Local Health Service Response to COVID-19 in Mexico: Notes From an Exploratory Qualitative Study

BACKGROUND

The main goal of a health system is to maintain or improve people's health. The COVID-19 pandemic showed the fragility of health systems worldwide. In Mexico, the pandemic affected the performance of the health system, along with the presence of contextual conditions such as its segmentation and high prevalence of chronic diseases.

AIMS

To analyze from an approach to the functions of the health system, the service delivery, human resources, financing, and stewardship/governance in the local health services of five states of Mexico, from the perspective of the staff working in health centers.

METHODS

This is an exploratory qualitative study conducted from November 2020 to August 2021, involving 124 health professionals from 39 health facilities (18 rural and 21 urban). The technique used was the semi-structured interview. Interview guides were developed according to core topics. Subsequently, the thematic analysis method was used.

RESULTS

The lack of financial resources delayed prevention efforts and made it difficult for health centers to adapt to the crisis. Inequity was found in the distributive efficiency of staff between rural and urban areas and levels of care. In addition, there was evidence of capacity for coordination, capacity sharing, and joint participation between health institutions, civil authorities, and the population to face the emergency.

CONCLUSIONS

We identified relevant public health actions that showed the capacity of local health services to organize a response to the pandemic at the level of the actors responsible for these services.

Defining Malaysia's health research ethics system through a stakeholder driven approach

The need to understand the systems that support ethical health research has long been recognized, but there are limited descriptions of actual health research ethics (HRE) systems. Using participatory network mapping methods, we empirically defined Malaysia's HRE system. 13 Malaysian stakeholders identified 4 overarching and 25 specific HRE system functions and 35 actors internal and 3 external to the Malaysian HRE system responsible for those functions. Functions requiring the most attention were: advising on legislation related to HRE; optimizing research value to society; and defining standards for HRE oversight. Internal actors with the greatest potential for more influence were: the national network of research ethics committees; non-institution-based research ethics committees; and research participants. The World Health Organization, an external actor, had the largest untapped potential for influence overall. In summary, this stakeholder-driven process identified HRE system functions and actors that could be targeted to increase HRE system capacity.

Preference-aligned fertility management among married adolescent girls in Northern Nigeria: assessing a new measure of contraceptive autonomy

INTRODUCTION

Universal access to sexual and reproductive healthcare-including family planning (FP)-is a global priority, yet there is no standard outcome measure to evaluate rights-based FP programme performance at the regional, national or global levels.

METHODS

We collected a modified version of preference-aligned fertility management (PFM), a newly proposed rights-based FP outcome measure which we operationalised as concordance between an individual's desired and actual current contraceptive use. We also constructed a modified version (satisfaction-adjusted PFM) that reclassified current contraceptive users who wanted to use contraception but who were dissatisfied with their method as not having PFM. Our analysis used data collected 3.5 months after contraceptive method initiation within an ongoing prospective cohort of married adolescent girls aged 15-19 years in Northern Nigeria. We described and compared prevalence of contraceptive use and PFM in this population.

RESULTS

Ninety-seven per cent (n=1020/1056) of respondents were practising PFM 3.5 months after initiating modern contraception, while 93% (n=986/1056) were practising satisfaction-adjusted PFM. Among participants not practising satisfaction-adjusted PFM (n=70), most were using contraception but did not want to be (n=30/70, 43%) or wanted to use contraception but were dissatisfied with their method (n=34/70, 49%), while the remaining 9% (n=6/70) wanted but were not currently using contraception.

CONCLUSION

PFM captured meaningful discordance between contraceptive use desires and behaviours in this cohort of married Nigerian adolescent girls. Observed discordance in both directions provides actionable insights for intervention. PFM is a promising rights-focused FP outcome measure that warrants future field-testing in programmatic and population-based research.

Did the healthcare vaccine mandate work? An evaluation of the impact of the COVID-19 vaccine mandate on vaccine uptake and infection risk in a large cohort of Canadian healthcare workers

BACKGROUND

We aimed to evaluate the impact of healthcare vaccine mandates on vaccine uptake and infection risk in a cohort of Canadian healthcare workers (HCWs).

METHODS

We conduct interrupted time series analysis through a regression discontinuity in time approach to estimate the immediate and delayed impact of the mandate. Multi-level mixed effect modelling fitted with restricted maximum likelihood was used to estimate impact on infection risk.

RESULTS

The immediate and sustained effects of the mandate was a 0.19% (p <0.05) and a 0.012% (p <0.05) increase in the daily proportion of unvaccinated HCWs getting their first dose, respectively. An additional 623 (95% confidence interval (CI): 613 - 667) HCWs received first doses compared to the predicted uptake absent the mandate. Adjusted test positivity declined by 0.053% (95% CI: 0.035%,0.069) for every additional day the mandate was in effect.

DISCUSSION

Our results indicate that the mandate was associated with significant increases in vaccine uptake and infection risk reduction in the cohort.

CONCLUSIONS

Given the benefit that vaccination could bring to HCWs, understanding strategies to enhance uptake is crucial for bolstering health system resilience, but steps must be taken to avert approaches that sacrifice trust, foster animosity, or exacerbate staffing constraints for short-term results.

Retention of Doctors and Dentists to Serve in Remote Areas in Indonesia: A Discrete Choice Experiment

Introduction

Retaining doctors and dentists in remote areas of Indonesia remains a national priority of the Indonesian government. The purpose of this study was to analyze the interventions for retention of doctors and dentists in remote areas using the discrete choice experiment (DCE) approach.

Materials and Methods

A DCE was conducted to investigate preferences of doctors and dentists for retention in remote areas. This research was conducted in 78 primary healthcare settings across 15 provinces in Indonesia. The conditional logit model was used to explore stated preferences for each attribute.

Results

The total number of respondents was 158, including 113 doctors and 45 dentists. In general, doctors placed the highest preference on getting priority for government scholarships to facilitate retention in remote areas (OR=5.65, p<0.001). Specifically, dentists preferred security guarantees from local government (OR = 4.87, p<0.001). Both groups valued having an official residence (OR=3.6, p<0.001) as a factor for retention in remote areas.

Conclusion

Scholarship, security guarantees, housing facilities, and medical facilities were the most considered factors for retaining doctors and dentists in a remote area. This study confirms the importance of a combination of interventions in maintaining doctors and dentists in remote areas. Policy options in the form of non-financial and financial intervention packages can be combined to improve their retention.

Hypertension Trends and Disparities Over 12 Years in a Large Health System: Leveraging the Electronic Health Records

BACKGROUND

The digital transformation of medical data enables health systems to leverage real-world data from electronic health records to gain actionable insights for improving hypertension care.

