges, the WHO Alliance for Health Policy and Systems Research, in collaboration with partners across five global regions, recently initiated a global community of practice for applied systems thinking in policy and practice contexts within LMICs. Individual one on one calls were conducted with 56 researchers, practitioners & decision-makers across 9 countries in Southeast Asia to elucidate key barriers and opportunities for applying systems thinking in individual country settings. Consultations presented the potential for collaboration and co-production of knowledge across diverse stakeholders to strengthen opportunities by applying systems thinking tools in practice. While regional nuances warrant further exploration, there is a clear indication that policy documentation relevant to health systems will be instrumental in advancing a shared vision and interest in strengthening capacities for applied systems thinking in health systems across Southeast Asia.
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Affiliation(s)
- Siddharth Srivastava
- The George Institute for Global Health, New Delhi, India
- *Correspondence: Siddharth Srivastava
| | - Devaki Nambiar
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
- Devaki Nambiar
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Amewu RK, Akolgo GA, Asare ME, Abdulai Z, Ablordey AS, Asiedu K. Evaluation of the fluorescent-thin layer chromatography (f-TLC) for the diagnosis of Buruli ulcer disease in Ghana. PLoS One 2022; 17:e0270235. [PMID: 35917367 PMCID: PMC9345483 DOI: 10.1371/journal.pone.0270235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 06/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Buruli ulcer is a tissue necrosis infection caused by an environmental mycobacterium called Mycobacterium ulcerans (MU). The disease is most prevalent in rural areas with the highest rates in West and Central African countries. The bacterium produces a toxin called mycolactone which can lead to the destruction of the skin, resulting in incapacitating deformities with an enormous economic and social burden on patients and their caregivers. Even though there is an effective antibiotic treatment for BU, the control and management rely on early case detection and rapid diagnosis to avert morbidities. The diagnosis of Mycobacterium ulcerans relies on smear microscopy, culture histopathology, and PCR. Unfortunately, all the current laboratory diagnostics have various limitations and are not available in endemic communities. Consequently, there is a need for a rapid diagnostic tool for use at the community health centre level to enable diagnosis and confirmation of suspected cases for early treatment. The present study corroborated the diagnostic performance and utility of fluorescent-thin layer chromatography (f-TLC) for the diagnosis of Buruli ulcer. Methodology/Principal findings The f-TLC method was evaluated for the diagnosis of Buruli ulcer in larger clinical samples than previously reported in an earlier preliminary study Wadagni et al. (2015). A total of 449 patients suspected of BU were included in the final data analysis out of which 122 (27.2%) were positive by f-TLC and 128 (28.5%) by PCR. Using a composite reference method generated from the two diagnostic methods, 85 (18.9%) patients were found to be truly infected with M. ulcerans, 284 (63.3%) were uninfected, while 80 (17.8%) were misidentified as infected or noninfected by the two methods. The data obtained was used to determine the discriminatory accuracy of the f-TLC against the gold standard IS2404 PCR through the analysis of its sensitivity, specificity, positive (+LR), and negative (–LR) likelihood ratio. The positive (PPV) and negative (NPV) predictive values, area under the receiver operating characteristic curve Azevedo et al. (2014), and diagnostic odds ratio were used to assess the predictive accuracy of the f-TLC method. The sensitivity of f-TLC was 66.4% (85/128), specificity was 88.5% (284/321), while the diagnostic accuracy was 82.2% (369/449). The AUC stood at 0.774 while the PPV, NPV, +LR, and–LR were 69.7% (85/122), 86.9% (284/327), 5.76, and 0.38, respectively. The use of the rule-of-thumb interpretation of diagnostic tests suggests that the method is good for use as a diagnostic tool. Conclusions/Significance Larger clinical samples than previously reported had been used to evaluate the f-TLC method for the diagnosis of Buruli ulcer. A sensitivity of 66.4%, a specificity of 88.5%, and diagnostic accuracy of 82.2% were obtained. The method is good for diagnosis and will help in making early clinical decisions about the patients as well as patient management and facilitating treatment decisions. However, it requires a slight modification to address the challenge of background interference and lack of automatic readout to become an excellent diagnostic tool.
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Affiliation(s)
- Richard K. Amewu
- Department of Chemistry, University of Ghana, Accra, Ghana
- * E-mail:
| | | | | | - Zigli Abdulai
- Department of Chemistry, University of Ghana, Accra, Ghana
| | - Anthony S. Ablordey
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Kingsley Asiedu
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Hategeka C, Adu P, Desloge A, Marten R, Shao R, Tian M, Wei T, Kruk ME. Implementation research on noncommunicable disease prevention and control interventions in low- and middle-income countries: A systematic review. PLoS Med 2022; 19:e1004055. [PMID: 35877677 PMCID: PMC9359585 DOI: 10.1371/journal.pmed.1004055] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 08/08/2022] [Accepted: 06/21/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND While the evidence for the clinical effectiveness of most noncommunicable disease (NCD) prevention and treatment interventions is well established, care delivery models and means of scaling these up in a variety of resource-constrained health systems are not. The objective of this review was to synthesize evidence on the current state of implementation research on priority NCD prevention and control interventions provided by health systems in low- and middle-income countries (LMICs). METHODS AND FINDINGS On January 20, 2021, we searched MEDLINE and EMBASE databases from 1990 through 2020 to identify implementation research studies that focused on the World Health Organization (WHO) priority NCD prevention and control interventions targeting cardiovascular disease, cancer, diabetes, and chronic respiratory disease and provided within health systems in LMICs. Any empirical and peer-reviewed studies that focused on these interventions and reported implementation outcomes were eligible for inclusion. Given the focus on this review and the heterogeneity in aims and methodologies of included studies, risk of bias assessment to understand how effect size may have been compromised by bias is not applicable. We instead commented on the distribution of research designs and discussed about stronger/weaker designs. We synthesized extracted data using descriptive statistics and following the review protocol registered in PROSPERO (CRD42021252969). Of 9,683 potential studies and 7,419 unique records screened for inclusion, 222 eligible studies evaluated 265 priority NCD prevention and control interventions implemented in 62 countries (6% in low-income countries and 90% in middle-income countries). The number of studies published has been increasing over time. Nearly 40% of all the studies were on cervical cancer. With regards to intervention type, screening accounted for 49%, treatment for 39%, while prevention for 12% (with 80% of the latter focusing on prevention of the NCD behavior risk factors). Feasibility (38%) was the most studied implementation outcome followed by adoption (23%); few studies addressed sustainability. The implementation strategies were not specified well enough. Most studies used quantitative methods (86%). The weakest study design, preexperimental, and the strongest study design, experimental, were respectively employed in 25% and 24% of included studies. Approximately 72% of studies reported funding, with international funding being the predominant source. The majority of studies were proof of concept or pilot (88%) and targeted the micro level of health system (79%). Less than 5% of studies report using implementation research framework. CONCLUSIONS Despite growth in implementation research on NCDs in LMICs, we found major gaps in the science. Future studies should prioritize implementation at scale, target higher levels health systems (meso and macro levels), and test sustainability of NCD programs. They should employ designs with stronger internal validity, be more conceptually driven, and use mixed methods to understand mechanisms. To maximize impact of the research under limited resources, adding implementation science outcomes to effectiveness research and regional collaborations are promising.
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Affiliation(s)
- Celestin Hategeka
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Prince Adu
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allissa Desloge
- School of Public Health, University of Illinois Chicago, Chicago, Illinois, United States of America
| | - Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
| | | | - Maoyi Tian
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- School of Public Health, Harbin Medical University, Harbin, China
| | - Ting Wei
- The George Institute for Global Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Margaret E. Kruk
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, United States of America
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Trivedi M, Saxena A, Shroff Z, Sharma M. Experiences and challenges in accessing hospitalization in a government-funded health insurance scheme: Evidence from early implementation of Pradhan Mantri Jan Aarogya Yojana (PM-JAY) in India. PLoS One 2022; 17:e0266798. [PMID: 35552557 PMCID: PMC9098065 DOI: 10.1371/journal.pone.0266798] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/29/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Government-sponsored health insurance schemes can play an important role in improving the reach of healthcare services. Launched in 2018 in India, Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest government-sponsored health insurance schemes. The objective of this study is to understand beneficiaries' experience of availing healthcare services at the empaneled hospitals in PM-JAY. This study examines the responsiveness of PM-JAY by measuring the prompt attention in service delivery, and access to information by the beneficiaries; financial burden experienced by the beneficiaries; and beneficiary's satisfaction with the experience of hospitalization under PMJAY and its determinants. METHODS The study was conducted during March-August 2019. Data were obtained through a survey conducted with 200 PM-JAY beneficiaries (or their caregivers) in the Indian states of Gujarat and Madhya Pradesh. The study population comprised of patients who received healthcare services at 14 study hospitals in April 2019. Prompt attention was measured in the form of a) effectiveness of helpdesk, and b) time taken at different stages of hospitalization and discharge events. Access to information by the beneficiaries was measured using the frequency and purpose of text messages and phone calls from the scheme authorities to the beneficiaries. The financial burden was measured in terms of the incidence and magnitude of out-of-pocket payments made by the beneficiaries separate from the cashless payment provided to hospitals by PMJAY. Beneficiaries' satisfaction was measured on a five-point Likert scale. RESULTS Socio-economically weaker sections of the society are availing healthcare services under PM-JAY. In Gujarat, the majority of the beneficiaries were made aware of the scheme by the government official channels. In Madhya Pradesh, the majority of the beneficiaries got to know about the scheme from informal sources. For most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, hospitals in Gujarat performed significantly better than the hospitals in Madhya Pradesh. Similarly, for most of the elements of prompt attention, access to information, and beneficiaries' satisfaction, public hospitals performed significantly better than private hospitals. Incidence and magnitude of out-of-pocket payments were significantly higher in Madhya Pradesh as compared to Gujarat, and in private hospitals as compared to the public hospitals. CONCLUSION There is a need to focus on Information, Education, and Communication (IEC) activities for PM-JAY, especially in Madhya Pradesh. Capacity-building efforts need to be prioritized for private hospitals as compared to public hospitals, and for Madhya Pradesh as compared to Gujarat. There is a need to focus on enhancing the responsiveness of the scheme, and timely exchange of information with beneficiaries. There is also an urgent need for measures aimed at reducing the out-of-pocket payments made by the beneficiaries.
