SSM - Health Systems最新文献

Impact of the COVID-19 pandemic on the functioning of front-line health services in the Kati health district in Mali, West Africa: A qualitative study COVID-19大流行对西非马里卡蒂卫生区一线卫生服务运作的影响：一项定性研究

SSM - Health Systems

Pub Date : 2024-11-22 DOI: 10.1016/j.ssmhs.2024.100041

Mohamed Ali Ag Ahmed , Mahmoud Cissé , Hassane Alami , Bart Criel

Background

Front-line health services (FHSs) are the gateway to health systems. FHSs in Africa have been hit hard by the COVID-19 pandemic. In Mali, FHSs are provided by community health centres (Centres de Santé Communautaires (CSComs)). The objective of this study, which, to our knowledge, is the first of its kind in Mali, was to assess the impact of the COVID-19 pandemic on the functioning of CSComs within a health district.

Method

This qualitative case study was carried out in four CSComs in the Kati Health District in Mali. A three-dimensional analytical framework was designed and used. Data was collected from 24 key informants through semi-structured interviews. Thematic content analysis was performed, and Nvivo software was used.

Results

Data analysis showed that the COVID-19 pandemic impacted all dimensions of our analytical framework. Within the CSComs, the following were particularly impacted: 1) the management of activities with adaptations in the management of human and financial resources, infrastructure and equipment, the supply of inputs and medicines and the national health information system/surveillance; 2) the provision of curative, preventive and promotional health services; and 3) the interactions among stakeholders with little coordination of their actions.

Conclusion

This study offers insights into how to improve FHSs' resilience to crises. The results indicated dysfunction in routine health services, a decline in patients' use of them, and inadequate coordination among stakeholders. Despite their low level of preparedness, the CSComs were able to ensure continuity of care.

一线卫生服务是通往卫生系统的门户。非洲的fhs受到COVID-19大流行的严重打击。在马里，家庭保健服务由社区保健中心（centres de sant communautaire）提供。据我们所知，本研究是马里首个此类研究，其目的是评估COVID-19大流行对卫生区内社区服务委员会运作的影响。方法对马里卡蒂卫生区的4家社区医院进行定性个案研究。设计并使用了三维分析框架。通过半结构化访谈收集了24名关键线人的数据。采用Nvivo软件进行主题内容分析。结果数据分析显示，COVID-19大流行影响了我们分析框架的所有维度。在cscom内，下列方面受到特别影响：1)管理人力和财政资源、基础设施和设备、投入物和药品供应以及国家卫生信息系统/监测方面的活动；2)提供治疗、预防和促进保健服务；3)利益相关者之间的相互作用，他们的行动很少协调。结论本研究为提高金融服务机构的危机应变能力提供了新的思路。结果表明，常规卫生服务功能失调，患者使用这些服务的人数下降，利益相关者之间的协调不足。尽管ccoms的准备水平较低，但它们能够确保护理的连续性。

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引用次数: 0

Identifying the active ingredients in payment for performance programmes using system dynamics modelling 使用系统动力学模型确定绩效方案支付中的有效成分

SSM - Health Systems

Pub Date : 2024-11-08 DOI: 10.1016/j.ssmhs.2024.100040

Rachel Cassidy , Agnes Rwashana Semwanga , Peter Binyaruka , Karl Blanchet , Neha S. Singh , John Maiba , Josephine Borghi

Payment for performance (P4P) is not a uniform intervention, with programme effect dependent on several interconnected factors. In this study, a system dynamics model was developed to explore the pathways to improved outcomes and how changes in the design, implementation and context of a P4P programme affected maternal and child health (MCH) service delivery outcomes in Tanzania. A previously developed causal loop diagram of the programme effects was used to inform model development, with further data sources (including an impact evaluation of programme, health surveys, stakeholder feedback and relevant literature) used to build the model. A number of pathways were identified to improved services under P4P, with increased availability of drugs underpinning the content of care outcome (intermittent preventative treatment during ANC), which together with increased supervision, enhanced health worker motivation. This in turn increased perceived quality of care at the facility which improved the coverage of services outcome (facility-based deliveries), and with increased outreach, increased awareness of services also boosted demand. Minor delays in payment reduced provider purchasing power for medicines, with severe delays driving erosion of provider trust and motivation for programme participation. Allocating a larger share of funds for facility operations can enhance performance effects, particularly for those services that rely on efficient drug administration. Contextual factors including limited baseline provision of essential medications, lower community awareness of facility services and dispersed/distant populations reduced programme effect. This paper demonstrates the feasibility and the potential of such models to inform the design of effective health system interventions.