METHODS AND RESULTS

We performed a serial cross-sectional analysis of outpatients of a large regional health system from 2010 to 2021. Hypertension was defined by systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or recorded treatment with antihypertension medications. We evaluated 4 methods of using blood pressure measurements in the electronic health record to define hypertension. The primary outcomes were age-adjusted prevalence rates and age-adjusted control rates. Hypertension prevalence varied depending on the definition used, ranging from 36.5% to 50.9% initially and increasing over time by ≈5%, regardless of the definition used. Control rates ranged from 61.2% to 71.3% initially, increased during 2018 to 2019, and decreased during 2020 to 2021. The proportion of patients with a hypertension diagnosis ranged from 45.5% to 60.2% initially and improved during the study period. Non-Hispanic Black patients represented 25% of our regional population and consistently had higher prevalence rates, higher mean systolic and diastolic blood pressure, and lower control rates compared with other racial and ethnic groups.

CONCLUSIONS

In a large regional health system, we leveraged the electronic health record to provide real-world insights. The findings largely reflected national trends but showed distinctive regional demographics and findings, with prevalence increasing, one-quarter of the patients not controlled, and marked disparities. This approach could be emulated by regional health systems seeking to improve hypertension care.

The mental health needs of healthcare workers: When evidence does not guide policy. A comparative assessment of selected European countries

BACKGROUND

The healthcare workforce (HCWF) globally is facing high stress levels and deteriorating mental health due to workplace, labour market and policy deficiencies that further exacerbate the existing crisis. However, comprehensive and effective action is missing.

AIMS

We adopt a health system and governance perspective to address the mental health needs of healthcare workers (HCWs), considering the nature of interventions and the levels and actors involved in governance. The aim is to move the debate forward by identifying governance gaps hampering the implementation of health workforce policies and exploring strategies to effectively increase mental health support.

MATERIAL AND METHODS

A qualitative comparative methodology is applied based on a case study design utilising a multi-level intersectoral governance matrix. We conducted a rapid assessment of HCWF developments in the European context (Germany, Portugal, Romania, Switzerland and the United Kingdom), drawing on secondary sources and country experts.

RESULTS AND DISCUSSION

Awareness of mental health threats among HCWs increased, but policy discourse is driven by service delivery and labour market demands. The attention to HCWs' needs is stronger on the international level and weakest at national/regional levels. Although organisations and professions demonstrate varying degrees of activity, their efforts are scattered and lack sustainability. Similar challenges were identified across healthcare systems, including limited action, disconnected actors, missing coordination, and a lack of attention to governance gaps and system weaknesses.

CONCLUSION

Adopting a health system approach is important but not sufficient. Successful mental health policy implementation needs multi-level governance and coherent coordination mechanisms.

Filling the Gaps in the Pandemic Response: Impact of COVID-19 on Telehealth in the Military Health System

Introduction: As a result of the COVID-19 pandemic, telehealth use became widespread, allowing for continued health care while minimizing COVID-19 transmission risk for patients and providers. This rapid scale-up highlighted shortcomings of the current telehealth infrastructure in many health systems. We aimed to identify and address gaps in the United States Military Health System (MHS) response to the COVID-19 pandemic related to the implementation and utilization of telehealth. Methods: We conducted semistructured key informant interviews of MHS stakeholders, including policymakers, program managers, and health care providers. We recruited respondents using purposive and snowball sampling until we reached thematic saturation. Interviews were conducted virtually from December 2022 to March 2023 and coded by deductive thematic analysis using NVivo. Results: We interviewed 28 key informants. Several themes emerged from the interviews and were categorized into four defined areas of obstacles to the effective utilization of telehealth: administrative, technical, organizational, and quality issues. While respondents had positive perceptions of telehealth, issues such as billing, licensure portability, network connectivity and technology, and ability to monitor health outcomes represent major barriers in the current system, preventing the potential for further expansion. Conclusions: While the shift to telehealth during the COVID-19 pandemic demonstrated robust potential within the MHS, it highlighted shortcomings that impair the utility and expansion of telehealth on a level comparable to that of other large health systems. Future focus should be directed toward generating and implementing actionable recommendations that target these identified challenges in the MHS.

Barriers and enablers to people-centred viral hepatitis care in Vietnam and the Philippines: Results of a patient journey mapping study

In Vietnam and the Philippines, viral hepatitis is the leading cause of cirrhosis and liver cancer. This study aims to understand the barriers and enablers of people receiving care for hepatitis B and C to support both countries' efforts to eliminate viral hepatitis as a public health threat by 2030. Retrospective, semi-structured interviews were conducted with a purposive, quota-based sample of 63 people living with hepatitis B or C in one province of Vietnam and one region of the Philippines. A rapid deductive approach to thematic analysis produced key findings among the three phases of care: (1) pre-awareness and testing, (2) linkage and treatment initiation and (3) ongoing treatment and recovery. The research found that participants followed five typical journeys, from a variety of entry points. Barriers during the pre-awareness and testing phase included limited awareness about hepatitis and its management, stigma and psychological impacts. Enablers included being familiar with the health system and/or patients benefiting from social connections within the health systems. During the linkage and treatment initiation phase, barriers included difficult physical access, complex navigation and inadequate counselling. In this phase, family support emerged as a critical enabler. During the ongoing treatment and recovery phase, the cost of care and socially and culturally informed perceptions of the disease and medication use were both barriers and enablers. Exploring peoples' journeys with hepatitis B and C in Vietnam and the Philippines revealed many similarities despite the different cultural and health system contexts. Insights from this study may help generate a contextualized, people-centred evidence base to inform the design and improvement of primary care services for hepatitis in both research sites.

Identifying Opportunities to Deliver High-Quality Cancer Care Across a Health System: A Clinical Responsibility

OBJECTIVE

We examined process-related quality metrics for oral squamous cell carcinoma (OSCC) depending on treating facility type across a health system and region.

STUDY DESIGN

Retrospective in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

SETTING

Single health system and region.

METHODS

Patients with OSCC diagnosed between 2012 and 2018 were identified from tumor registries of 6 hospitals (1 academic and 5 community) within a single health system. Patients were categorized into 3 care groups: (1) solely at the academic center, (2) solely at community facilities, and (3) combined care at academic and community facilities. Primary outcome measures were process-related quality metrics: positive surgical margin rate, lymph node yield (LNY), adjuvant treatment initiation ≤6 weeks, National Comprehensive Cancer Network (NCCN)-guideline adherence.

RESULTS

A total of 499 patients were included: 307 (61.5%) patients in the academic-only group, 101 (20.2%) in the community-only group, and 91 (18.2%) in the combined group. Surgery at community hospitals was associated with increased odds of positive surgical margins (11.9% vs 2.5%, odds ratio [OR]: 47.73, 95% confidence interval [CI]: 11.2-275.86, P < .001) and lower odds of LNY ≥ 18 (52.8% vs 85.9%, OR: 0.15, 95% CI: 0.07-0.33, P < .001) relative to the academic center. Compared with the academic-only group, odds of adjuvant treatment initiation ≤6 weeks were lower for the combined group (OR: 0.30, 95% CI: 0.13-0.64, P = .002) and odds of NCCN guideline-adherent treatment were lower in the community only group (OR: 0.35, 95% CI: 0.18-0.70, P = .003).