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Affiliation(s)
- Mayur Trivedi
- Indian Institute of Public Health, Gandhinagar, Gujarat, India
- * E-mail:
| | - Anurag Saxena
- Indian Institute of Public Health, Gandhinagar, Gujarat, India
| | | | - Manas Sharma
- Indian Institute of Public Health, Gandhinagar, Gujarat, India
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Akwataghibe NN, Ogunsola EA, Broerse JEW, Agbo AI, Dieleman MA. Inclusion strategies in multi-stakeholder dialogues: The case of a community-based participatory research on immunization in Nigeria. PLoS One 2022; 17:e0264304. [PMID: 35316275 PMCID: PMC8939808 DOI: 10.1371/journal.pone.0264304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 02/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Community-Based Participatory Research (CBPR) has been used to address health disparities within several contexts by actively engaging communities. Though dialogues are recognized as a medium by which community members and other actors can make their voices heard through processes that support shared-decision making, power asymmetries often impede the achievement of this objective. Traditionally such relationship asymmetries exist between communities, health workers, and other professionals resulting in the exclusion of communities from decision making in participatory practices and dialogues. This study aimed to explore the experiences in the dialogues between different groups within communities, health workers and local government officials in a CBPR project on immunization in Nigeria. We adapted the framework by Elberse et al. (2011) to structure the possible exclusion mechanisms that could exist in dialogues between the three groups and we set up inclusion strategies to diminish the inequalities as much as possible.
Methods and findings
This is an exploratory and descriptive case study, using qualitative methods. Data was collected through observation and semi-structured interviews (SSI) with dialogue participants. All 24 participants in the multi-stakeholder dialogues were interviewed. Inclusion strategies involved creating enabling circumstances; influencing behaviour; and influencing use of language. Verbal and circumstantial strategies were of limited value in reducing exclusion. Behavioural inclusion strategies created more awareness of the importance of inclusion; and enabled different community stakeholders to direct their influences towards achieving the collective goals of the collaboration. An important learning is that if evidence is used in the dialogues, even when exclusion of certain individuals occurs, the outcomes could still favour them. A key issue is the difference between participation and representation and the need for more efficient ways of carrying out such interactive processes to ensure that the participation of the vulnerable groups is not merely symbolic. The study makes a case for the use of ‘boundary spanners’ in this dynamic—these are ‘elite’ individuals (or community champions) who can be a voice for the minorities and who could have the opportunity to influence decision making.
Conclusion
CBPR can enable local governments to develop effective partnerships with health workers and communities to achieve health-related goals even in the presence of asymmetries in relationships. Inclusion strategies in dialogues can improve participation and enable shared decision making, however exclusion of vulnerable groups may still occur. Intra-community dynamics and socio-cultural contexts can drive exclusion and less privileged community members require proper representation to enable their issues to be captured effectively.
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Affiliation(s)
- Ngozi N. Akwataghibe
- Knowledge Unit Health, Royal Tropical Institute, Amsterdam, The Netherlands
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- * E-mail:
| | | | - Jacqueline E. W. Broerse
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Adanna I. Agbo
- Morgan State University, Baltimore, Maryland, United States of America
| | - Marjolein A. Dieleman
- Knowledge Unit Health, Royal Tropical Institute, Amsterdam, The Netherlands
- Faculty of Science, Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Bashar F, Islam R, Khan SM, Hossain S, Sikder AAS, Yusuf SS, Adams AM. Making doctors stay: Rethinking doctor retention policy in a contracted-out primary healthcare setting in urban Bangladesh. PLoS One 2022; 17:e0262358. [PMID: 34986200 PMCID: PMC8730431 DOI: 10.1371/journal.pone.0262358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 12/21/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND "Contracting Out" is a popular strategy to expand coverage and utilization of health services. Bangladesh began contracting out primary healthcare services to NGOs in urban areas through the Urban Primary Health Care Project (UPHCP) in 1998. Over the three phases of this project, retention of trained and skilled human resources, especially doctors, proved to be an intractable challenge. This paper highlights the issues influencing doctor's retention both in managerial as well as service provision level in the contracted-out setting. METHODOLOGY In this qualitative study, 42 Key Informant Interviews were undertaken with individuals involved with UPHCP in various levels including relevant ministries, project personnel representing the City Corporations and municipalities, NGO managers and doctors. Verbatim transcripts were coded in ATLAS.ti and analyzed using the thematic analysis. Document review was done for data triangulation. RESULTS The most cited problem was a low salary structure in contrast to public sector pay scale followed by a dearth of other financial incentives such as performance-based incentives, provident funds and gratuities. Lack of career ladder, for those in both managerial and service delivery roles, was also identified as a factor hindering staff retention. Other disincentives included inadequate opportunities for training to improve clinical skills, ineffective staffing arrangements, security issues during night shifts, abuse from community members in the context of critical patient management, and lack of job security after project completion. CONCLUSIONS An adequate, efficient and dedicated health workforce is a pre-requisite for quality service provision and patient utilization of these services. Improved career development opportunities, the provision of salaries and incentives, and a safer working environment are necessary actions to retain and motivate those serving in managerial and service delivery positions in contracting out arrangements.
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Affiliation(s)
- Farzana Bashar
- Health Systems and Population Studies Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- * E-mail:
| | - Rubana Islam
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Shaan Muberra Khan
- Health Systems and Population Studies Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shahed Hossain
- Health Systems and Population Studies Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Adel A. S. Sikder
- Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sifat Shahana Yusuf
- Health Systems and Population Studies Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Alayne M. Adams
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
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Fentie AM, Degefaw Y, Asfaw G, Shewarega W, Woldearegay M, Abebe E, Gebretekle GB. Multicentre point-prevalence survey of antibiotic use and healthcare-associated infections in Ethiopian hospitals. BMJ Open 2022; 12:e054541. [PMID: 35149567 PMCID: PMC8845215 DOI: 10.1136/bmjopen-2021-054541] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Effective antimicrobial containment strategies such as Antimicrobial Stewardship Programs (ASPs) require comprehensive data on antibiotics use which are scarce in Ethiopia. This study sought to assess antibiotics use and healthcare-associated infections (HCAIs) in Ethiopian public hospitals. DESIGN We conducted a cross-sectional study using the WHO point-prevalence survey protocol for systemic antibiotics use and HCAIs for low/middle-income countries. SETTING The study was conducted among 10 public hospitals in 2021. PARTICIPANTS All patients admitted to adult and paediatric inpatient and emergency wards before or at 08:00 on the survey date were enrolled. OUTCOME MEASURE The primary outcome measures were the prevalence of antibiotic use, HCAIs and the hospitals' readiness to implement ASP. RESULTS Data were collected from 1820 patient records. None of the surveyed hospitals had functional ASP. The common indication for antibiotics was for HCAIs (40.3%). Pneumonia was the most common bacterial infection (28.6%) followed by clinical sepsis (17.8%). Most treatments were empiric (96.7%) and the overall prevalence of antibiotic use was 63.8% with antibiotics prescription per patient ratio of 1.77. Ceftriaxone was the most commonly prescribed antibiotic (30.4%) followed by metronidazole (15.4%). Age, having HIV infection, ward type, type of hospital, catheterisation and intubation history had significant association with antibiotic use. Patients who were treated in paediatric surgical wards were about four times more likely to be on antibiotics compared with patients treated at an adult emergency ward. Patients on urinary catheter (adjusted OR (AOR)=2.74, 95% CI: 2.04 to 3.68) and intubation device (AOR=2.62, 95% CI: 1.02 to 6.76) were more likely to be on antibiotics than their non-intubated/non-catheterised counterparts. Patients treated at secondary-level hospitals had 0.34 times lower odds of being on antibiotics compared with those in tertiary hospitals. CONCLUSIONS Antibiotic use across the surveyed hospitals was common and most were empiric which has both practical and policy implications for strengthening ASP and promoting rational antibiotics use.