绩效付费（P4P）并不是一种统一的干预措施，其方案效果取决于几个相互关联的因素。在本研究中，开发了一个系统动力学模型，以探索改善结果的途径，以及P4P计划的设计、实施和背景的变化如何影响坦桑尼亚妇幼保健（MCH）服务提供结果。利用先前编制的方案效果因果循环图为模型开发提供信息，并利用其他数据来源（包括方案影响评价、健康调查、利益攸关方反馈和相关文献）建立模型。在P4P下，确定了一些改善服务的途径，增加了支持护理结果内容的药物供应（ANC期间的间歇性预防性治疗），加上加强了监督，增强了卫生工作者的积极性。这反过来又提高了人们对该设施护理质量的认识，从而提高了服务成果（以设施为基础的交付）的覆盖范围，而且随着外联范围的扩大，对服务认识的提高也促进了需求。支付方面的轻微延误降低了提供者对药品的购买力，严重延误则会侵蚀提供者的信任和参与规划的动机。为设施业务拨出更大份额的资金可以提高业绩效果，特别是对那些依赖有效药物管理的服务。环境因素包括基本药物的基线供应有限、社区对设施服务的认识较低以及分散/偏远人口降低了方案效果。本文论证了这些模型为设计有效的卫生系统干预措施提供信息的可行性和潜力。

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引用次数: 0

Assessing challenges and solutions in substance abuse prevention, harm reduction, and treatment services in New York State 评估纽约州在预防药物滥用、减少危害和治疗服务方面的挑战和解决方案

SSM - Health Systems

Pub Date : 2024-10-25 DOI: 10.1016/j.ssmhs.2024.100039

Daniel J. Kruger , Hilary M. Kirk , Kenneth E. Leonard , Joshua J. Lynch , Nancy Nielsen , Brian M. Clemency

Drug overdose is a leading cause of death in New York State, with opioid-related deaths increasing by more than 300 % from 2010 to 2020. Survey respondents (N = 392) for organizations providing a wide range of substance misuse related services rated the importance of barriers to accessing services, the helpfulness of strategies in addressing challenges, and priorities for further scientific study. Difficulties in obtaining funding were rated the highest barrier to accessing substance use services, insufficient skills in the workforce were rated as the second most important barrier, and stigma towards addiction was rated third. An analysis of wages and scale-up strategies to provide competitive workforce opportunities was rated as the most helpful strategy in addressing workforce challenges. The most helpful strategy in addressing stigma was to work in partnership with other organizations to enhance the continuum of substance misuse related services. Most of the strategies that were surveyed were rated as very helpful overall, which may not be surprising given that they were nominated by experts as very important. Customized prevention, treatment, harm reduction, and recovery services based on individual characteristics and integrating medications for opioid use disorder into other medical settings were rated as the most important strategies in prioritizing further scientific study. The pattern of ratings showed only a few differences based on organizational role and geographic region, for example respondents in New York City considered increasing the availability of telemedicine as a higher priority.

吸毒过量是纽约州的主要死因，2010 年至 2020 年，与阿片类药物相关的死亡人数增加了 300%。提供各种药物滥用相关服务的组织的调查对象（N = 392）对获得服务的障碍的重要性、应对挑战的策略的有用性以及进一步科学研究的优先事项进行了评级。难以获得资金被评为获得药物滥用服务的最大障碍，劳动力技能不足被评为第二大障碍，对成瘾的污名化被评为第三大障碍。对工资和扩大战略进行分析，以提供有竞争力的劳动力机会，被评为应对劳动力挑战最有帮助的战略。在解决污名化问题方面，最有帮助的战略是与其他组织合作，加强药物滥用相关服务的连续性。接受调查的大多数战略都被评为非常有用，这并不奇怪，因为这些战略都被专家提名为非常重要。根据个人特点定制预防、治疗、减少伤害和康复服务，以及将治疗阿片类药物使用障碍的药物纳入其他医疗环境，被评为优先开展进一步科学研究的最重要战略。评级模式仅显示出基于组织角色和地理区域的一些差异，例如，纽约市的受访者认为增加远程医疗的可用性是更高的优先事项。