CONCLUSION

Quality of oral cancer care across the health system and region is comparable to or better-than national standards, indicating good baseline quality of care. Differences by facility type and fragmentation of care present an opportunity for bringing best in-class cancer care across an entire region.

Usability and Feasibility Evaluation of a Web-Based and Offline Cybersecurity Resource for Health Care Organizations (The Essentials of Cybersecurity in Health Care Organizations Framework Resource): Mixed Methods Study

BACKGROUND

Cybersecurity is a growing challenge for health systems worldwide as the rapid adoption of digital technologies has led to increased cyber vulnerabilities with implications for patients and health providers. It is critical to develop workforce awareness and training as part of a safety culture and continuous improvement within health care organizations. However, there are limited open-access, health care-specific resources to help organizations at different levels of maturity develop their cybersecurity practices.

OBJECTIVE

This study aims to assess the usability and feasibility of the Essentials of Cybersecurity in Health Care Organizations (ECHO) framework resource and evaluate the strengths, weaknesses, opportunities, and threats associated with implementing the resource at the organizational level.

METHODS

A mixed methods, cross-sectional study of the acceptability and usability of the ECHO framework resource was undertaken. The research model was developed based on the technology acceptance model. Members of the Imperial College Leading Health Systems Network and other health care organizations identified through the research teams' networks were invited to participate. Study data were collected through web-based surveys 1 month and 3 months from the date the ECHO framework resource was received by the participants. Quantitative data were analyzed using R software (version 4.2.1). Descriptive statistics were calculated using the mean and 95% CIs. To determine significant differences between the distribution of answers by comparing results from the 2 survey time points, 2-tailed t tests were used. Qualitative data were analyzed using Microsoft Excel. Thematic analysis used deductive and inductive approaches to capture themes and concepts.

RESULTS

A total of 16 health care organizations participated in the study. The ECHO framework resource was well accepted and useful for health care organizations, improving their understanding of cybersecurity as a priority area, reducing threats, and enabling organizational planning. Although not all participants were able to implement the resource as part of information computing technology (ICT) cybersecurity activities, those who did were positive about the process of change. Learnings from the implementation process included the usefulness of the resource for raising awareness and ease of use based on familiarity with other standards, guidelines, and tools. Participants noted that several sections of the framework were difficult to operationalize due to costs or budget constraints, human resource limitations, leadership support, stakeholder engagement, and limited time.

CONCLUSIONS

The research identified the acceptability and usability of the ECHO framework resource as a health-focused cybersecurity resource for health care organizations. As cybersecurity in health care organizations is everyone's responsibility, there is potential for the framework resource to be used by staff with varied job roles. Future research needs to explore how it can be updated for ICT staff and implemented in practice and how educational materials on different aspects of the framework could be developed.

Examining the Use and Application of the WHO Integrated People-Centred Health Services Framework in Research Globally - a Systematic Scoping Review

Introduction

The World Health Organisation (WHO) accepted the Integrated People-centred Health Services (IPCHS) framework in 2016 as an essential component for achieving universal health coverage in fragmented health systems. We aimed to examine the empirical applications of the WHO IPCHS framework to guide its use in strengthening health-service research.

Methods

Academic databases and the IPCHS website were searched for relevant articles published between 2016 and July 2023. Two reviewers independently screened and extracted data on the study design, setting, IPCHS framework components, and facilitators and barriers to implementing the IPCHS strategies. Descriptive and content analyses were conducted.

Results

Six studies were identified using the IPCHS framework. Studies have examined a combination of the five IPCHS strategies. All studies reported building strong primary care-based systems and coordinating care for individuals. Continued relationships and trust, co-production of health programmes, diversity of health care team, and technology were major facilitators, while low health literacy, lack of primary setting capacity and healthcare workforce were principal barriers to IPCHS implementation.

Conclusion

This scoping review offers an overview of IPCHS strategies employed in healthcare research. Generally, the IPCHS framework remains underutilised in primary research. These results offer guidance for future research to support effective healthcare delivery.

Trends in Medicare utilization and reimbursement for hematology/oncology procedures from 2012 to 2023: A geriatric oncology perspective

Objectives

Given the scarcity of data exploring reimbursement trends in the field of hematology/oncology, we sought to characterize these trends for common procedures in this field from 2012 to 2023.

Methods

Using the Centers for Medicare and Medicaid Services' Physician Fee Schedule Look-Up Tool we collected reimbursement data for 40 hematology/oncology procedure codes from 2012 to 2023. Data was adjusted to 2023 United States (US) dollars using the Consumer Price Index (CPI).

Results

From 2012 to 2023 gross reimbursement for the facility price decreased 4.4% and increased 9.2% for the non-facility price. When adjusted for inflation, compensation decreased 96.1% and 96.6%, respectively. None of the 40 examined Current Procedural Terminology (CPT) codes increased in net reimbursement over the study period.

Conclusions

Medicare reimbursement for common hematology/oncology procedures decreased from 2012 to 2023. Further research is necessary to explore the implications of these trends on the delivery of patient care.

Systemic failures in nursing home care-A scoping study

Nursing homes (also referred to as residential aged care facilities, or long-term care facilities) cater for older people on a respite or long-term basis for those who are no longer able to live independently at home. Globally the sector struggles to meet societal expectations since it is torn between three competing agendas-meeting the needs of residents, meeting the demands of regulators, and meeting the financial imperatives of nursing home proprietors. Competing demands indicate that the system lacks a clear understanding of its purpose-without a clearly understood purpose any system will become dysfunctional overall and across all its levels of organisation. This scoping study aims to summarise and synthesise what is already known about the systemic function and failures in the nursing home system, and the impact this has on the wider health and aged care system.

METHOD

MEDLINE, EMBASE, PSYCHINFO, CINAHL and SCOPUS were searched using the terms: (nursing home care OR residential aged care OR nursing home) AND (organisational failure OR institutional failure OR systemic failure), limited to English language articles, including all years up to the end of February 2021. In addition, we used snowballing of article references and Google searches of the grey literature. System-focused articles were defined as those that explored how an issue at one system level impacted other system levels, or how an issue impacted at least two different agents at the same system level.

RESULT

Thirty-eight articles addressed systemic issues as defined in four different contexts: United States (14), Canada (2), Australia (11) and European countries (11). Only four studies reported whole-of-system findings, whereas the remaining 34 more narrowly addressed systemic features of specific nursing home issues. The thematic analysis identified 29 key systemic issues across five system layers which consistently appear across every country/health system context. The negative outcomes of these systemic failings include: high rates of regulatory reprimands for unacceptable or unsafe practices; dissatisfaction in care experiences on the part of residents, families, and care staff-including a fear of being sent to a nursing home; and the perception amongst staff that nursing homes are not preferred places to work.