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Affiliation(s)
- Atalay Mulu Fentie
- School of Pharmacy, Department of Pharmacology and Clinical Pharmacy, Addis Ababa University, College of Health Sciences, Addis Ababa, Ethiopia
| | - Yidnekachew Degefaw
- Pharmaceuticals and Medical Equipment Directorate, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | - Getachew Asfaw
- Pharmaceuticals and Medical Equipment Directorate, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | - Wendosen Shewarega
- Pharmaceuticals and Medical Equipment Directorate, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | | | - Ephrem Abebe
- College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Gebremedhin Beedemariam Gebretekle
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
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Md. Sharif S, Yap WS, Fun WH, Yoon EL, Abd Razak NF, Sararaks S, Lee SWH. Midwifery Qualification in Selected Countries: A Rapid Review. Nurs Rep 2021; 11:859-880. [PMID: 34968274 PMCID: PMC8715462 DOI: 10.3390/nursrep11040080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/08/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND While the global maternal mortality ratio (MMR) shows a decreasing trend, there is room for improvement. Midwifery education has been under scrutiny to ensure that graduates acquire knowledge and skills relevant to the local context. OBJECTIVE To review the basic professional midwifery qualification and pre-practice requirements in countries with lower MMR compared with Malaysia. METHODS A rapid review of country-specific Ministry of Health and Midwifery Association websites and Advanced Google using standardised key words. English-language documents reporting the qualifications of midwives or other requirements to practise midwifery from countries with a lower MMR than Malaysia were included. RESULTS Sixty-three documents from 35 countries were included. The minimum qualification required to become a midwife was a bachelor's degree. Most countries require registration or licensing to practise, and 35.5% have implemented preregistration national midwifery examinations. In addition, 13 countries require midwives to have nursing backgrounds. CONCLUSION In countries achieving better maternal outcomes than Malaysia, midwifes often have a degree or higher qualification. As such, there is a need to reinvestigate and revise the midwifery qualification requirements in Malaysia.
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Affiliation(s)
- Shakirah Md. Sharif
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam 40170, Malaysia; (W.S.Y.); (W.H.F.); (E.L.Y.); (N.F.A.R.); (S.S.)
| | - Wuan Shuen Yap
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam 40170, Malaysia; (W.S.Y.); (W.H.F.); (E.L.Y.); (N.F.A.R.); (S.S.)
| | - Weng Hong Fun
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam 40170, Malaysia; (W.S.Y.); (W.H.F.); (E.L.Y.); (N.F.A.R.); (S.S.)
| | - Ee Ling Yoon
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam 40170, Malaysia; (W.S.Y.); (W.H.F.); (E.L.Y.); (N.F.A.R.); (S.S.)
| | - Nur Fadzilah Abd Razak
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam 40170, Malaysia; (W.S.Y.); (W.H.F.); (E.L.Y.); (N.F.A.R.); (S.S.)
| | - Sondi Sararaks
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health Malaysia, Shah Alam 40170, Malaysia; (W.S.Y.); (W.H.F.); (E.L.Y.); (N.F.A.R.); (S.S.)
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Aftab W, Piryani S, Rabbani F. Does supportive supervision intervention improve community health worker knowledge and practices for community management of childhood diarrhea and pneumonia? Lessons for scale-up from Nigraan and Nigraan Plus trials in Pakistan. Hum Resour Health 2021; 19:99. [PMID: 34404445 PMCID: PMC8371843 DOI: 10.1186/s12960-021-00641-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 08/06/2021] [Indexed: 05/19/2023]
Abstract
BACKGROUND Lack of programmatic support and supervision is one of the underlying reasons of the poor performance of Pakistan's Lady Health Worker Program (LHWP). This study describes the findings and potential for scale-up of a supportive supervision intervention in two districts of Pakistan for improving LHWs skills for integrated community case management (iCCM) of childhood diarrhea and pneumonia. METHODS The intervention comprised an enhanced supervision training to lady health supervisors (LHSs) and written feedback to LHWs by LHSs, implemented in Districts Badin and Mirpur Khas (MPK). Clinical skills of LHWs and LHSs and supervision skills of LHSs were assessed before, during, and after the intervention using structured tools. RESULTS LHSs' practice of providing written feedback improved between pre- and mid-intervention assessments in both trials (0% to 88% in Badin and 25% to 75% in MPK) in the study arm. Similarly, supervisory performance of study arm LHSs was better than that in the comparison arm in reviewing the treatment suggested by workers' (94% vs 13% in MPK and 94% vs 69% in Badin) during endline skills assessment in both trials. There were improvements in LHWs' skills for iCCM of childhood diarrhea and pneumonia in both districts. In intervention arm, LHWs' performance for correctly assessing for dehydration (28% to 92% in Badin and 74% to 96% in MPK), and measuring the respiratory rate correctly (12% to 44% in Badin and 46% to 79% in MPK) improved between baseline and endline assessments in both trials. Furthermore, study arm LHWs performed better than those in comparison arm in classifying diarrhea correctly during post-intervention skills assessment (68% vs 40% in Badin and 96% vs 83% in MPK). CONCLUSION Supportive supervision including written feedback and frequent supervisor contact could improve the performance of community-based workers in managing diarrhea and pneumonia among children. Positive lessons for provincial scale-up can be drawn. Trial registration Both trials are registered with the 'Australian New Zealand Clinical Trials Registry'. Registration numbers: Nigraan Trial: ACTRN1261300126170; Nigraan Plus: ACTRN12617000309381.
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Affiliation(s)
- Wafa Aftab
- Department of Community Health Sciences, The Aga Khan University, Karachi, Stadium Road, P.O Box 3500, Karachi, 74800 Pakistan
| | - Suneel Piryani
- Department of Community Health Sciences, The Aga Khan University, Karachi, Stadium Road, P.O Box 3500, Karachi, 74800 Pakistan
| | - Fauziah Rabbani
- Department of Community Health Sciences, The Aga Khan University, Karachi, Stadium Road, P.O Box 3500, Karachi, 74800 Pakistan
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Edelman A, Marten R, Montenegro H, Sheikh K, Barkley S, Ghaffar A, Dalil S, Topp SM. Modified scoping review of the enablers and barriers to implementing primary health care in the COVID-19 context. Health Policy Plan 2021; 36:1163-1186. [PMID: 34185844 PMCID: PMC8344743 DOI: 10.1093/heapol/czab075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/13/2021] [Accepted: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
Since the Alma Ata Declaration of 1978, countries have varied in their progress towards establishing and sustaining comprehensive primary health care (PHC) and realizing its associated vision of 'Health for All'. International health emergencies such as the coronavirus-19 (COVID-19) pandemic underscore the importance of PHC in underpinning health equity, including via access to routine essential services and emergency responsiveness. This review synthesizes the current state of knowledge about PHC impacts, implementation enablers and barriers, and knowledge gaps across the three main PHC components as conceptualized in the 2018 Astana Framework. A scoping review design was adopted to summarize evidence from a diverse body of literature with a modification to accommodate four discrete phases of searching, screening and eligibility assessment: a database search in PubMed for PHC-related literature reviews and multi-country analyses (Phase 1); a website search for key global PHC synthesis reports (Phase 2); targeted searches for peer-reviewed literature relating to specific components of PHC (Phase 3) and searches for emerging insights relating to PHC in the COVID-19 context (Phase 4). Evidence from 96 included papers were analysed across deductive themes corresponding to the three main components of PHC. Findings affirm that investments in PHC improve equity and access, healthcare performance, accountability of health systems and health outcomes. Key enablers of PHC implementation include equity-informed financing models, health system and governance frameworks that differentiate multi-sectoral PHC from more discrete service-focussed primary care, and governance mechanisms that strengthen linkages between policymakers, civil society, non-governmental organizations, community-based organizations and private sector entities. Although knowledge about, and experience in, PHC implementation continues to grow, critical knowledge gaps are evident, particularly relating to country-level, context-specific governance, financing, workforce, accountability and service coordination mechanisms. An agenda to guide future country-specific PHC research is outlined.