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引用次数: 0

Evaluating access during change: A qualitative exploration of access impacts to Canadian primary care rehabilitation providers during the COVID-19 pandemic 评估变革期间的就医情况：定性探索 COVID-19 大流行期间对加拿大初级保健康复提供者的影响

SSM - Health Systems

Pub Date : 2024-10-16 DOI: 10.1016/j.ssmhs.2024.100038

Tory Crawford, Louise Chartrand, Cara Brown, Brontë Vollebregt, Patricia Thille

Introduction

The COVID-19 pandemic required substantial changes in delivery of team-based primary care, impacting both how and which patients accessed the more comprehensive services teams provide. We sought to explore changes in access to primary care rehabilitation services during the first year of the COVID-19 pandemic to identify potential new problems and improvements.

Methods

In this longitudinal study, sixteen rehabilitation professionals working on primary care teams in Manitoba and Ontario recorded audio-diaries and later participated in interviews throughout the first year of the pandemic. Qualitative analysis included data immersion, coding to identify the practice changes and associated access impacts, then applying Levesque and colleagues’ Patient-Centred Access to Healthcare framework to interpret findings.

Findings

Participants described service changes that both enhanced and reduced access, including redeployment, outreach, virtual care, discontinuation of some services and start of new ones, and new risk management strategies. Some implied equity-specific impacts. Virtual care and outreach activities created access for patient populations who previously may have been underserved, while virtual care, redeployment, and new risk management activities created new access barriers and inequities, leaving some patients completely unable to reach care. Changes to team collaboration activities could help or hinder access.

Conclusion

Continuing outreach activities, strengthening team collaboration, and thoughtfully integrating virtual care can improve access to comprehensive primary care. As the primary care sector works to recover from pandemic impacts and address population health needs, applying a patient-centred access framework during practice redesign offers a meaningful way to strengthen services.

导言：COVID-19 大流行要求以团队为基础的初级医疗服务的提供方式发生重大变化，这对患者如何以及哪些患者获得团队提供的更全面的服务产生了影响。在这项纵向研究中，16 名在马尼托巴省和安大略省基层医疗团队工作的康复专业人员录制了录音日记，随后在大流行的第一年参与了访谈。定性分析包括数据沉浸、编码以识别实践变化和相关的获取影响，然后应用 Levesque 及其同事的 "以患者为中心的医疗保健获取 "框架来解释研究结果。研究结果参与者描述了增强和减少获取的服务变化，包括重新部署、外联、虚拟护理、停止某些服务和开始新的服务，以及新的风险管理战略。其中一些暗示了对公平的具体影响。虚拟医疗和外联活动为以前可能得不到充分服务的患者群体创造了就医机会，而虚拟医疗、重新部署和新的风险管理活动则造成了新的就医障碍和不公平，使一些患者完全无法获得医疗服务。结论：继续开展外展活动、加强团队合作、深思熟虑地整合虚拟医疗，可以改善综合初级医疗服务的可及性。在初级医疗部门努力从大流行病的影响中恢复并满足人口健康需求的过程中，在重新设计实践过程中应用以患者为中心的就医框架为加强服务提供了一种有意义的方法。

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引用次数: 0

Ongoing impacts of the COVID-19 pandemic on access to primary care among im/migrant communities in British Columbia, Canada COVID-19 大流行对加拿大不列颠哥伦比亚省移民社区获得初级保健的持续影响

SSM - Health Systems

Pub Date : 2024-10-05 DOI: 10.1016/j.ssmhs.2024.100037

Elmira Tayyar , Yasmin Bozorgi , Cecilia Sierra-Heredia , Hanah Damot , Ruth Carrillo , Stefanie Machado , Mei-ling Wiedmeyer , Shira Goldenberg , Ruth Lavergne

Background

The COVID-19 pandemic changed healthcare delivery in multiple ways, including a widespread shift to virtual care. Evidence of how these changes were experienced is mixed and varies among populations and Canadian provinces. We sought to generate new information about how these changes were experienced by im/migrants in British Columbia (BC), assessing their impact on access to virtual and in-person primary care.