CONCLUSIONS

The key issues affecting nursing home residents, and the care home sector more generally, are systemic in nature arising from two key issues: first, the lack of shared agreement on the care home system's purpose; and second, the lack of clear governance and accountability frameworks for system regulation and performance at a national level. Addressing these two key issues must be the starting point for any 'real' nursing home system redesign that can achieve a seamlessly integrated system that delivers the outcomes nursing home residents and their families expect. 'Systems thinking' is required to simultaneously improve care quality and outcomes for residents, strengthen regulation and accountability, and enable financial viability.

Continuity of Trust: Health Systems' Role in Advancing Health Equity Beyond the COVID-19 Pandemic

Given COVID-19's disproportionate impact on populations that identify as Black, Indigenous, and People of Color (BIPOC) in the United States, researchers and advocates have recommended that health systems and institutions deepen their engagement with community-based organizations (CBOs) with longstanding relationships with these communities. However, even as CBOs leverage their earned trust to promote COVID-19 vaccination, health systems and institutions must also address underlying causes of health inequities more broadly. In this commentary, we discuss key lessons learned about trust from our participation in the U.S. Equity-First Vaccination Initiative, an effort funded by The Rockefeller Foundation to promote COVID-19 vaccination equity. The first lesson is that trust cannot be "surged" to meet the needs of the moment until it is no longer deemed important; rather, it must predate and outlast the crisis. Second, to generate long-term change, health systems cannot simply rely on CBOs to bridge the trust gap; instead, they must directly address the root causes of this gap among BIPOC populations.

"I feel broken": Chronicling burnout, mental health, and the limits of individual resilience in nursing

Healthcare systems and health professionals are facing a litany of stressors that have been compounded by the pandemic, and consequently, this has further perpetuated suboptimal mental health and burnout in nursing. The purpose of this paper is to report select findings from a larger, national study exploring gendered experiences of mental health, leave of absence (LOA), and return to work from the perspectives of nurses and key stakeholders. Given the breadth of the data, this paper will focus exclusively on the qualitative results from 53 frontline Canadian nurses who were purposively recruited for their workplace insight. This paper focuses on the substantive theme of "Breaking Point," in which nurses articulated a multiplicity of stress points at the individual, organizational, and societal levels that amplified burnout and accelerated mental health LOA from the workplace. These findings exemplify the complexities that underlie nurses' mental health and burnout and highlight the urgent need for multipronged individual, organizational, and structural interventions. Robust and timely interventions are needed to restore the health of the nursing profession and sustain its future.

Assessment of Patient Safety in a Low-Resource Health Care System: Proposal for a Multimethod Study

BACKGROUND

The high prevalence of adverse events (AEs) globally in health care delivery has led to the establishment of many guidelines to enhance patient safety. However, patient safety is a relatively nascent concept in low- and middle-income countries (LMICs) where health systems are already overburdened and underresourced. This is why it is imperative to study the nuances of patient safety from a local perspective to advocate for the judicious use of scarce public health resources.

OBJECTIVE

This study aims to assess the status of patient safety in a health care system within a low-resource setting, using a multipronged, multimethod approach of standardized methodologies adapted to the local setting.

METHODS

We propose purposive sampling to include a representative mix of public and private, rural and urban, and tertiary and secondary care hospitals, preferably those ascribed to the same hospital quality standards. Six different approaches will be considered at these hospitals including (1) focus group discussions on the status quo of patient safety, (2) Hospital Survey on Patient Safety Culture, (3) Hospital Consumer Assessment of Healthcare Providers and Systems, (4) estimation of incidence of AEs identified by patients, (5) estimation of incidence of AEs via medical record review, and (6) assessment against the World Health Organization's Patient Safety Friendly Hospital Framework via thorough reviews of existing hospital protocols and in-person surveys of the facility.

RESULTS

The abovementioned studies collectively are expected to yield significant quantifiable information on patient safety conditions in a wide range of hospitals operating within LMICs.

CONCLUSIONS

A multidimensional approach is imperative to holistically assess the patient safety situation, especially in LMICs. Our low-budget, non-resource-intensive research proposal can serve as a benchmark to conduct similar studies in other health care settings within LMICs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50532.

Maintaining essential health services during COVID-19 in Ghana: a qualitative study

INTRODUCTION

Evidence suggests that non-pharmaceutical interventions such as lockdown policies, restriction of movement and physical distancing to control the novel COVID-19 contributed to the decline in utilisation of essential health services. We explored healthcare providers' and policy-makers' experiences of the barriers, interventions and response actions that contributed to ensuring the continuity of essential health services during the COVID-19 pandemic in Ghana to help inform future practice and policy.

METHODS

We used a qualitative study approach. Data were analysed using thematic analysis. Thirty Four participants composed of 20 healthcare providers and 14 policy-makers who worked across regions with low and high recorded COVID-19 cases in Ghana during the COVID-19 pandemic were involved in this study.

RESULTS

Participants reported that essential health services including maternal, reproductive and child health services, communicable and non-communicable disease care, and elective surgeries were disrupted during the COVID-19 pandemic. Barriers to the utilisation of essential services were constructed into three subthemes: (1) fear, (2) poor quality of care at the facility and (3) financial limitation. These barriers were mitigated with population-based interventions underpinned by the socioecological model at the individual and interpersonal level (including psychosocial care for families and home visits), institutional and community levels (such as allocation of funds, training of health workers, public education, triage stations, provision of logistics, appointment scheduling, telemedicine and redeployment of health workers) and public policy level (tax relief packages, transportation arrangements and provision of incentives), which helped in maintaining essential health services during COVID-19.

CONCLUSION

Disruption of essential health services during COVID-19 in Ghana instigated population-based interventions which aided in expanding the populations' continuous access to essential health services and strengthened health service delivery.

Humanitarian-Development Nexus: strengthening health system preparedness, response and resilience capacities to address COVID-19 in Sudan-case study of repositioning external assistance model and focus

The advent of the COVID-19 pandemic and the establishment of a new transitional government in Sudan with rejuvenated relations with the international community paved the way for external assistance to the EU COVID-19 response project, a project with a pioneering design within the region. The project sought to operationalize the humanitarian-development-peace nexus, perceiving the nexus as a continuum rather than sequential due to the protracted nature of emergencies in Sudan and their multiplicity and contextual complexity. It went further into enhancing peace through engaging with conflict and post-conflict-affected states and communities and empowering local actors. Learning from this experience, external assistance models to low- or middle-income countries (LMICs) should apply principles of flexibility and adaptability, while maintaining trust through transparency in exchange, to ensure sustainable and responsive action to domestic needs within changing contexts. Careful selection and diverse project team skills, early and continuous engagement with stakeholders, and robust planning, monitoring and evaluation processes were the project highlights. Yet, the challenges of political turmoil, changing Ministry of Health leadership, competing priorities and inactive coordination mechanisms had to be dealt with. While applying such an approach of a health system lens to health emergencies in LMICs is thought to be a success factor in this case, more robust technical guidance to the nexus implementation is crucial and can be best attained through encouraging further case reports analysing context-specific practices.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

Introduction

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

Methods

We conducted 40 semi-structured interviews with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) model and used deductive coding approach. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities.