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Affiliation(s)
- Alexandra Edelman
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
| | - Robert Marten
- Alliance for Health Policy and Systems Research, World Health Organization, Switzerland
| | - Hernán Montenegro
- Special Programme on Primary Health Care, World Health Organization, Geneva, Switzerland
| | - Kabir Sheikh
- Alliance for Health Policy and Systems Research, World Health Organization, Switzerland
| | - Shannon Barkley
- Special Programme on Primary Health Care, World Health Organization, Geneva, Switzerland
| | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, World Health Organization, Switzerland
| | - Suraya Dalil
- Special Programme on Primary Health Care, World Health Organization, Geneva, Switzerland
| | - Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, QLD, Australia
- Nossal Institute for Global Health, University of Melbourne, VIC, Australia
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Mancuso A, Ahmed Malm S, Sharkey A, Shahabuddin ASM, Shroff ZC. Cross-cutting lessons from the Decision-Maker Led Implementation Research initiative. Health Res Policy Syst 2021; 19:83. [PMID: 34380519 PMCID: PMC8356374 DOI: 10.1186/s12961-021-00706-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/15/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Almost 20 million children under one year of age did not receive basic vaccines in 2019, and most of these children lived in low- and middle-income countries. Implementation research has been recognized as an emerging area that is critical to strengthen the implementation of interventions proven to be effective. As a component of strengthening implementation, WHO has called for greater embedding of research within decision-making processes. One strategy to facilitate the embedding of research is to engage decision-makers as Principal Investigators of the research. Since 2015, the Alliance for Health Policy and Systems Research within the WHO and the United Nations Children's Fund have supported decision-maker led research by partnering with Gavi, the Vaccine Alliance, in an initiative called "Decision-Maker Led Implementation Research". This synthesis paper describes the cross-cutting lessons from the initiative to further understand and develop future use of the decision-maker led strategy. METHODS This study used qualitative methods of data collection, including a document review and in-depth interviews with decision-makers and researchers engaged in the initiative. Document extraction and thematic content analysis were applied. The individual project was the unit of analysis and the results were summarized across projects. RESULTS Research teams from 11 of the 14 projects participated in this study, for an overall response rate of 78.6%. Most projects were carried out in countries in Africa and conducted at the sub-state or sub-district level. Seven enablers and five barriers to the process of conducting the studies or bringing about changes were identified. Key enablers were the relevance, acceptability, and integration of the research, while key barriers included unclear results, limited planning and support, and the limited role of a single study in informing changes to strengthen implementation. CONCLUSIONS Decision-maker led research is a promising strategy to facilitate the embedding of research into decision-making processes and contribute to greater use of research to strengthen implementation of proven-effective interventions, such as immunization. We identified several lessons for consideration in the future design and use of the decision-maker led strategy.
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Affiliation(s)
- Arielle Mancuso
- Alliance for Health Policy and Systems Research, WHO headquarters, Avenue Appia 20, 1211, Geneva, Switzerland.
| | - Shahira Ahmed Malm
- Nutrition Section, United Nations Children's Fund, UNICEF headquarters, New York, NY, 10017, United States of America
| | - Alyssa Sharkey
- Implementation Research and Delivery Science Unit, Health Section, United Nations Children's Fund, UNICEF headquarters, New York, NY, 10017, United States of America
| | - A S M Shahabuddin
- Implementation Research and Delivery Science Unit, Health Section, United Nations Children's Fund, UNICEF headquarters, New York, NY, 10017, United States of America
| | - Zubin Cyrus Shroff
- Alliance for Health Policy and Systems Research, WHO headquarters, Avenue Appia 20, 1211, Geneva, Switzerland
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Varallyay NI, Bennett SC, Kennedy C, Ghaffar A, Peters DH. How does embedded implementation research work? Examining core features through qualitative case studies in Latin America and the Caribbean. Health Policy Plan 2021; 35:ii98-ii111. [PMID: 33156937 PMCID: PMC7646734 DOI: 10.1093/heapol/czaa126] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 01/04/2023] Open
Abstract
Innovative strategies are needed to improve the delivery of evidence-informed health interventions. Embedded implementation research (EIR) seeks to enhance the generation and use of evidence for programme improvement through four core features: (1) central involvement of programme/policy decision-makers in the research cycle; (2) collaborative research partnerships; (3) positioning research within programme processes and (4) research focused on implementation. This paper examines how these features influence evidence-to-action processes and explores how they are operationalized, their effects and supporting conditions needed. We used a qualitative, comparative case study approach, drawing on document analysis and semi-structured interviews across multiple informant groups, to examine three EIR projects in Bolivia, Colombia and the Dominican Republic. Our findings are presented according to the four core EIR features. The central involvement of decision-makers in EIR was enhanced by decision-maker authority over the programme studied, professional networks and critical reflection. Strong research-practice partnerships were facilitated by commitment, a clear and shared purpose and representation of diverse perspectives. Evidence around positioning research within programme processes was less conclusive; however, as all three cases made significant advances in research use and programme improvement, this feature of EIR may be less critical than others, depending on specific circumstances. Finally, a research focus on implementation demanded proactive engagement by decision-makers in conceptualizing the research and identifying opportunities for direct action by decision-makers. As the EIR approach is a novel approach in these low-resource settings, key supports are needed to build capacity of health sector stakeholders and create an enabling environment through system-level strategies. Key implications for such supports include: promoting EIR and creating incentives for decision-makers to engage in it, establishing structures or mechanisms to facilitate decision-maker involvement, allocating funds for EIR, and developing guidance for EIR practitioners.
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Affiliation(s)
- N Ilona Varallyay
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
- Corresponding author. Malabia 1970, Buenos Aires CABA 1414,
Argentina. E-mail:
| | - Sara C Bennett
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
| | - Caitlin Kennedy
- Social and Behavioral Interventions Program, Department of
International Health, Johns Hopkins School of Public Health, 615 N Wolfe St,
Baltimore, MD 21205, United States
| | - Abdul Ghaffar
- The Alliance for Health Policy and Systems Research at the
World Health Organization, 20 avenue Appia, 1211 Geneva, Switzerland
| | - David H Peters
- Department of International Health, Johns Hopkins School
of Public Health, 615 N Wolfe St, Baltimore, MD 21205, United States
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Reñosa MDC, Mwamba C, Meghani A, West NS, Hariyani S, Ddaaki W, Sharma A, Beres LK, McMahon S. Selfie consents, remote rapport, and Zoom debriefings: collecting qualitative data amid a pandemic in four resource-constrained settings. BMJ Glob Health 2021; 6:bmjgh-2020-004193. [PMID: 33419929 PMCID: PMC7798410 DOI: 10.1136/bmjgh-2020-004193] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/26/2020] [Accepted: 12/03/2020] [Indexed: 11/03/2022] Open
Abstract
In-person interactions have traditionally been the gold standard for qualitative data collection. The COVID-19 pandemic required researchers to consider if remote data collection can meet research objectives, while retaining the same level of data quality and participant protections. We use four case studies from the Philippines, Zambia, India and Uganda to assess the challenges and opportunities of remote data collection during COVID-19. We present lessons learned that may inform practice in similar settings, as well as reflections for the field of qualitative inquiry in the post-COVID-19 era. Key challenges and strategies to overcome them included the need for adapted researcher training in the use of technologies and consent procedures, preparation for abbreviated interviews due to connectivity concerns, and the adoption of regular researcher debriefings. Participant outreach to allay suspicions ranged from communicating study information through multiple channels to highlighting associations with local institutions to boost credibility. Interviews were largely successful, and contained a meaningful level of depth, nuance and conviction that allowed teams to meet study objectives. Rapport still benefitted from conventional interviewer skills, including attentiveness and fluency with interview guides. While differently abled populations may encounter different barriers, the included case studies, which varied in geography and aims, all experienced more rapid recruitment and robust enrollment. Reduced in-person travel lowered interview costs and increased participation among groups who may not have otherwise attended. In our view, remote data collection is not a replacement for in-person endeavours, but a highly beneficial complement. It may increase accessibility and equity in participant contributions and lower costs, while maintaining rich data collection in multiple study target populations and settings.