Methods

We conducted in-depth, semi-structured interviews in Dari, English, Farsi, Spanish, and Tigrinya with im/migrants living in BC for less than 10 years. We analyzed 50 interviews using a team-based approach to reflexive thematic analysis to explore how changes in service delivery in the context of the COVID-19 pandemic impacted im/migrant's healthcare experiences and access in BC.

Results

Interview participants described impacts of changes in service delivery in terms of accessibility, human connections, quality of care, and safety. Impacts were experienced positively as opportunities or negatively as obstacles. Experiences were shaped by immigration status, English language fluency, having a regular source of primary care before the pandemic, and economic resources. An overarching theme was trust, with healthcare experiences during the pandemic either increasing or decreasing participants’ trust in the healthcare system.

Conclusions

Our findings reveal that within im/migrant communities, the same changes in health service delivery were experienced differently, depending on various determining factors. Whether people experienced opportunities or obstacles, and increased or decreased trust, was shaped by modifiable policies that predate the pandemic and will persist beyond the pandemic unless significant and intentional, evidence-based changes are implemented.

背景COVID-19 大流行从多方面改变了医疗服务，包括广泛转向虚拟医疗。关于这些变化是如何经历的证据不一，而且因人群和加拿大省份而异。我们试图获得有关不列颠哥伦比亚省（BC 省）的移民如何经历这些变化的新信息，评估这些变化对获得虚拟和面对面初级医疗服务的影响。我们以团队为基础，采用反思性主题分析方法对 50 个访谈进行了分析，以探讨在 COVID-19 大流行的背景下，服务提供的变化如何影响移民在不列颠哥伦比亚省的医疗保健体验和获取。对这些影响的正面体验是机遇，负面体验是障碍。移民身份、英语流利程度、在大流行之前是否有固定的初级保健来源以及经济资源都影响了他们的体验。一个最重要的主题是信任，大流行期间的医疗保健经历增加或减少了参与者对医疗保健系统的信任。结论我们的研究结果表明，在移民社区内，医疗服务提供方面的相同变化因各种决定因素的不同而有不同的体验。人们是经历了机遇还是障碍，是增加了信任还是减少了信任，这些都是由大流行之前可修改的政策决定的，除非实施重大的、有意的、以证据为基础的改革，否则这些政策将在大流行之后继续存在。

{"title":"Ongoing impacts of the COVID-19 pandemic on access to primary care among im/migrant communities in British Columbia, Canada","authors":"Elmira Tayyar , Yasmin Bozorgi , Cecilia Sierra-Heredia , Hanah Damot , Ruth Carrillo , Stefanie Machado , Mei-ling Wiedmeyer , Shira Goldenberg , Ruth Lavergne","doi":"10.1016/j.ssmhs.2024.100037","DOIUrl":"10.1016/j.ssmhs.2024.100037","url":null,"abstract":"<div><h3>Background</h3><div>The COVID-19 pandemic changed healthcare delivery in multiple ways, including a widespread shift to virtual care. Evidence of how these changes were experienced is mixed and varies among populations and Canadian provinces. We sought to generate new information about how these changes were experienced by im/migrants in British Columbia (BC), assessing their impact on access to virtual and in-person primary care.</div></div><div><h3>Methods</h3><div>We conducted in-depth, semi-structured interviews in Dari, English, Farsi, Spanish, and Tigrinya with im/migrants living in BC for less than 10 years. We analyzed 50 interviews using a team-based approach to reflexive thematic analysis to explore how changes in service delivery in the context of the COVID-19 pandemic impacted im/migrant's healthcare experiences and access in BC.</div></div><div><h3>Results</h3><div>Interview participants described impacts of changes in service delivery in terms of accessibility, human connections, quality of care, and safety. Impacts were experienced positively as opportunities or negatively as obstacles. Experiences were shaped by immigration status, English language fluency, having a regular source of primary care before the pandemic, and economic resources. An overarching theme was trust, with healthcare experiences during the pandemic either increasing or decreasing participants’ trust in the healthcare system.</div></div><div><h3>Conclusions</h3><div>Our findings reveal that within im/migrant communities, the same changes in health service delivery were experienced differently, depending on various determining factors. Whether people experienced opportunities or obstacles, and increased or decreased trust, was shaped by modifiable policies that predate the pandemic and will persist beyond the pandemic unless significant and intentional, evidence-based changes are implemented.</div></div>","PeriodicalId":101183,"journal":{"name":"SSM - Health Systems","volume":"3 ","pages":"Article 100037"},"PeriodicalIF":0.0,"publicationDate":"2024-10-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142425555","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