Results

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level), providers' approach to the HPV vaccine recommendations (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and information (practice level).

Conclusions

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Cross-country comparisons in health price growth over time

OBJECTIVE

To examine how the United States compares in terms of health price growth relative to four other countries - Australia, Canada, France, and the Netherlands.

DATA SOURCES AND STUDY SETTING

Secondary data on health expenditure were extracted from international and national agencies spanning the years 2000-2020.

STUDY DESIGN

International price indices specific to health were constructed using available international expenditure data and compared to existing health-specific national and general international price indices.

DATA COLLECTION/EXTRACTION METHODS

Health expenditure data were extracted from the Organization for Economic Cooperation and Development (OECD) database. We obtained a time series of health price indices from the national agencies in each of the study countries.

PRINCIPAL FINDINGS

We find meaningful variation across countries in the rate at which health prices grow relative to general prices. The United States had the highest cumulative health price growth compared to general price growth over the years 2000-2020 at 14%, followed by Canada and the Netherlands. Unlike the other study countries, health prices in France grew consistently in line with general prices. Price growth for health care paid for by public funds and households grew at different rates across countries, where price growth was higher for public payers. US households faced the greatest mean annual price growth.

CONCLUSIONS

The choice of price index has major implications for comparative analysis. Despite their widespread use internationally, general price indices likely underestimate the contribution of price growth to overall health expenditure growth. We find that in addition to its reputation for having high health price levels compared to other high-income countries, the United States also faces health price growth for goods and services paid for by government and households in excess of general price growth. Furthermore, US households are exposed to greater health price growth than households in comparator countries.

Management of pharmaceutical services in the fight against COVID-19 in universal public health systems: a rapid review

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic brought new challenges and lessons were learnt for health services. In the field of pharmaceutical care, several interventions have been proposed to optimize and expand the response capacity of services.

OBJECTIVE

To identify and characterize interventions performed in the management of pharmaceutical services during the COVID-19 pandemic in universal public health systems.

METHODS

A rapid literature review was conducted and registered in PROSPERO (CRD42022360902). Systematic searches in the MEDLINE (PubMed), Embase, and Virtual Health Library databases were conducted to identify interventions and practices adopted for the management of pharmaceutical care during the COVID-19 pandemic.

RESULTS

Thirteen articles reporting interventions developed in six countries were included. The interventions were summarized under three major themes: actions for continuous access to medicines, logistical measures for acquisition and storage, and organizational strategies. Telepharmacy services stand out as a typical action adopted in different services, which highlights the use and consolidation of digital technologies in these services. Strategies for process management were described and focused on the reorganization of the internal service of pharmacies, flow of services, and people management.

CONCLUSIONS

Many interventions were developed during the pandemic, some of which have already been incorporated into routine service delivery. Although the studies did not measure the effect of each intervention, the strategies developed are a source of information for the future delivery of care. Studies should be conducted to evaluate the potential of similar interventions in other health emergency contexts.

Application of an opioid use disorder cascade of care in a large public health system

Background: Over the past decade, hospitals and health systems have increasingly adopted interventions to address the needs of patients with substance use disorders. The Opioid Use Disorder (OUD) Cascade of Care provides a framework for organizing and tracking patient health milestones over time and can assist health systems in identifying areas of intervention to maximize the impact of evidence-based services. However, detailed protocols are needed to guide health systems in how to operationalize the OUD Cascade and track outcomes using electronic health records.Objective: In this paper, we describe the process of operationalizing and applying the OUD Cascade in a large, urban, public hospital system.Methods: Through this case example, we describe the technical processes around data mining, as well as the decision-making processes, challenges encountered, lessons learned from compiling preliminary patient data and defining stages and outcome measures for the OUD Cascade of Care, and preliminary dataResults: We identified 33,616 (26.17% female) individuals with an OUD diagnosis. Almost half (48%) engaged with addiction services, while only 10.7% initiated medication-based treatment in an outpatient setting, 6.7% had timely follow-up, and 3.5% were retained for a minimum of 6 months.Conclusion: The current paper serves as a primer for other health systems seeking to implement data-informed approaches to guide more efficient care and improved substance use-related outcomes. An OUD Cascade of Care must be tailored to local systems based on inherent data limitations and services design with an emphasis on early stages wherein drop-off is the greatest.

Targeting systems not individuals: Institutional and structural drivers of absenteeism among primary healthcare workers in Nigeria

Universal Health Coverage (UHC) can only be achieved if people receive good quality care from health workers, yet in Nigeria, as in many other low- and middle-income countries (LMICs), many health workers are absent from work. Absenteeism is a well-known phenomenon but is often considered as the self-serving behaviour of individuals, independent from the characteristics of health systems structures and processes and the broader contexts that enable it. We undertook a qualitative inquiry among 40 key informants, comprising health facility heads and workers, community leaders and state-level health policymakers in Nigeria. We employed a phenomenology approach to examine their lived experiences and grouped findings into thematic clusters. Absenteeism by health workers was found to be a response to structural problems at two levels -midstream (facility-level) and upstream (government level) - rather than being a result of moral failure of individuals. The problems at midstream level pointed to an inconsistent and unfair application of rules and regulations in facilities and ineffective management, while the upstream drivers relate mainly to political interference and suboptimal health system leadership. Reducing absenteeism requires two-pronged interventions that tackle defects in the upstream and midstream rather than just focusing on sanctioning deviant staff (downstream).

Global Health Impact: Human rights, access to medicines, and measurement

Should people have a legal human right to health? And, if so, what exactly does protecting this right require? This essay defends some answers to these questions recently articulated in Global Health Impact. It explains how these answers depend on a particular way of thinking about health and the minimally good life, how quality of life matters at and over time, what various agents should do to help people who are unable to live well enough, and many other things. Moreover, it suggests some ways of improving common metrics for measuring and advancing our collective global health impact.

Assessing public health sector performance in Bangladesh: Implications for health systems strengthening and universal health coverage - A secondary data analysis

The Ministry of Health and Family Welfare has established a health systems strengthening initiative for measuring the performance of public sector health facilities in Bangladesh. The objective of the performance management initiative is to establish routine systems for measuring and scoring health facility performance and promote best practices in public health service management. The performance initiative includes a set of assessments conducted across the four tiers of the public health sector. The findings of assessments demonstrate improvements in the quality of health services and a sharp increase in the utilisation of services across all tiers during the period 2017-2019. The performance management initiative has also identified areas for improvement in the supply-side health system readiness, including ensuring an adequate supply of human resources, essential medicines, and functioning medical equipment and technologies. This initiative outlines the need to systematically address the issue of high health workforce vacancy rates through effective human resource planning and management strategies. The reporting of these ongoing health systems successes and challenges through the performance management initiative in Bangladesh provides an opportunity to develop evidence-based policy reforms for strengthening supply-side health systems. The initiative results, particularly in the context of growing public demand for services, also justifies a monitoring and evaluation mechanism focusing on the quality and coverage of frontline health facilities and the development of more integrated health systems. The performance management initiative will facilitate the maintenance of essential health services while addressing emergency health needs and tracking progress towards achieving the Universal Health Coverage goal.