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Affiliation(s)
- Mark Donald C Reñosa
- Heidelberg Institute of Global Health, Ruprechts-Karls-Universität Heidelberg, Heidelberg, Germany
- Department of Epidemiology and Biostatistics, Research Institute for Tropical Medicine, Department of Health, Manila, Philippines
| | - Chanda Mwamba
- On behalf of the Social & Behavioural Science Group, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Ankita Meghani
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nora S West
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shreya Hariyani
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Johns Hopkins India Private Limited (JHIPL), Delhi, India
| | - William Ddaaki
- On behalf of the Social & Behavioral Sciences Team, The Rakai Health Sciences Program, Rakai, Uganda
| | - Anjali Sharma
- On behalf of the Social & Behavioural Science Group, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Laura K Beres
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shannon McMahon
- Heidelberg Institute of Global Health, Ruprechts-Karls-Universität Heidelberg, Heidelberg, Germany
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Alonge O, Chiumento A, Hamoda HM, Gaber E, Huma ZE, Abbasinejad M, Hosny W, Shakiba A, Minhas A, Saeed K, Wissow L, Rahman A. Identifying pathways for large-scale implementation of a school-based mental health programme in the Eastern Mediterranean Region: a theory-driven approach. Health Policy Plan 2020; 35:ii112-ii123. [PMID: 33156933 PMCID: PMC7646738 DOI: 10.1093/heapol/czaa124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 11/28/2022] Open
Abstract
Globally there is a substantial burden of mental health problems among children and adolescents. Task-shifting/task-sharing mental health services to non-specialists, e.g. teachers in school settings, provide a unique opportunity for the implementation of mental health interventions at scale in low- and middle-income countries (LMICs). There is scant information to guide the large-scale implementation of school-based mental health programme in LMICs. This article describes pathways for large-scale implementation of a School Mental Health Program (SMHP) in the Eastern Mediterranean Region (EMR). A collaborative learning group (CLG) comprising stakeholders involved in implementing the SMHP including policymakers, programme managers and researchers from EMR countries was established. Participants in the CLG applied the theory of change (ToC) methodology to identify sets of preconditions, assumptions and hypothesized pathways for improving the mental health outcomes of school-aged children in public schools through implementation of the SMHP. The proposed pathways were then validated through multiple regional and national ToC workshops held between January 2017 and September 2019, as the SMHP was being rolled out in three EMR countries: Egypt, Pakistan and Iran. Preconditions, strategies and programmatic/contextual adaptations that apply across these three countries were drawn from qualitative narrative summaries of programme implementation processes and facilitated discussions during biannual CLG meetings. The ToC for large-scale implementation of the SMHP in the EMR suggests that identifying national champions, formulating dedicated cross-sectoral (including the health and education sector) implementation teams, sustained policy advocacy and stakeholders engagement across multiple levels, and effective co-ordination among education and health systems especially at the local level are among the critical factors for large-scale programme implementation. The pathways described in this paper are useful for facilitating effective implementation of the SMHP at scale and provide a theory-based framework for evaluating the SMHP and similar programmes in the EMR and other LMICs.
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Affiliation(s)
- Olakunle Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E8140, Baltimore, MD 21205, USA
| | - Anna Chiumento
- Department of Psychological Sciences, Institute of Population Health Sciences, The University of Liverpool, Block B, Waterhouse Buildings, 1-5 Brownlow Street, Liverpool L69 3GL, UK
| | - Hesham M Hamoda
- Department of Psychiatry, Boston Children’s Hospital 300 Longwood Avenue, Boston, MA 02115, USA
| | - Eman Gaber
- General Secretariat of Mental Health and Addiction Treatment, Ministry of Health, Al-Inshaa WA Al-Munirah, El-Sayeda Zainab, Cairo Governorate, Egypt
| | - Zill-e- Huma
- Human Development Research Foundation, House 06, Street 55, F-7/4, Islamabad, Pakistan
| | - Maryam Abbasinejad
- Department for Mental Health and Substance Abuse, Ministry of Health and Medical Education, Shahrak-e-Gharb, Eivanak Blvd, Islamic Republic of Iran
| | - Walaa Hosny
- General Secretariat of Mental Health and Addiction Treatment, Ministry of Health, Al-Inshaa WA Al-Munirah, El-Sayeda Zainab, Cairo Governorate, Egypt
| | - Alia Shakiba
- Department of Psychiatry, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Ayesha Minhas
- Institute of Psychiatry, Benazir Bhutto Hospital, Benazir Bhutto Road, Chah Sultan, Rawalpindi, Punjab 46000, Pakistan
| | - Khalid Saeed
- Department of Non-communicable Diseases and Mental Health, World Health Organization, Regional Office for the Eastern Mediterranean, Monazamet El Seha El Alamia Street, Nasr City, Cairo 11371, Egypt
| | - Lawrence Wissow
- Department of Psychiatry and Behavioral Sciences, Division of Child and Adolescent Psychiatry, University of Washington, 1959 NE Pacific Street, Seattle WA 98195, USA
| | - Atif Rahman
- Department of Psychological Sciences, Institute of Population Health Sciences, The University of Liverpool, Block B, Waterhouse Buildings, 1-5 Brownlow Street, Liverpool L69 3GL, UK
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Lazo‐Porras M, Ruiz‐Alejos A, Miranda JJ, Carrillo‐Larco RM, Gilman RH, Smeeth L, Bernabé‐Ortiz A. Intermediate hyperglycaemia and 10-year mortality in resource-constrained settings: the PERU MIGRANT Study. Diabet Med 2020; 37:1519-1527. [PMID: 32181918 PMCID: PMC7649719 DOI: 10.1111/dme.14298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2020] [Indexed: 12/13/2022]
Abstract
AIM To determine whether intermediate hyperglycaemia, defined by fasting plasma glucose and HbA1c criteria, is associated with mortality in a 10-year cohort of people in a Latin American country. METHODS Analysis of the PERU MIGRANT Study was conducted in three different population groups (rural, rural-to-urban migrant, and urban). The baseline assessment was conducted in 2007/2008, with follow-up assessment in 2018. The outcome was all-cause mortality, and the exposure was intermediate hyperglycaemia, using three definitions: (1) impaired fasting glucose, defined according to American Diabetes Association criteria [fasting plasma glucose 5.6-6.9 mmol/l (100-125 mg/dl)]; (2) intermediate hyperglycaemia defined according to American Diabetes Association criteria [HbA1c levels 39-46 mmol/mol (5.7-6.4%)]; and (3) intermediate hyperglycaemia defined according to the International Expert Committee criteria [HbA1c levels 42-46 mmol/mol (6.0-6.4%)]. Crude and adjusted hazard ratios and 95% CIs were estimated using Cox proportional hazard models. RESULTS At baseline, the mean (sd) age of the study population was 47.8 (11.9) years and 52.5% of the cohort were women. The study cohort was divided into population groups as follows: 207 people (20.0%) in the rural population group, 583 (59.7%) in the rural-to-urban migrant group and 198 (20.3%) in the urban population group. The prevalence of intermediate hyperglycaemia was: 6%, 12.9% and 38.5% according to the American Diabetes Association impaired fasting glucose definition, the International Expert Committee HbA1c -based definition and the American Diabetes Association HbA1c -based definition, respectively, and the mortality rate after 10 years was 63/976 (7%). Intermediate hyperglycaemia was associated with all-cause mortality using the HbA1c -based definitions in the crude models [hazard ratios 2.82 (95% CI 1.59-4.99) according to the American Diabetes Association and 2.92 (95% CI 1.62-5.28) according to the International Expert Committee], whereas American Diabetes Association-defined impaired fasting glucose was not [hazard ratio 0.84 (95% CI 0.26-2.68)]. In the adjusted model, however, only the American Diabetes Association HbA1c -based definition was associated with all-cause mortality [hazard ratio 1.91 (95% CI 1.03-3.53)], whereas the International Expert Committee HbA1c -based and American Diabetes Association impaired fasting glucose-based definitions were not [hazard ratios 1.42 (95% CI 0.75-2.68) and 1.09 (95% CI 0.33-3.63), respectively]. CONCLUSIONS Intermediate hyperglycaemia defined using the American Diabetes Association HbA1c criteria was associated with an elevated mortality rate after 10 years in a cohort from Peru. HbA1c appears to be a factor associated with mortality in this Peruvian population.