The COVID-19 pandemic: A focusing event to promote domestic investment for health systems strengthening in the WHO African Region COVID-19 大流行：促进国内投资以加强世卫组织非洲地区卫生系统的重点活动

SSM - Health Systems

Pub Date : 2024-10-05 DOI: 10.1016/j.ssmhs.2024.100034

Alison T. Mhazo , Arush Lal , Elias Mossialos

Background

The COVID-19 pandemic has been framed as a catalytic occurrence that exposed the chronic underinvestment in health systems strengthening (HSS) in the WHO African Region as well as its potential to galvanize much-needed political attention towards the issue. This expectation aligns with the portrayal of COVID-19 as a ‘focusing event’ for HSS. This study analyzes whether COVID-19 met the criteria of a focusing event for HSS as set forth by John Kingdon, and then, if as a focusing event, it generated political attention towards policy making and implementation for HSS and whether there could be prospects for sustaining such momentum in the post COVID-19 era.

Methods

We carried out a scoping review of available literature using the O’Malley and Arksey method (2005).

Results

The COVID-19 pandemic presented an unprecedented crisis that drew attention to the problem of weak health systems in the WHO African region, a problem that had long been acknowledged but largely ignored. This study has also shown that COVID-19 had a profound personal experience on policy makers since it severely limited their opportunity to seek medical care abroad and forced them to personally witness the weak state of domestic health systems. These attributes suit the criteria of COVID-19 as a focusing event according to Kingdon, which helped to stimulate governmental action on HSS.

Conclusion

The COVID-19 pandemic can indeed be leveraged as a salient focusing event to generate political attention for HSS in the WHO African Region. However, such attention cannot be guaranteed in the long-term, due to the differential dynamics between policy making and implementation in crises and non-crisis situations. By casting light on a plausible but rarely examined mechanism for driving policy change –the personal experience of policy makers, we conclude that lack of financial resources does not sufficiently explain the lack of domestic investments for HSS. This calls for attention towards other reasons of inaction towards HSS, including the insulation of the elite from facing the weak health systems.

背景 COVID-19 大流行被认为是一种催化剂，它暴露了世卫组织非洲地区在加强卫生系统（HSS）方面长期投资不足的问题，并有可能激发对这一问题亟需的政治关注。这一预期与 COVID-19 被描述为卫生系统强化的 "焦点事件 "相吻合。本研究分析了 COVID-19 是否符合 John Kingdon 提出的人文社科焦点事件的标准，以及作为焦点事件，COVID-19 是否引发了对人文社科政策制定和实施的政治关注，以及在 COVID-19 之后是否有可能保持这种势头。方法我们采用 O'Malley 和 Arksey 方法（2005 年）对现有文献进行了范围审查。结果COVID-19 大流行带来了一场前所未有的危机，引起了人们对世界卫生组织非洲地区卫生系统薄弱问题的关注，这一问题长期以来一直被人们所承认，但在很大程度上却被忽视。本研究还表明，COVID-19 给决策者带来了深刻的个人体验，因为它严重限制了他们出国就医的机会，迫使他们亲眼目睹了国内卫生系统的薄弱状况。根据 Kingdon 的观点，这些特征符合 COVID-19 作为焦点事件的标准，它有助于激发政府在人文社科领域采取行动。然而，由于危机和非危机情况下政策制定和实施的动态不同，这种关注不能得到长期保证。通过揭示一个看似合理但却很少被研究的推动政策变化的机制--政策制定者的个人经历，我们得出结论，缺乏财政资源并不能充分解释国内缺乏对人文社科投资的原因。这就需要关注对卫生和社会服务不作为的其他原因，包括精英阶层不愿面对薄弱的卫生系统。

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引用次数: 0

Supply-side factors influencing national health insurance uptake, access and use of primary health care: Evidence from the Upper West Region, Ghana 影响国家医疗保险覆盖率、初级卫生保健的获取和使用的供应方因素：加纳上西部地区的证据