COVID-19 vaccine wastage in Africa: A case of Nigeria

The World Health Organization has launched campaigns to boost immunisation rates to 70 percent globally by the middle of 2022. However, despite the global success of about 64% COVID-19 vaccination coverage, there is a big gap in Nigeria. To date, only 13.8% of the population has received the recommended dose. This demonstrates a significant disparity between the vaccinated and the unvaccinated. Amidst the wide gap in vaccination, COVID-19 vaccine wastage still occurs in Nigeria. At the end of 2021, it was estimated that over a million doses of the COVID-19 vaccine had been wasted. It is anticipated that there will be more COVID-19 vaccine wastage in Nigeria, because of the combined factors that threaten vaccination uptake including vaccine accessibility, lack of appropriate storage facilities, poor electricity supply, insecurity challenges, and inadequate health promotion. This results in concomitant financial and opportunity losses. In this paper, we discuss COVID-19 vaccine wastage in Nigeria including causes, and solutions that can be applied to mitigate this wastage.

Challenges of Implementing Telemedicine Technology: A systematized Review

Background

Today, the technologies in the world are rapidly evolving, and global infrastructure of information is spreading rapidly. The health system of different countries is facing a variety of challenges in order to apply telemedicine services. The aim of this study was to determine the challenges facing the health system of different countries in the application of telemedicine.

Method

The present research was conducted in 2022 as a systematized review of studies related to challenges of telemedicine. In this study, Preferred Reporting Items for Systematic Reviews (PRISMA) and Critical Appraisal Skills Program (CASP) guidelines were used to assess the articles. The keywords "telemedicine," "telehealth," "E-health," and "tele care" were used in combination with the Boolean operators OR and AND. The ISI Web of Science, PubMed, Scopus, Science Direct, Ovid, Pro Quest, Wiley, and Google Scholar were searched.

Results

In this study, based on the search strategy, databases were searched from January 2012 to January 2022, and in the final stage, analysis was performed on 27 selected identified articles. The use of telemedicine technology faced major formality and legality, required bandwidth, development of multilingual systems, economic efficiency, available patterns, payment for services, moral barriers, social status, differences and national and legal contradictions in the world, lack of insurance coverage challenges, and so on. Recognizing gaps and challenges can provide a way to fill these gaps and create opportunities for improvement.

Conclusions

Utilizing telemedicine technology can be considered as an effective step in the health system. This technology has weaknesses that may challenge it. Successful application of telemedicine technology cannot be very effective without removing these barriers.

Politics, law and a lack of sperm: single women and fertility treatment in the Swedish health system

In 2016 Swedish law was amended to allow single women to access fertility treatment with donor sperm. In this paper, based on interviews, document analysis and autoethnographic insights, I examine the implementation of this law using human rights approaches, specifically the availability, accessibility, acceptability, and quality framework (AAAQ Framework). While the law extended the scope of reproductive rights, the health system was unprepared. Five years on, women seek care in the private sector or continue to travel abroad due in large part to waiting times which can be up to four years in some regions. The paper also provides a meeting point between anthropology and policy analysis. The law change provides a pathway for analyzing the Swedish health system and political context, particularly the relationships between the private and public sectors and between different regions, and the balance of responsibility between national and regional levels. While many of the challenges are unique to the Swedish context, they also offer lessons for countries which have or are considering expanding access to fertility treatment for single women and other patient groups, thus demonstrating the importance of ethnographic approaches in health policy analysis.

Rapid systematic review of interventions to improve antenatal screening rates for syphilis, hepatitis B, and HIV in low- and middle-income countries

BACKGROUND

Infectious diseases including syphilis, HIV, and hepatitis B are major contributors to maternal and neonatal morbidity and mortality worldwide, especially in low- and middle-income countries (LMICs). The World Health Organization has prioritized elimination of vertical transmission of these three diseases.

OBJECTIVES

To rapidly assess the impact of interventions designed to improve antenatal screening rates for syphilis, HIV, and hepatitis B in LMICs and to identify areas for future implementation research.

SEARCH STRATEGY

A comprehensive search was conducted across PubMed, Embase, and EconLit, targeting articles published between January 1, 2013, and June 27, 2023.

SELECTION CRITERIA

We included quantitative interventional studies in English, involving pregnant adults (15 years or older) from LMICs. Exclusions were studies based in high-income countries, qualitative studies, or those investigating accuracy of diagnostic methods.

DATA COLLECTION AND ANALYSIS

From an initial 5549 potential studies, 27 were finalized for review after various screening stages. Data extraction covered aspects such as study design, intervention details, and outcomes. Findings were qualitatively synthesized within a systems thinking framework.

MAIN RESULTS

The interventions assessed varied in terms of geographic locations, health care system levels, and modalities. The review highlighted the effectiveness of interventions such as community health interventions, service quality improvements, and financial incentives.

CONCLUSIONS

The study underscores the potential of specific interventions in enhancing antenatal screening rates in LMICs. However, there is a discernible research gap concerning hepatitis B. The findings emphasize the importance of capacity building and health systems strengthening in public health interventions.

A Low-Cost, Integrated Immunization, Health, and Nutrition Intervention in Conflict Settings in Pakistan-The Impact on Zero-Dose Children and Polio Coverage

Pakistan is one of two countries globally still endemic for poliovirus. While increasing immunization coverage is a concern, providing equitable access to care is also a priority, especially for conflict-affected populations. Recognizing these challenges, Naunehal, an integrated model of maternal, newborn, and child health (MNCH), immunization, and nutrition services delivered through community mobilization, mobile outreach, and private-sector engagement was implemented in conflict-affected union councils (UCs) with high poliovirus transmission, including Kharotabad 1(Quetta, Balochistan) and Bakhmal Ahmedzai (Lakki Marwat, Khyber Pakhtunkhwa). A quasi-experimental pre-post-design was used to assess the impact of the interventions implemented between April 2021 and April 2022, with a baseline and an endline survey. For each of the intervention UCs, a separate, matched-control UC was identified. At endline, the proportion of fully immunized children increased significantly from 27.5% to 51.0% in intervention UCs with a difference-in-difference (DiD) estimate of 13.6%. The proportion of zero-dose children and non-recipients of routine immunization (NR-RI) children decreased from 31.6% to 0.9% and from 31.9% to 3.4%, respectively, with a significant decrease in the latter group. Scaling up and assessing the adoption and feasibility of integrated interventions to improve immunization coverage can inform policymakers of the viability of such services in such contexts.