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Affiliation(s)
- M. Lazo‐Porras
- CRONICAS Centre of Excellence in Chronic DiseasesUniversidad Peruana Cayetano HerediaLimaPeru
- Division of Tropical and Humanitarian MedicineGeneva University Hospitals and University of GenevaGenevaSwitzerland
| | - A. Ruiz‐Alejos
- CRONICAS Centre of Excellence in Chronic DiseasesUniversidad Peruana Cayetano HerediaLimaPeru
- Autonomic Dysfunction CentreDepartment of MedicineVanderbilt University Medical CentreTNUSA
| | - J. J. Miranda
- CRONICAS Centre of Excellence in Chronic DiseasesUniversidad Peruana Cayetano HerediaLimaPeru
- School of MedicineUniversidad Peruana Cayetano HerediaLimaPeru
| | - R. M. Carrillo‐Larco
- CRONICAS Centre of Excellence in Chronic DiseasesUniversidad Peruana Cayetano HerediaLimaPeru
- Department of Epidemiology and BiostatisticsSchool of Public HealthImperial College LondonLondonUK
| | - R. H. Gilman
- Department of International HealthBloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - L. Smeeth
- Faculty of Epidemiology and Population HealthLondon School of Hygienel and Tropical MedicineLondonUK
| | - A. Bernabé‐Ortiz
- CRONICAS Centre of Excellence in Chronic DiseasesUniversidad Peruana Cayetano HerediaLimaPeru
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Bou-Karroum L, El-Harakeh A, Kassamany I, Ismail H, El Arnaout N, Charide R, Madi F, Jamali S, Martineau T, El-Jardali F, Akl EA. Health care workers in conflict and post-conflict settings: Systematic mapping of the evidence. PLoS One 2020; 15:e0233757. [PMID: 32470071 PMCID: PMC7259645 DOI: 10.1371/journal.pone.0233757] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 05/13/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Health care workers (HCWs) are essential for the delivery of health care services in conflict areas and in rebuilding health systems post-conflict. OBJECTIVE The aim of this study was to systematically identify and map the published evidence on HCWs in conflict and post-conflict settings. Our ultimate aim is to inform researchers and funders on research gap on this subject and support relevant stakeholders by providing them with a comprehensive resource of evidence about HCWs in conflict and post-conflict settings on a global scale. METHODS We conducted a systematic mapping of the literature. We included a wide range of study designs, addressing any type of personnel providing health services in either conflict or post-conflict settings. We conducted a descriptive analysis of the general characteristics of the included papers and built two interactive systematic maps organized by country, study design and theme. RESULTS Out of 13,863 identified citations, we included a total of 474 studies: 304 on conflict settings, 149 on post-conflict settings, and 21 on both conflict and post-conflict settings. For conflict settings, the most studied counties were Iraq (15%), Syria (15%), Israel (10%), and the State of Palestine (9%). The most common types of publication were opinion pieces in conflict settings (39%), and primary studies (33%) in post-conflict settings. In addition, most of the first and corresponding authors were affiliated with countries different from the country focus of the paper. Violence against health workers was the most tackled theme of papers reporting on conflict settings, while workforce performance was the most addressed theme by papers reporting on post-conflict settings. The majority of papers in both conflict and post-conflict settings did not report funding sources (81% and 53%) or conflicts of interest of authors (73% and 62%), and around half of primary studies did not report on ethical approvals (45% and 41%). CONCLUSIONS This systematic mapping provides a comprehensive database of evidence about HCWs in conflict and post-conflict settings on a global scale that is often needed to inform policies and strategies on effective workforce planning and management and in reducing emigration. It can also be used to identify evidence for policy-relevant questions, knowledge gaps to direct future primary research, and knowledge clusters.
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Affiliation(s)
- Lama Bou-Karroum
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Amena El-Harakeh
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Clinical Research Institute (CRI), American University of Beirut Medical Center, Beirut, Lebanon
| | - Inas Kassamany
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Hussein Ismail
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Nour El Arnaout
- Global Health Institute, American University of Beirut, Beirut, Lebanon
| | - Rana Charide
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Farah Madi
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Sarah Jamali
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Tim Martineau
- Department of International Public Health, Liverpool School of Tropical Medicine, United Kingdom
| | - Fadi El-Jardali
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
| | - Elie A. Akl
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Clinical Research Institute (CRI), American University of Beirut Medical Center, Beirut, Lebanon
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Ontario, Canada
- Department of Internal Medicine, Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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El-Harakeh A, Lotfi T, Ahmad A, Morsi RZ, Fadlallah R, Bou-Karroum L, Akl EA. The implementation of prioritization exercises in the development and update of health practice guidelines: A scoping review. PLoS One 2020; 15:e0229249. [PMID: 32196520 PMCID: PMC7083273 DOI: 10.1371/journal.pone.0229249] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 02/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background The development of trustworthy guidelines requires substantial investment of resources and time. This highlights the need to prioritize topics for guideline development and update. Objective To systematically identify and describe prioritization exercises that have been conducted for the purpose of the de novo development, update or adaptation of health practice guidelines. Methods We searched Medline and CINAHL electronic databases from inception to July 2019, supplemented by hand-searching Google Scholar and the reference lists of relevant studies. We included studies describing prioritization exercises that have been conducted during the de novo development, update or adaptation of guidelines addressing clinical, public health or health systems topics. Two reviewers worked independently and in duplicate to complete study selection and data extraction. We consolidated findings in a semi-quantitative and narrative way. Results Out of 33,339 identified citations, twelve studies met the eligibility criteria. All included studies focused on prioritizing topics; none on questions or outcomes. While three exercises focused on updating guidelines, nine were on de novo development. All included studies addressed clinical topics. We adopted a framework that categorizes prioritization into 11 steps clustered in three phases (pre-prioritization, prioritization and post-prioritization). Four studies covered more than half of the 11 prioritization steps across the three phases. The most frequently reported steps for generating initial list of topics were stakeholders’ input (n = 8) and literature review (n = 7). The application of criteria to determine research priorities was used in eight studies. We used and updated a common framework of 22 prioritization criteria, clustered in 6 domains. The most frequently reported criteria related to the health burden of disease (n = 9) and potential impact of the intervention on health outcomes (n = 5). All the studies involved health care providers in the prioritization exercises. Only one study involved patients. There was a variation in the number and type of the prioritization exercises’ outputs. Conclusions This review included 12 prioritization exercises that addressed different aspects of priority setting for guideline development and update that can guide the work of researchers, funders, and other stakeholders seeking to prioritize guideline topics.
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Affiliation(s)
- Amena El-Harakeh
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Clinical Research Institute (CRI), American University of Beirut Medical Center, Beirut, Lebanon
| | - Tamara Lotfi
- Global Evidence Synthesis Initiative (GESI) Secretariat, American University of Beirut, Beirut, Lebanon
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Ali Ahmad
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Rami Z. Morsi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Racha Fadlallah
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Lama Bou-Karroum
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Elie A. Akl
- Center for Systematic Reviews on Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Clinical Research Institute (CRI), American University of Beirut Medical Center, Beirut, Lebanon
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, Canada
- * E-mail:
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Munshi S, Christofides NJ, Eyles J. Sub-national perspectives on the implementation of a national community health worker programme in Gauteng Province, South Africa. BMJ Glob Health 2019; 4:e001564. [PMID: 31908881 PMCID: PMC6936536 DOI: 10.1136/bmjgh-2019-001564] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 10/04/2019] [Accepted: 10/12/2019] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION In 2011, in line with principles for Universal Health Coverage, South Africa formalised community health workers (CHWs) into the national health system in order to strengthen primary healthcare. The national policy proposed that teams of CHWs, called Ward-based Primary Healthcare Outreach Teams (WBPHCOTs), supervised by a professional nurse were implemented. This paper explores WBPHCOTs' and managers' perspectives on the implementation of the CHW programme in one district in South Africa at the early stages of implementation guided by the Implementation Stages Framework. METHODS We conducted a qualitative study consisting of five focus group discussions and 14 in-depth interviews with CHWs, team leaders and managers. A content analysis of data was conducted. RESULTS There were significant weaknesses in early implementation resulting from a vague national policy and a rushed implementation plan. During the installation stage, adaptations were made to address gaps including the appointment of subdistrict managers and enrolled nurses as team leaders. Staff preparation of CHWs and team leaders to perform their roles was inadequate. To compensate, team members supported each another and assisted with technical skills where they could. Structural issues, such as CHWs receiving a stipend rather than being employed, were an ongoing implementation challenge. Another challenge was that facility managers were employed by the local government authority while the CHW programme was perceived to be a provincial programme. CONCLUSION The implementation of complex programmes requires a shared vision held by all stakeholders. Adaptations occur at different implementation stages, which require a feedback mechanism to inform the implementation in other settings. The CHW programme represented a policy advance but lacked detail with respect to human resources, budget, supervision, training and sustainability, which made it a difficult furrow to plough. This study points to how progressive reform remains fraught without due attention to the minutiae of practice.
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Affiliation(s)
- Shehnaz Munshi
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Nicola J Christofides
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - John Eyles
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
- School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada
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Liu B, Shi D, Wang W, Nan L, Yin B, Wei C, Emu A, Zhou H, Wazha W, Zhu J, Wang S, Ma W. What factors hinder ethnic minority women in rural China from getting antenatal care? A retrospective data analysis. BMJ Open 2019; 9:e023699. [PMID: 31420377 PMCID: PMC6701585 DOI: 10.1136/bmjopen-2018-023699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Mother-to-child transmission (MTCT) is one of the main transmission routes of HIV, and the probability of MTCT can be dramatically reduced with comprehensive interventions. In southwest and western regions in China, the level of development in rural areas is relatively backwards and retains some original features, which also increases the difficulty of controlling infectious diseases. The Liangshan Prefecture started the prevention of MTCT programme in 2009. However, the implementation of the programme is not ideal, and the coverage of HIV testing is still low. Many Yi (local major ethnicity) women did not take antenatal care (ANC) and just gave birth to their babies at home for a variety of reasons. METHODS Women with pregnancy history in the last 5 years were recruited from two townships based on cluster sampling. Face-to-face interviews were conducted to collect data. Descriptive analysis was performed to describe demographic characteristics, history of pregnancy and ANC uptake, knowledge of and attitudes towards ANC. Multivariable analysis was used to identify factors associated with uptake of ANC. RESULTS Among 538 women who completed the questionnaires, 77.9% knew that ANC was necessary during and after pregnancy. However, only 24.2% actually accessed ANC. Almost all women (94.6%) expressed their willingness to receive ANC for pregnancy but barriers towards actual uptake of ANC existed including shyness, lack of independence and unavoidable cost. Multivariate analysis showed that no experience of living outside of Zhaojue for more than 6 months, higher number of births, not knowing the necessity of ANC during pregnancy and not knowing the government's promotion policies for ANC were associated with lack of ANC uptake. CONCLUSION Although ethnic minority women in rural Liangshan expressed strong intention to use ANC, actual uptake of ANC was low. Knowledge of ANC and HIV prevention for MTCT should be improved among this population, and efforts should be made to help them overcome barriers to accessing ANC.
