Health policy and planning最新文献

This article explores the ideologies, interests, and institutions affecting health policymaking in Nigeria, and the role of the private sector therein. It covers the period from the late-1950s, the years leading up to independence, to 2014, when the country enacted its first-ever law to govern its healthcare system. The National Health Act (NHAct) was adopted after a decade of preparation and civil society-driven advocacy, making the objective of Universal Health Coverage (UHC) explicit. However, in its final version, the NHAct earmarked only a small share of public funds for UHC, solidifying the country's reliance on private healthcare and out-of-pocket payments. To examine the specific set of ideologies, interests, and institutions defining Nigeria's pathway toward UHC and the contribution of the private sector, we adopted Rizvi and colleagues' political economy framework, situating the genesis of the 2014 NHAct within the broader political and economic context of Nigeria's health system reform process since the 1950s. Drawing on qualitative data collected during interviews and focus groups, we found that the deep entrenchment of private-sector healthcare in Nigeria is the result of a path-dependent process. This implies that Nigeria's current reliance on the private sector is influenced by historical patterns, competing interests, and institutional practices that have reinforced the role of private actors over time. We identified three major explanatory factors that have shaped health policymaking in Nigeria. First, since the 1980s, the ideology that private healthcare is the solution to an underfunded and underperforming public healthcare system has been reinforced by leading international organisations. Second, private actors in Nigeria have been in a strong position to influence health policymaking since independence. Third, Nigeria's challenging socioeconomic context and the limitations of its federal governance structure have fostered a general level of public distrust in the capacity of the public sector to provide quality healthcare.

Substandard and falsified (SF) medical products are a serious health and economic concern that disproportionately impact low- and middle-income countries and marginalized groups. Public education campaigns are demand-side interventions that may reduce risk of SF exposure, but the effectiveness of such campaigns, and their likelihood of benefitting everybody, is unclear. Nationwide pilot risk communication campaigns, involving multiple media, were deployed in Ghana, Nigeria, Sierra Leone, Uganda in 2020-2021. Focus group discussions (n=73 FGDs with n=611 total participants) and key informant interviews (n=80 individual interviews and n=4 group interviews with n=111 total informants) were conducted within each of the four countries to ascertain the reach and effectiveness of the campaign. Small proportions of focus group discussants (8.0%-13.9%) and key informants (12.5%-31.4%) had previously encountered the campaign materials. Understandability was varied: the use of English and select local languages, combined with high rates of illiteracy, meant that some were not able to understand the campaign. The capacity for people to act on the messages was extremely limited: inaccessibility, unavailability, and unaffordability of quality-assured medicines from official sources, as well as illiteracy, constrained what people could realistically do in response to the campaign. Importantly, reach, understandability, and capacity to respond were especially limited amongst marginalized groups, who are already at greatest risk of exposure to SF products. These findings suggest that there may be potential for public education campaigns to help combat the issue of SF medicines through prevention, but that the impact of public education is likely to be limited and may even inadvertently widen health inequities. This indicates that public education campaigns are not a single solution; they can only be properly effective if accompanied by health system strengthening and supply-side interventions that aim to increase the effectiveness of regulation.

Understanding health systems as comprising interacting elements of hardware and software acknowledges health systems as complex adaptive systems (CAS). Hardware represents the concrete components of systems, whereas software represents the elements which influence actions and underpin relationships, such as processes, values and norms As a specific call for research on health system software was made in 2011, we conducted a qualitative scoping review considering how and for what purpose the concept has been used since then. Our overall purpose was to synthesise current knowledge and generate lessons about how to deepen research on, and understanding of, health system software. The review consisted of two phases: first, for the period 2011-2023, all papers which explicitly used the concept of health system software were identified and mapped; second, drawing on a sub-set of papers from phase 1, we explored how the concept was purposively used within research. The databases Pubmed, Scopus, EBSCOhost, Web of Science and Google Scholar were systematically searched using a strategy developed by a skilled librarian. In Phase 1, data were extracted from 98 papers. Our analysis revealed that a third of the papers used the software concept rather superficially; a third used it to conceptualise the importance of selected software elements; and a third used it in examining a specific health system experience, such as preparedness or resilience. In Phase 2, our analysis confirmed that researchers have found value in pro-actively using the software concept within studies, demonstrating two patterns of use. However, limited understanding of how to investigate interactions amongst hard- and software elements was also revealed. Future health policy and systems research should purposively investigate hardware-software interactions, in order to gain greater understanding of the complex, adaptive nature of health systems, understand their operations, and to institutionalise thinking that considers health systems as CASs.

Case management of malaria in Africa has evolved markedly over the past 20 years and updated cost estimates are needed to guide malaria control policies. We estimated the cost of malaria illness to households and the public health service and assessed the equity of these costs in Uganda. From December 2021 to May 2022, we conducted a costing exercise in eight government-run health centres covering seven sub-regions, collecting health service costs from patient observations, records review and a time-and-motion study. From November 2021 to January 2022, we gathered data on households' cost of illness from randomly selected households for 614 residents with suspected malaria. Societal costs of illness were estimated and combined with secondary data sources to estimate the total economic burden of malaria in Uganda. We used regression analyses and concentration curves to assess the equity of household costs across age, geographic location and socio-economic status. The mean societal economic cost of treating suspected malaria was $15.12 [95% confidence interval (CI): 12.83-17.14] per outpatient and $27.21 (95% CI: 20.43-33.99) per inpatient case. Households incurred 81% of outpatient and 72% of inpatient costs. Households bore nearly equal costs of illness, regardless of socio-economic status. A case of malaria cost households in the lowest quintile 26% of per capita monthly consumption, while a malaria case only cost households in the highest quintile 8%. We estimated the societal cost of malaria treatment in Uganda was $577 million (range: $302 million-1.09 billion) in 2021. The cost of malaria remains high in Uganda. Households bear the major burden of these costs. Poorer and richer households incur the same costs per case; this distribution is equal, but not equitable. These results can be applied to parameterize future economic evaluations of malaria control interventions and to evaluate the impact of malaria on Ugandan society, informing resource allocations in malaria prevention.