Key Learnings from the Development and Early Use of Global Guidance on the Integration of COVID-19 Vaccination into Broader Health Systems

More than 13.5 billion COVID-19 vaccine doses were delivered between 2021 and 2023 through a mix of delivery platforms, with mass vaccination campaigns being the main approach. In 2022, with the continued circulation of SARS-CoV2 and the need for periodic boosters being most likely, countries were required to plan for more sustainable approaches to provide COVID-19 vaccinations. In this context of uncertainty, a global tool for integrating COVID-19 vaccines into immunization programs and as part of broader health systems was published jointly by the WHO and UNICEF to respond to country needs. This paper summarizes the approach to, and lessons learned during, the development of a global guidance document and describes some examples of its early use in low- and middle-income countries (LMICs). The guidance leveraged existing health system frameworks, proposed four steps for planning and implementing the COVID-19 vaccination integration journey, and identified investment areas. The development process maximized robust global stakeholder and country engagement, and the timeframe was aligned with donor funding windows to support countries with the integration of COVID-19 vaccination. The rapid dissemination of the guidance document allowed countries to ascertain their readiness for integrating COVID-19 vaccination and inform the development of national plans and funding applications. While progress has been made in specific areas (e.g., optimizing cold chain and logistics leveraging COVID-19 vaccination), in the context of decreasing demand for COVID-19 vaccines, reaching adult COVID-19 vaccine high-priority-use groups and engaging and coordinating with other health programs (beyond immunization) remain challenges, particularly in LMICs. We share the learning that despite the uncertainties of a pandemic, guidance documents can be developed and used within a short timeframe. Working in partnership with stakeholders within and beyond immunization towards a common objective is powerful and can allow progress to be made in terms of integrating health services and better preparing for future pandemics.

Investigating socio-ecological factors influencing implementation of tuberculosis infection prevention and control in rural Papua New Guinea

BACKGROUND

Tuberculosis (TB) is a highly transmissible infectious disease killing millions of people yearly, particularly in low-income countries. TB is most likely to be transmitted in healthcare settings with poor infection control practices. Implementing TB infection prevention and control (TB-IPC) is pivotal to preventing TB transmission in healthcare settings. This study investigated diverse stakeholders' perspectives relating to barriers and strategies for TB-IPC in rural hospitals in Papua New Guinea.

METHODS

Multiple qualitative case studies were conducted with 32 key stakeholders with experience in TB services. Data collection drew on three primary sources to triangulate data: semi-structured interviews, document reviews and field notes. The data were analyzed using hybrid deductive-inductive thematic analysis.

RESULTS

Our results reveal that key stakeholders perceive multiple interdependent factors that affect TB-IPC practice. The key emerging themes include strategic planning for and prioritizing TB-IPC guidelines; governance, leadership and accountability at the provincial level; community attitudes towards TB control; institutional capacity to deliver TB care, healthcare workers' safety, and long-term partnership and integration of TB-IPC programmes into the broad IPC programme.

CONCLUSIONS

The evidence suggests that a multi-perspective approach is crucial for TB-IPC guidelines in healthcare institutions. Interventions focusing on addressing health systems strengthening may improve the implementation of TB-IPC guidelines.

Multi-professional perspectives to reduce moral distress: A qualitative investigation

BACKGROUND

Encounters of moral distress have long-term consequences on healthcare workers' physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited.

RESEARCH OBJECTIVE

The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center.

PARTICIPANTS & RESEARCH CONTEXT

Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim.

RESEARCH DESIGN

Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine's National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings.

ETHICAL CONSIDERATIONS

Ethics approval was obtained from the university and medical center institutional review boards.

FINDINGS

Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities.

CONCLUSION

Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.

Patterns of on-scene and healthcare system trauma deaths in the Western Cape of South Africa

BACKGROUND

Injuries account for 8% or 4.4 million deaths annually worldwide, with 90% of injury deaths occurring in low- and middle-income countries. Inter-personal violence and road traffic injuries account for most injury deaths in South Africa, with rates among the highest globally. Understanding the location, timing, and factors of trauma deaths can identify opportunities to strengthen care.

METHODS

This is a retrospective cross-sectional secondary analysis of trauma deaths from 2021 to 2022 in the Western Cape of South Africa. Healthcare system trauma deaths were identified from a multicenter study paired with a dataset for on-scene (i.e., prior to ambulance or hospital) trauma deaths in the same jurisdictions. We describe locations, timing, injury factors, and cause of death. We assess associations between those factors.

RESULTS

There were 2418 deaths, predominantly young men, with most (2274, 94.0%) occurring on-scene. The most frequent mechanism of injury for all deaths was firearms (32.6%), followed by road traffic collisions (17.8%). On-scene deaths (33.2%) were significantly more likely to be injured by firearms compared to healthcare system deaths (23.6%) (p-value <0.01). Most healthcare system deaths within 4-24 h of injury occurred in a hospital emergency center. Among healthcare system decedents, half died in the emergency unit.

CONCLUSIONS

We identified a large burden of deaths from interpersonal violence and road traffic collisions, mostly on-scene. In addition to primary prevention, shortening delays to care can improve mortality outcomes especially for deaths occurring within 4-24 h in emergency centers.

Outcomes measured in studies assessing health systems interventions for type 1 diabetes management: A scoping review

AIMS

Describe the outcomes reported in research on health systems interventions for type 1 diabetes management in comparison to the outcomes proposed by a core outcome set (COS) for this condition, an essential list of outcomes that studies should measure.

METHODS

Systematic search of studies published between 2010 and 2021 reporting health systems interventions directed to improve the management of type 1 diabetes using PubMed, EMBASE and CENTRAL. Information on the outcomes was extracted and classified according to a COS: self-management, level of clinical engagement, perceived control over diabetes, diabetes-related quality of life, diabetes burden, diabetes ketoacidosis, severe hypoglycemia, and glycated hemoglobin (HbA1C).

RESULTS

187 studies were included. Most of the studies included either children (n = 82/187) or adults (n = 82/187) living with type 1 diabetes. The most common outcome measured was HbA1C (n = 149/187), followed by self-management (n = 105/187). While the least measured ones were diabetes ketoacidosis (n = 15/187), and clinical engagement (n = 0/187). None of the studies measured all the outcomes recommended in the COS. Additionally, different tools were found to be used in measuring the same outcome.

CONCLUSIONS

This study provides a description of what researchers are measuring when assessing health systems interventions to improve type 1 diabetes management. In contrast to a COS, it was found that there is a predominance of clinical-based outcomes over patient-reported outcome measures.

"There are still broken or fragmented systems": Qualitative assessment of needs to strengthen adolescent mental health services in American Samoa

Mental health challenges appear common among adolescents in American Samoa. There is a community-identified need to better understand the health burden and identify opportunities to strengthen the mental health system to better meet adolescent mental health needs. The goal of this qualitative study was to gather community stakeholders' perceptions of common mental health problems among adolescents in American Samoa, identify existing services for adolescent mental health, and highlight strength-based opportunities to enhance care. Using the Fa'afaletui research framework, semi-structured in-depth interviews (n = 28) were conducted between October 2020 and February 2021 using Zoom. Key informants were adults living in American Samoa, sampled for diversity in profession, age, gender, education, and region of residence. Transcripts were coded in duplicate and analysed using deductive thematic analysis. Participants reported that suicide, depression, anxiety, and post-traumatic stress disorder are the conditions of highest burden. Participants identified an impressive amount of infrastructure and community mobilization, but also limitations in these services in addressing adolescents' health needs. Four themes arose related to the need to: (1) strengthen existing infrastructure; (2) reduce barriers to treatment access; (3) improve sustainability; and (4) encourage collaboration among leaders. Policymakers should prioritize the allocation of resources to strengthen infrastructure, public education, and stakeholder collaboration to improve adolescent mental health in American Samoa.