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Affiliation(s)
- Bo Liu
- Department of Epidemiology, Shandong University School of Public Health, Jinan, China
- School of Health Care Management, Shandong University, Jinan, China
| | - Duorui Shi
- School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Wei Wang
- Department of TB Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Lei Nan
- Department of AIDS Control and Prevention, Liangshan Prefecture Center for Disease Control and Prevention, Xichang, China
| | - Bibo Yin
- Department of AIDS Control and Prevention, Liangshan Prefecture Center for Disease Control and Prevention, Xichang, China
| | - Chongyi Wei
- Department of Epidemiology and Biostatistics & Global Health Sciences, University of California, San Francisco, California, USA
| | - Aga Emu
- Zhaojue Maternal and Child Care Service Centre, Zhaojue, China
| | - Haiqun Zhou
- Zhaojue Maternal and Child Care Service Centre, Zhaojue, China
| | - Wuha Wazha
- Zhaojue Zhuhe Central Hospital, Zhaojue, China
| | - Jianming Zhu
- Zhaojue Abingluogu Central Hospital, Zhaojue, China
| | - Shumei Wang
- Department of Epidemiology, Shandong University School of Public Health, Jinan, China
| | - Wei Ma
- Department of Epidemiology, Shandong University School of Public Health, Jinan, China
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Ramani S, Sivakami M, Gilson L. How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India. BMJ Glob Health 2019; 3:e001381. [PMID: 31354968 PMCID: PMC6626469 DOI: 10.1136/bmjgh-2018-001381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/27/2019] [Accepted: 03/16/2019] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION In this paper, we elucidate challenges posed by contexts to the implementation of the Primary Health Care (PHC) approach, using the example of primary health centres (rural peripheral health units) in India. We first present a historical review of 'written' policies in India-to understand macro contextual influences on primary health centres. Then we highlight micro level issues at primary health centres using a contemporary case study. METHODS To elucidate macro level factors, we reviewed seminal policy documents in India and some supporting literature. To examine the micro context, we worked with empirical qualitative data from a rural district in Maharashtra-collected through 12 community focus group discussions, 12 patient interviews and 34 interviews with health system staff. We interpret these findings using a combination of top-down and bottom-up lenses of the policy process. RESULTS Primary health centres were originally envisaged as 'social models' of service delivery; front-line institutions that delivered integrated care close to people's homes. However, macro issues of chronic underfunding and verticalisation have resulted in health centres with poor infrastructure, that mainly deliver vertical programmes. At micro levels, service provision at primary health centres is affected by doctors' disinterest in primary care roles and an institutional context that promotes risk-averseness and disregard of outpatient care. Primary health centres do not meet community expectations in terms of services, drugs and attention provided; and hence, private practitioners are preferred. Thus, primary health centres today, despite having the structure of a primary-level care unit, no longer embody PHC ideals. CONCLUSIONS This paper highlights some contextual complexities of implementing PHC-considering macro (pertaining to ideologies and fiscal priorities) and micro (pertaining to everyday behaviours and practices of actors) level issues. As we recommit to Alma-Ata, we must be cautious of the ceremonial adoption of interventions, that look like PHC-but cannot deliver on its ideals.
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Affiliation(s)
- Sudha Ramani
- Tata Institute of Social Sciences, Mumbai, India
| | - Muthusamy Sivakami
- School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
| | - Lucy Gilson
- University of Cape Town, Cape Town, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
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Maluka S, Chitama D, Dungumaro E, Masawe C, Rao K, Shroff Z. Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation. Int J Equity Health 2018; 17:118. [PMID: 30286767 PMCID: PMC6172831 DOI: 10.1186/s12939-018-0835-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 08/03/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Governments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented. METHODS We used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically. RESULTS The institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania's long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements. CONCLUSIONS Tanzania's central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.
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Affiliation(s)
- Stephen Maluka
- Institute of Development Studies, University of Dar es Salaam, P.O.BOX 35169, Dar es Salaam, Tanzania
| | - Dereck Chitama
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Esther Dungumaro
- Institute of Development Studies, University of Dar es Salaam, P.O.BOX 35169, Dar es Salaam, Tanzania
| | - Crecensia Masawe
- Dar es Salaam University College of Education, Dar es Salaam, Tanzania
| | - Krishna Rao
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
| | - Zubin Shroff
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland
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Mureithi L, Burnett JM, Bertscher A, English R. Emergence of three general practitioner contracting-in models in South Africa: a qualitative multi-case study. Int J Equity Health 2018; 17:107. [PMID: 30286772 PMCID: PMC6172712 DOI: 10.1186/s12939-018-0830-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/24/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The general practitioner contracting initiative (GPCI) is a health systems strengthening initiative piloted in the first phase of national health insurance (NHI) implementation in South Africa as it progresses towards universal health coverage (UHC). GPCI aimed to address the shortage of doctors in the public sector by contracting-in private sector general practitioners (GPs) to render services in public primary health care clinics. This paper explores the early inception and emergence of the GPCI. It describes three models of contracting-in that emerged and interrogates key factors influencing their evolution. METHODS This qualitative multi-case study draws on three cases. Data collection comprised document review, key informant interviews and focus group discussions with national, provincial and district managers as well as GPs (n = 68). Walt and Gilson's health policy analysis triangle and Liu's conceptual framework on contracting-out were used to explore the policy content, process, actors and contractual arrangements involved. RESULTS Three models of contracting-in emerged, based on the type of purchaser: a centralized-purchaser model, a decentralized-purchaser model and a contracted-purchaser model. These models are funded from a single central source but have varying levels of involvement of national, provincial and district managers. Funds are channelled from purchaser to provider in slightly different ways. Contract formality differed slightly by model and was found to be influenced by context and type of purchaser. Conceptualization of the GPCI was primarily a nationally-driven process in a context of high-level political will to address inequity through NHI implementation. Emergence of the models was influenced by three main factors, flexibility in the piloting process, managerial capacity and financial management capacity. CONCLUSION The GPCI models were iterations of the centralized-purchaser model. Emergence of the other models was strongly influenced by purchaser capacity to manage contracts, payments and recruitment processes. Findings from the decentralized-purchaser model show importance of local context, provincial capacity and experience on influencing evolution of the models. Whilst contract characteristics need to be well defined, allowing for adaptability to the local context and capacity is critical. Purchaser capacity, existing systems and institutional knowledge and experience in contracting and financial management should be considered before adopting a decentralized implementation approach.
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Affiliation(s)
- Linda Mureithi
- Health Systems Research Unit, Health Systems Trust, 1st Floor Block B, Aintree Park, Kenilworth, Cape Town, 7700 South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - James Michael Burnett
- Health Systems Research Unit, Health Systems Trust, 1st Floor Block B, Aintree Park, Kenilworth, Cape Town, 7700 South Africa
| | - Adam Bertscher
- Health Systems Research Unit, Health Systems Trust, 1st Floor Block B, Aintree Park, Kenilworth, Cape Town, 7700 South Africa
| | - René English
- Health Systems Research Unit, Health Systems Trust, 1st Floor Block B, Aintree Park, Kenilworth, Cape Town, 7700 South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Ssennyonjo A, Namakula J, Kasyaba R, Orach S, Bennett S, Ssengooba F. Government resource contributions to the private-not-for-profit sector in Uganda: evolution, adaptations and implications for universal health coverage. Int J Equity Health 2018; 17:130. [PMID: 30286757 PMCID: PMC6172798 DOI: 10.1186/s12939-018-0843-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 08/14/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND A case study was prepared examining government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. METHODS Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for GRCs and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study's findings were validated during two meetings with a broad set of stakeholders. RESULTS Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship's evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the "good will" of government actors, and 5) changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. CONCLUSIONS GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. Governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.
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Affiliation(s)
- Aloysius Ssennyonjo
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Justine Namakula
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
| | - Ronald Kasyaba
- Uganda Catholic Medical Bureau, Uganda Catholic Secretariat, Nsambya Hill, 672 Hanlon Road, P. O. Box 2886, Kampala, Uganda
| | - Sam Orach
- Uganda Catholic Medical Bureau, Uganda Catholic Secretariat, Nsambya Hill, 672 Hanlon Road, P. O. Box 2886, Kampala, Uganda
| | - Sara Bennett
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205 USA
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda
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Islam R, Hossain S, Bashar F, Khan SM, Sikder AAS, Yusuf SS, Adams AM. Contracting-out urban primary health care in Bangladesh: a qualitative exploration of implementation processes and experience. Int J Equity Health 2018; 17:93. [PMID: 30286751 PMCID: PMC6172767 DOI: 10.1186/s12939-018-0805-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 06/19/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Contracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh's two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries. METHODS This qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes. RESULTS In Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project's ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts. CONCLUSIONS This study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.