SSM - Health Systems

Pub Date : 2024-09-29 DOI: 10.1016/j.ssmhs.2024.100036

Justine Guguneni Tuolong , Kennedy A. Alatinga , Elijah Yendaw

Supply-side factors, such as the availability of health facilities, equipment, practitioners, and drugs, are crucial for improving global healthcare systems. However, systematic evidence of how these factors affect health insurance clients’ access to primary healthcare (PHC) services in Ghana is lacking. This study addresses this gap by examining the impact of these factors on insured individuals' access to PHC services in Wa Municipality. An explanatory sequential mixed-methods design was employed, involving a quantitative survey of 413 insured individuals randomly selected from 40 communities and 47 healthcare facilities. Purposive sampling was used for qualitative interviews with 17 healthcare providers and 20 key insured informants. Quantitative data were analysed using descriptive statistics, correlation, independent t-tests, and binary logistic regression, while qualitative data were thematically analysed to provide insight into the quantitative findings. Result from quantitative data showed that Community-Based Health Planning and Services (CHPS) were more accessible than hospitals, diagnostic centres, and health centres. Proximity to health facilities influenced access to PHC services and National Health Insurance Scheme (NHIS) uptake. Perceived availability and functionality of healthcare equipment also affected NHIS uptake. Qualitatively, health facilities reported a shortage of human resources, such as midwives and nurses, for PHC service delivery. Triangulating quantitative and qualitative results show that healthcare supplies and skilled professionals are essential for NHIS uptake and access to PHC services. This study recommends that Government of Ghana prioritise expanding healthcare facilities, recruiting and retaining skilled practitioners, procuring medical equipment, and equitably distributing essential medications to improve access to essential healthcare services in underserved areas.

供应方因素，如医疗设施、设备、从业人员和药品的可用性，对于改善全球医疗保健系统至关重要。然而，关于这些因素如何影响加纳医疗保险客户获得初级医疗保健（PHC）服务的系统性证据却很缺乏。本研究通过考察这些因素对瓦市投保人获得初级医疗保健服务的影响，填补了这一空白。本研究采用了解释性顺序混合方法设计，对从 40 个社区和 47 家医疗机构随机抽取的 413 名投保人进行了定量调查。对 17 名医疗服务提供者和 20 名主要投保信息提供者进行了定性访谈。定量数据采用描述性统计、相关性、独立 t 检验和二元逻辑回归等方法进行分析，定性数据则采用主题分析方法，以深入了解定量研究结果。定量数据结果显示，与医院、诊断中心和保健中心相比，社区保健规划和服务（CHPS）更容易获得。与医疗设施的距离影响了初级保健服务的获得和国家医疗保险计划（NHIS）的参加。医疗保健设备的可用性和功能性也影响着国民健康保险计划（NHIS）的采用率。从定性角度看，医疗机构报告称，助产士和护士等提供初级保健服务的人力资源短缺。对定量和定性结果进行三角分析的结果表明，医疗用品和熟练的专业人员对 NHIS 的吸收和 PHC 服务的获取至关重要。本研究建议加纳政府优先扩建医疗保健设施、招聘和留住熟练从业人员、采购医疗设备并公平分配基本药物，以改善服务不足地区获得基本医疗保健服务的机会。

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引用次数: 0

The impact of Ghana’s national health insurance exemption policies on healthcare-seeking behaviour 加纳国家医疗保险豁免政策对就医行为的影响