Value-Based Healthcare Delivery: A Scoping Review

Healthcare systems are transforming from the traditional volume-based model of healthcare to a value-based model of healthcare. Value generation in healthcare is about emphasising the health outcomes achieved by patients and organisations while maintaining an optimal relationship with costs. This scoping review aimed to identify the key elements and outcomes of implementing value-based healthcare (VBHC). The review process included studies published from 2013 to 2023 in four different databases (SpringerLink, PubMed, ProQuest and Scopus). Of the 2801 articles retrieved from the searches, 12 met the study's inclusion criteria. A total of 11 studies referred to value as the relationship between the outcomes achieved by patients and the costs of achieving those outcomes. Most of the studies highlighted the presence of leadership, the organisation of care into integrated care units, the identification and standardisation of outcome measures that generate value for the patient, and the inclusion of the patient perspective as the most prominent key elements for optimal VBHC implementation. Furthermore, some benefits were identified from VBHC implementation, which could shed light for future implementation actions. Therefore, the VBHC model is a promising approach that may contribute to an improvement in the efficiency and sustainability of healthcare.

Implementation of Artificial Intelligence Applications in Australian Healthcare Organisations: Environmental Scan Findings

Artificial Intelligence (AI) has great potential to improve healthcare, but implementation into routine practice remains a challenge. This study scoped the extent to which AI and Natural Language Processing (NLP) is being implemented into routine practice in Australian healthcare organisations. An environmental scan of publicly available data was undertaken to identify AI applications. Publicly available data consisted of news posts from Australian public healthcare organisations and conference proceedings from key research organisations. Two researchers reviewed and analysed posts related to AI applications to create a list of potential implementation case studies. The final list of AI applications was reviewed by a governance committee in order to identify any missing applications. One application was identified by the governance committee and subsequently added. The environmental scan identified eighteen AI applications, of which eleven met all eligibility criteria. Only one application included NLP. Twelve applications were included when the application identified by the governance committee was added to the list. Implementation of AI applications is spread across four broad categories of use: 1) Decision Support, 2) Monitoring Treatment Effectiveness, 3) Personalised Care and 4) Risk Prediction.

HIV programme sustainability in Southern and Eastern Africa and the changing role of external assistance for health

High human immunodeficiency virus (HIV)-prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability. Our respondents described HIV systems' vulnerability to donor departure, as well as how development partner priorities and practices have created challenges to promoting long-term HIV control. The challenges exacerbated by EA patterns include an emphasis on treatment over prevention, limiting effects on new infection rates; resistance to service integration driven in part by 'winners' under current EA patterns and challenges in ensuring coverage for marginalized populations; persistent structural barriers to effectively serving key populations and limited capacity among organizations best positioned to respond to community needs; and the need for advocacy given the erosion of political commitment by the long-term and substantive nature of HIV EA. Our recommendations include developing a robust investment case for primary prevention, providing operational support for integration processes, investing in local organizations and addressing issues of political will. While strategies must be locally crafted, our paper provides initial suggestions for how EA partners could change operational approaches to support long-term HIV control and the achievement of universal health coverage.

Sustaining essential health services in Lao PDR in the context of donor transition and COVID-19

Lao People's Democratic Republic (Lao PDR) aims at graduating from least developed country status by 2026 and must increase the level of domestic financing for health. This paper examines how the government has prepared for the decline of external assistance and how donors have applied their transition approaches. Adapting a World Health Organization (WHO) framework, reflections and lessons were generated based on literature review, informal and formal consultations and focus group discussions with the Lao PDR government and development partners including budget impact discussion. The government has taken three approaches to transition from external to domestic funding: mobilizing domestic resources, increasing efficiency across programs and prioritization with a focus on strengthening primary health care (PHC). The government has increased gradually domestic government health expenditures as a share of the government expenditure from 2.6% in 2013 to 4.9% in 2019. The Ministry of Health has made efforts to design and roll out integrated service delivery of maternal, newborn, child, and adolescent health services, immunization and nutrition; integrated 13 information systems of key health programs into one single District Health Information Software 2; and prioritized PHC, which has led to shifting donors towards supporting PHC. Donors have revisited their aid policies designed to improve sustainability and ownership of the government. However, the government faces challenges in improving cross-programmatic efficiency at the operational level and in further increasing the health budget due to the economic crisis aggravated during Coronavirus disease 2019 (COVID-19). Working to implement donor transition strategies under the current economic situation and country challenges, calls into question the criteria used to evaluate transition. This criterion needs to include more appropriate indicators other than gross national income per capita, which does not reflect a country's readiness and capacity of the health system. There should be a more country-tailored strategy and support for considering the context and system-wide readiness during donor transition.

The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015-21)

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.

Sri Lanka's COVID-19 response and maintaining health services: implications for future pandemics

This study examines how Sri Lanka, a lower-middle income country, managed its COVID-19 response and maintained health services. It draws on an extensive document review, key informant interviews and a national survey of public experience and opinion to assess what Sri Lanka did, its effectiveness and why.Owing to a strong health system and luck, Sri Lanka stopped the first wave of COVID-19 infections, and it adopted a 'Zero-COVID' approach with the explicit goal of stopping outbreaks. This was initially effective. Outbreaks reduced healthcare use, but with minimal impact on health outcomes. But from end-2020, Sri Lanka switched its approach to tolerating transmission and mitigation. It took proactive actions to maintain healthcare access, and it pursued a COVID-19 vaccination effort that was successful in covering its adult population rapidly and with minimal disparities. Despite this, widespread transmission during 2021-2022 disrupted health services through the pressure on health facilities of patients with COVID-19 and infection of healthcare workers, and because COVID-19 anxiety discouraged patients from seeking healthcare. This led to substantial mortality and more than 30 000 excess deaths by 2022.We find that Sri Lanka abandoned its initially successful approach, because it failed to understand that its chosen strategy required symptomatic PCR testing in primary care. Failure to invest in testing was compounded by groupthink and a medical culture averse to testing.Sri Lanka's experience confirms that strong public health capacities, robust healthcare systems and intersectoral action are critical for pandemic response. It shows that civilian-military collaboration can be beneficial but contested, and that lack of fiscal space will undermine any response. It also demonstrates that pandemic preparedness cannot guarantee a successful pandemic response. Policy and research must pay more attention to improving decision-making processes when faced with pandemics involving novel pathogens, rapid spread, and substantial scientific uncertainty.