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Affiliation(s)
- Rubana Islam
- School of Public Health & Community Medicine, University of New South Wales (UNSW), Sydney, Australia
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shahed Hossain
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
| | - Farzana Bashar
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Shaan Muberra Khan
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Adel A. S. Sikder
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sifat Shahana Yusuf
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Alayne M. Adams
- Health Systems and Population Sciences Division, International Center for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
- Department of International Health, Georgetown University, Washington DC, USA
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Grimmer K, Louw Q, Dizon JM, van Niekerk SM, Ernstzen D, Wiysonge C. Standardising evidence strength grading for recommendations from multiple clinical practice guidelines: a South African case study. Implement Sci 2018; 13:117. [PMID: 30157898 PMCID: PMC6114483 DOI: 10.1186/s13012-018-0803-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 08/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Significant resources are required to write de novo clinical practice guidelines (CPGs). There are many freely-available CPGs internationally, for many health conditions. Developing countries rarely have the resources for de novo CPGs, and there could be efficiencies in using CPGs developed elsewhere. This paper outlines a novel process developed and tested in a resource-constrained country (South Africa) to synthesise findings from multiple international CPGs on allied health (AH) stroke rehabilitation. METHODS Methodologists, policy-makers, content experts and consumers collaborated to describe the pathway of an 'average' stroke patient through the South African public healthcare system and pose questions about best-practice stroke rehabilitation along this pathway. A comprehensive search identified international guidance documents published since January 2010. These were scanned for relevance to the South African AH stroke rehabilitation questions and critically appraised for methodological quality. Recommendations were extracted from guidance documents for each question. Strength of the body of evidence (SoBE) gradings underpinning recommendations were standardised, and composite recommendations were developed using qualitative synthesis. An algorithm was developed to guide assignment of overall SoBE gradings to composite recommendations. RESULTS Sixteen CPGs were identified, and all were included, as they answered different project questions differently. Methodological quality varied and was unrelated to currency. Seven clusters, outlining 20 composite recommendations were proposed (organise for best practice rehabilitation, operationalise strategies for best practice communication throughout the patient journey, admit to an acute hospital, refer to inpatient rehabilitation, action inpatient rehabilitation, discharge from inpatient rehabilitation and longer-term community-based rehabilitation). CONCLUSION The methodological development process, tested by writing a South African AH stroke rehabilitation guideline from existing evidence sources, took 9 months. The process was efficient, collaborative, effective, rewarding and positive. Using the proposed methods, similar synthesis of existing evidence could be conducted in shorter time periods, in other resource-constrained countries, avoiding the need for expensive and time-consuming de novo CPG development.
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Affiliation(s)
- K. Grimmer
- Clinical Teaching and Education Centre, College of Nursing and Health Sciences, Flinders University, Daw Park, Adelaide, South Australia 5041 Australia
- Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505 South Africa
| | - Q. Louw
- Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505 South Africa
| | - J. M. Dizon
- International Centre for Allied Health Evidence, University of South Australia, City East Campus, Adelaide, 5000 Australia
| | - S-M van Niekerk
- Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505 South Africa
| | - D. Ernstzen
- Department of Physiotherapy, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie van Zijl Drive, Tygerberg, Cape Town, 7505 South Africa
| | - C. Wiysonge
- Cochrane South Africa, South African Medical Research Council, Francie van Zijl Drive, Parow Valley, Cape Town, 7505 South Africa
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George A, Campbell J, Ghaffar A. Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health. Hum Resour Health 2018; 16:35. [PMID: 30103757 PMCID: PMC6090660 DOI: 10.1186/s12960-018-0302-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/22/2018] [Indexed: 06/08/2023]
Abstract
Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.
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Affiliation(s)
- A.S. George
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, Cape Town, 7535 South Africa
| | - J. Campbell
- Health Workforce, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - A. Ghaffar
- The Alliance for Health Policy and Systems Research, 20 Avenue Appia, 1211 Geneva, Switzerland
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48
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George A, Campbell J, Ghaffar A. Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health. Health Res Policy Syst 2018; 16:80. [PMID: 30103778 PMCID: PMC6090771 DOI: 10.1186/s12961-018-0346-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/22/2018] [Indexed: 11/10/2022] Open
Abstract
Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.
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Affiliation(s)
- A.S. George
- School of Public Health, University of the Western Cape, Private Bag x17, Bellville, Cape Town, 7535 South Africa
| | - J. Campbell
- Health Workforce, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - A. Ghaffar
- The Alliance for Health Policy and Systems Research, 20 Avenue Appia, 1211 Geneva, Switzerland
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Alcalde-Rabanal JE, Becerril-Montekio VM, Langlois EV. Evaluation of Communities of Practice performance developing implementation research to enhance maternal health decision-making in Mexico and Nicaragua. Implement Sci 2018; 13:41. [PMID: 29530055 PMCID: PMC5848447 DOI: 10.1186/s13012-018-0735-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/05/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jacqueline E. Alcalde-Rabanal
- Centre for Health Systems Research, National Institute of Public Health, Av. Universidad 655, Col. Santa María Ahuacatitlán, CP 62100 Cuernavaca, Morelos Mexico
| | - Victor M. Becerril-Montekio
- Centre for Health Systems Research, National Institute of Public Health, Av. Universidad 655, Col. Santa María Ahuacatitlán, CP 62100 Cuernavaca, Morelos Mexico
| | - Etienne V. Langlois
- Alliance for Health Policy and Systems Research, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
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50
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Okonofua F, Ntoimo L, Ogu R, Galadanci H, Abdus-salam R, Gana M, Okike O, Agholor K, Abe E, Durodola A, Randawa A. Association of the client-provider ratio with the risk of maternal mortality in referral hospitals: a multi-site study in Nigeria. Reprod Health 2018; 15:32. [PMID: 29471845 PMCID: PMC5824472 DOI: 10.1186/s12978-018-0464-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 01/23/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The paucity of human resources for health buoyed by excessive workloads has been identified as being responsible for poor quality obstetric care, which leads to high maternal mortality in Nigeria. While there is anecdotal and qualitative research to support this observation, limited quantitative studies have been conducted to test the association between the number and density of human resources and risk of maternal mortality. This study aims to investigate the association between client-provider ratios for antenatal and delivery care and the risk of maternal mortality in 8 referral hospitals in Nigeria. METHODS Client-provider ratios were calculated for antenatal and delivery care attendees during a 3-year period (2011-2013). The maternal mortality ratio (MMR) was calculated per 100,000 live births for the hospitals, while unadjusted Poisson regression analysis was used to examine the association between the number of maternal deaths and density of healthcare providers. RESULTS A total of 334,425 antenatal care attendees and 26,479 births were recorded during this period. The client-provider ratio in the maternity department for antenatal care attendees was 1343:1 for doctors and 222:1 for midwives. The ratio of births to one doctor in the maternity department was 106:1 and 18:1 for midwives. On average, there were 441 births per specialist obstetrician. The results of the regression analysis showed a significant negative association between the number of maternal deaths and client-provider ratios in all categories. CONCLUSION We conclude that the maternal mortality ratios in Nigeria's referral hospitals are worsened by high client-provider ratios, with few providers attending a large number of pregnant women. Efforts to improve the density and quality of maternal healthcare providers, especially at the first referral level, would be a critical intervention for reducing the currently high rate of maternal mortality in Nigeria. TRIAL REGISTRATION Trial Registration Number: NCTR91540209 . Nigeria Clinical Trials Registry. Registered 14 April 2016.
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Affiliation(s)
- Friday Okonofua
- University of Medical Sciences, Ondo City, Ondo State Nigeria
- the Women’s Health and Action Research Centre, WHO Implementation Research Group, Benin City, Nigeria
- Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin City, Nigeria
| | - Lorretta Ntoimo
- the Women’s Health and Action Research Centre, WHO Implementation Research Group, Benin City, Nigeria
- Department of Demography and Social Statistics, Federal University Oye-Ekiti, Oye, Ekiti State Nigeria
| | - Rosemary Ogu
- the Women’s Health and Action Research Centre, WHO Implementation Research Group, Benin City, Nigeria
- Centre of Excellence in Reproductive Health Innovation, University of Benin, Benin City, Nigeria
- Department of Obstetrics and Gynaecology, University of Port Harcourt, Port Harcourt, Rivers State Nigeria
| | | | | | | | - Ola Okike
- Karshi General Hospital, Federal Capital Territory, Abuja, Nigeria
| | | | - Eghe Abe
- Central Hospital, Benin City, Edo State Nigeria
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