Governments in low and middle-income countries (LMICs) are increasingly considering the introduction of national health insurance scheme (NHIS) as a strategy to achieve universal health coverage (UHC) targets. The literature has widely documented the technical challenges associated with implementing UHC policies in LMICs but much less is known about the political process necessary to pass UHC legislation. In this article, we document the political economy issues surrounding the establishment of the Zambia NHIS in 2018. We adapted a political economy framework incorporating, semi-structured interviews with diverse stakeholders and document analysis of policies, operational reports and legislatures from 1991 and 2018. Our findings show the 26-year journey towards the establishment of the NHIS in Zambia involved a long sequence of policy dialogue, technical review and stakeholder engagement. Our interviews with key stakeholders suggest that the act was eventually passed due to strong political will and dominant leadership of the Ministry of Health. Passing the law required trade-offs between choices influenced by stakeholder pressures and recommendations from research and actuarial studies. Another equally critical factor was the high public support and legacies of past policies, such as the removal of user fees that had created quality gaps and inequities in the health system. Furthermore, global ideas about UHC and initiatives implemented by other countries also generated support for Zambia's NHIS. Overall, this study highlights the complex set of political economy factors that need to align in order for governments to be able to adopt health insurance in low-income settings. We show that political leadership and commitment to getting reforms passed is crucial. We also highlight how certain narratives about countries in the global health sphere can shape policies in other countries.

The Integrated Disease Surveillance and Response (IDSR) system was adopted by the Sierra Leone Ministry of Health (MOH) in 2008, which was based on paper-based tools for health data recording and reporting from health facilities to the national level. The Sierra Leone MoH introduced the implementation of electronic case-based disease surveillance reporting of immediately notifiable diseases. This study aims to document and describe the experience of Sierra Leone in transforming her paper-based disease surveillance system into an electronic disease surveillance system. Retrospective mixed methods of qualitative and quantitative data were reviewed. Qualitative data were collected by reviewing surveillance technical reports, epidemiological bulletins, COVID-19, IDSR technical guidelines, Digital Health strategy and DHIS2 documentation. Content and thematic data analyses were performed for the qualitative data, while Microsoft Excel and DHIS2 platform were used for the quantitative data analysis to document the experience of Sierra Leone in digitalizing its disease surveillance system. In the early 2017, a web-based electronic Case-Based Disease Surveillance (eCBDS) for real-time reporting of immediately notifiable diseases and health threats was piloted using the District Health Information System 2 (DHIS2) software. The eCBDS integrates case profile, laboratory, and final outcome data. All captured data and information are immediately accessible to users with the required credentials. The system can be accessed via a browser or an Android DHIS2 application. By 2021, there was a significant increase in the proportion of immediately notifiable cases reported through the facility-level electronic platform, and more than 80% of the cases reported through the weekly surveillance platform had case-based data in eCBDS. Case-based data from the platform are analysed and disseminated to stakeholders for public health decision-making. Several outbreaks of Lassa fever, Measles, vaccine-derived Polio and Anthrax have been tracked in real-time through the eCBDS.

Gender impacts exposure and vulnerability to tuberculosis (TB) evidenced by a higher prevalence of both TB disease and missed TB diagnoses among men, who significantly contribute to new TB infections. We present the formative research phase of a study, which used participatory methods to identify gender-specific interventions for systematic screening of TB among men in Uganda. Health facility-level data were collected at four Ugandan general hospitals (Kawolo, Gombe, Mityana and Nakaseke) among 70 TB stakeholders, including healthcare workers, TB survivors, policymakers and researchers. Using health-seeking pathways, they delineated and compared men's ideal and actual step-by-step TB health-seeking processes to identify barriers to TB care. The stepping stones method, depicting barriers as a 'river' and each 'steppingstone' as a solution, was employed to identify interventions which would help link men with TB symptoms to care. These insights were then synthesized in a co-analysis meeting with 17 participants, including representatives from each health facility to develop a consensus on proposed interventions. Data across locations revealed the actual TB care pathway diverted from the ideal pathway due to health system, community, health worker and individual-level barriers such as delayed health seeking, unfavourable facility operating hours and long waiting times that conflicted with men's work schedules. Stakeholders proposed to address these barriers through the introduction of male-specific services; integrated TB services that prioritize X-ray screening for men with cough; healthcare worker training modules on integrated male-friendly services; training and supporting TB champions to deliver health education to people seeking care; and engagement of private practitioners to screen for TB. In conclusion, our participatory co-design approach facilitated dialogue, learning and consensus between different health actors on context-specific, person-centred TB interventions for men in Uganda. The acceptability, effectiveness and cost effectiveness of the package will now be evaluated in a pilot study.