SSM - Health Systems

Pub Date : 2024-09-26 DOI: 10.1016/j.ssmhs.2024.100035

Yaw Boateng Atakorah , Eric Arthur , Anthony Kofi Osei-Fosu , Jacob Novignon

Countries all over the world are seeking to enhance the general well-being of their populations by instituting a prepayment health system in which people can access healthcare at any time without financial risks. In Ghana, the National Health Insurance Scheme (NHIS) seeks to achieve this objective while leaving no one behind. To accelerate the country’s UHC agenda, the scheme was designed to also provide premium exemptions to the poor and vulnerable. While the exemption policy removes financial barriers to both subscription and healthcare, its impact on health-seeking is unknown. This study, therefore, sought to evaluate the impact of the premium exemption policies on healthcare-seeking behaviours. Data from the most recent round of the Ghana Living Standards Survey (GLSS 7) was used. A total sample of 8297 individuals were included in the analysis comprising 5686 rural and 2611 urban dwellers. We used the Lewbel instrumental variable technique to correct potential endogeneity problems. We found that NHIS exemption policies improved both general and formal healthcare-seeking. For general healthcare-seeking, the impact was driven by individuals exempted through under 18 and aged category. However, focusing on formal care, both exemption through under 18 or aged category as well as through indigents or Free Maternal Services category both improved healthcare-seeking. The magnitude of the impact was also greater for categories that were fully exempted and did not require any form of payment to subscribe. The findings call for a policy review to differentially target individuals living in areas with different economic and health system realities.

世界各国都在寻求通过建立预付费医疗系统来提高人民的总体福祉，在这种系统中，人们可以随时获得医疗保健服务，而无需承担经济风险。在加纳，国家医疗保险计划（NHIS）力求实现这一目标，同时不让任何人掉队。为了加快加纳的全民医保议程，该计划还为穷人和弱势群体提供保费豁免。虽然免缴保费政策消除了参保和就医的经济障碍，但其对就医的影响尚不得而知。因此，本研究试图评估保费豁免政策对就医行为的影响。研究采用了最近一轮加纳生活水平调查（GLSS 7）的数据。参与分析的样本共有 8297 人，其中农村居民 5686 人，城市居民 2611 人。我们使用 Lewbel 工具变量技术来纠正潜在的内生性问题。我们发现，NHIS 豁免政策提高了一般和正规医疗保健的寻求率。对于一般医疗服务而言，影响主要来自于 18 岁以下和高龄人群。然而，就正规医疗而言，通过 18 岁以下或老年人类别以及贫困人口或免费孕产妇服务类别获得的豁免都改善了就医情况。对于完全豁免且不需要支付任何形式费用的类别，其影响程度也更大。研究结果要求对政策进行审查，以便针对生活在不同经济和卫生系统现实地区的个人进行区别对待。

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引用次数: 0

Adjusting for quality of care in primary health care utilization and benefits in Bihar, India: A benefit incidence analysis 调整印度比哈尔邦初级保健利用率和收益中的保健质量：受益发生率分析

SSM - Health Systems

Pub Date : 2024-09-25 DOI: 10.1016/j.ssmhs.2024.100033

Akriti Mehta , Bryan N. Patenaude, Krishna D. Rao

India’s public health policies prioritize the least wealthy and vulnerable. Additionally, for Primary Health Care (PHC) to achieve equitable health outcomes, all must receive high-quality care. This study determined equality of utilization and benefit incidence of PHC services across socioeconomic (SE) groups in Bihar, with and without adjusting for quality of care. It used secondary data from linked PHC facility and household surveys in Bihar that included information on PHC facility utilization, quality of care and household expenditure patterns. Lorenz curves and concentration indices were constructed to examine relative distribution of utilization and benefits from public sector PHC services by SE status, before and after adjusting for quality of care using quality weights. We found that relative distribution of public sector PHC utilization, total and net benefits was statistically no different from perfect equality. With quality weights, utilization and benefits of PHC facilities in Bihar were slightly more pro-rich but statistically no different from perfect equality. The wealthiest do not disproportionately benefit from public sector PHC facilities, but neither do the least wealthy. In conclusion, relative utilization and benefits of public sector PHC facilities were equally distributed across socioeconomic groups in Bihar. Benefits from public sector PHC facilities are not disproportionately concentrated among the least wealthy in the community. As the Ayushman-Bharat Health and Wellness Centers are strengthened to improve public sector PHC services, it would be important to target its benefits towards the least wealthy by ensuring services are accessible and amenable.

印度的公共卫生政策优先考虑最不富裕的弱势群体。此外，要使初级卫生保健（PHC）取得公平的卫生成果，所有人都必须获得高质量的医疗服务。本研究确定了比哈尔邦不同社会经济（SE）群体在使用初级保健服务和受益发生率方面的平等性，并对保健质量进行了调整和未进行调整。研究使用了比哈尔邦相关初级保健设施和家庭调查的二手数据，其中包括初级保健设施利用率、保健质量和家庭支出模式等信息。在使用质量权重对医疗质量进行调整之前和之后，我们构建了洛伦兹曲线和集中指数，以研究公共部门初级保健服务利用率和收益在社会经济地位方面的相对分布情况。我们发现，公共部门初级保健服务的利用率、总收益和净收益的相对分布在统计上与完全平等没有区别。使用质量权重后，比哈尔邦初级保健设施的利用率和收益略微偏向富人，但在统计上与完全平等无异。最富有的人并没有从公共部门的初级保健设施中过多受益，但最不富有的人也没有。总之，比哈尔邦各社会经济群体对公共部门初级保健设施的相对利用率和受益程度相当。公共部门初级保健设施的惠益并没有不成比例地集中于社区中最不富裕的人群。随着 Ayushman-Bharat 保健和健康中心得到加强，公共部门初级保健服务也将得到改善，重要的是通过确保服务的可及性和便利性，使其惠及最不富裕人群。

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引用次数: 0

“We do these audits, but in the end, it’s useless.” How can facility-based maternal death reviews improve the quality of care in Benin? "我们做了这些审核，但最终都是无用功"。以医疗机构为基础的孕产妇死亡评审如何提高贝宁的医疗质量？

SSM - Health Systems

Pub Date : 2024-09-24 DOI: 10.1016/j.ssmhs.2024.100032

Christelle Boyi Hounsou , Jean-Paul Dossou , Thérèse Delvaux , Lenka Benova , Edgard-Marius Ouendo , Sorel Lokossou , Marjolein Zweekhorst , Bruno Marchal

Benin scaled up facility-based Maternal Death Reviewss (MDRs) in 2013 to address its high maternal mortality rate. This study aims to assess the extent to which facilitybased MDR captured the complex causes of maternal deaths in 2022. In this mixedmethod study, we first conducted a quantitative analysis of dysfunctions, root causes,and recommendations extracted from all facility-based MDR reports that occurred in Benin's health facilities in 2022. We calculated frequency distributions based on the systemic maternal care quality assessment framework's components and the iceberg model for system thinking's layers. Second, we conducted in-depth and informal interviews and (non)participant observations and reviewed facility-based MDR policyrelated documents. Content analysis was applied to qualitative data. facility-based MDR teams identified 1295 dysfunctions, 1216 root causes, and 1082 recommendations in facility-based MDR reports of 540 maternal deaths. One-fifth of reports were uninformative, lacking dysfunctions, root causes, or recommendations.Within the health system components, leadership and governance received the least attention regarding dysfunctions (1 %) and root causes (12 %).Most dysfunctions (87 %) and root causes (73 %) focused on the iceberg's tip, leading to reactive recommendations rather than addressing deeper systemic issues. Two main factors emerged: non-compliance with facility-based MDR requirements (time constraints, unreliable data, fear of strained provider relationships) and limitations in facility-based MDR processes (data collection and analysis tool constraints),

贝宁于2013年扩大了基于设施的孕产妇死亡审查（MDRs），以解决孕产妇死亡率高的问题。本研究旨在评估以医疗机构为基础的孕产妇死亡评审在多大程度上反映了 2022 年孕产妇死亡的复杂原因。在这项混合方法研究中，我们首先对 2022 年发生在贝宁医疗机构的所有基于医疗机构的 MDR 报告中提取的功能障碍、根本原因和建议进行了定量分析。我们根据系统性孕产妇护理质量评估框架的组成部分和系统思维冰山模型的层级计算了频率分布。其次，我们进行了深入的非正式访谈和（非）参与者观察，并查阅了基于医疗机构的 MDR 政策相关文件。我们对定性数据进行了内容分析。在针对 540 例孕产妇死亡的医疗机构孕产妇死亡报告中，医疗机构孕产妇死亡报告团队发现了 1295 项功能障碍、1216 项根本原因和 1082 项建议。大多数功能障碍（87%）和根本原因（73%）都集中在冰山一角，导致了被动的建议，而不是解决更深层次的系统性问题。出现了两个主要因素：不遵守基于设施的 MDR 要求（时间限制、数据不可靠、担心提供者关系紧张）和基于设施的 MDR 流程的限制（数据收集和分析工具限制）、

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引用次数: 0