Health policy and planning最新文献

Two billion people globally lack access to a basic toilet, and sanitation is a critical determinant of health and wellbeing. Evaluations of sanitation programmes typically measure disease or behaviour, and visual analogue scales (VAS) have not been used to measure users' feelings about their level of sanitation. In this study, we assess the validity of a horizontal sanitation VAS numbered 0-10, with end-anchors "best imaginable" and "worst imaginable" sanitation. In Kumasi, Ghana, we surveyed 291 participants before and after uptake of a container-based sanitation service. In Maputo, Mozambique, we surveyed 424 participants from treatment groups of a prior trial. We assessed construct validity by testing hypothesised associations between VAS scores and toilet characteristics, and by respondents valuing three hypothetical sanitation states. We assessed responsiveness by comparing VAS with/without sanitation interventions. There was evidence (p<0.05) for 60% of hypothesised associations in Ghana, and 100% in Mozambique. For responsiveness, there was a 3.4 point increase (2.1 SD) in VAS 10 weeks post-intervention in Ghana, and a 2.9 point difference (1.3 SD) in Mozambique. In valuation exercises, the mean was higher (p<0.001) for the objectively better sanitation state. The sanitation VAS could be useful in economic evaluation to identify which improvements achieve quality of life gains most efficiently. For future studies we recommend a vertical sanitation VAS numbered 0-100 with emojis at end-anchors but retaining a 0-10 option for those who struggle with numeracy.

A health systems reform known as Service Delivery Redesign for Maternal and Newborn Health seeks to make high-quality delivery care universal in Kakamega County, in western Kenya, by strengthening hospital-level care and making hospital deliveries the default option for pregnant women. Using a large prospective survey of new mothers in Kakamega County, we examine several key assumptions which underpin the Service Delivery Redesign policy's theory of change. We analyze data on place of delivery, travel time and distance, out-of-pocket spending, and self-reported quality of care for 19,127 women prospectively enrolled at antenatal care and surveyed two times after their delivery. We assess womens' delivery location preferences over the course of pregnancy and compared to previous pregnancies, and compare travel time, out of pocket expenditures, and patient satisfaction for women who deliver in public hospitals versus primary health centers. We find substantial changes in delivery location at population level over time, and for individual women over the course of pregnancy: Facility delivery has increased from 50.4% in 2010 to 89.5% in 2019; and 70% of respondents deliver at a different facility than their reported intention at antenatal care. Out of pocket delivery expenditures are on average 1351 Kenyan shillings (Ksh) in hospitals compared to 964 Ksh in PHCs (p<0.01) . Transport expenditures are 337 Ksh for PHC deliveries versus 422 Ksh for hospitals (p<0.01). Self-reported average travel time is 51 minutes (PHC delivery) vs 47 (hospital delivery) (p=0.78). Average distance to delivery location is 15.1 km for PHC deliveries vs 15.2 km for hospitals (p=0.99). There were no differences in overall patient-reported quality scores, while some subcomponents of quality favored hospitals. These findings generally support key assumptions of the SDR theory of change in Kakamega County, while also highlighting challenges that should be addressed to increase the likelihood of successful implementation.

Resilience is crucial for the health system better preventing and responding to public health threats and providing high-quality services. Despite the growing interest in the concept of resilience in health care, however, there is little empirical evidence of the impact of organizational resilience, especially in primary care settings. As the largest professional group in primary care, primary care nurses are taking more and more responsibilities during their daily practice, which influences both their work conditions and wellbeing. This study aims to examine the association between organizational resilience and primary care nurses' working conditions and wellbeing. Using a convenience sampling approach, we recruited 175 primary care nurses from 38 community health centers (CHCs) in four cities in China. Organizational resilience was operationalized as comprising two domains: adaptive capacity and planning capacity, and measured using a 16-item scale. The primary care nurses' working condition indicators comprised variables of psychological safety, organizational commitment, professional commitment, and self-directed learning; wellbeing indicators included depression and burnout. Hierarchical linear regression models were built for analysis. We found that the sampled CHCs have a relatively high level of organizational resilience. The organizational resilience was positively associated with the four indicators of working conditions: psychological safety (β=0.04, p<0.01), organizational commitment (β=0.38,p<0.01), professional commitment (β=0.39, p<0.01), and self-directed learning (β=0.28, p<0.01). However, organizational resilience was not significantly associated with the two wellbeing indicators. Furthermore, we found the adaptive capacity has stronger association compared with planning capacity. Therefore, primary care manager should build resilient organizations, especially the adaptive capacity, in order to enhance primary care nurses' psychological safety, commitment and learning behaviors. Further studies should also be conducted to understand the link between organizational resilience and primary care nurses' wellbeing.

Improving access to abortion services has been coined a high priority by the Ethiopian Federal Ministry of Health. Nevertheless, many women are still struggling to access abortion services. The dedicated commitment to expanding abortion services by central authorities and the difficulties in further improving access to the services make for an interesting case to explore the real-life complexities of health priority setting. This article thus explores what it means to make abortion services a priority by drawing on in-depth interviews with healthcare bureaucrats and key stakeholders working closely with abortion service policy and implementation. Data were collected from February to April 2022. Health bureaucrats from 9 of the 12 regional states in Ethiopia and the Federal Ministry of Health were interviewed in addition to key stakeholders from professional organizations and NGOs. The study found that political will and priority to abortion services by central authorities were not necessarily enough to ensure access to the service across the health sector. At the regional and local level, there were considerable challenges with a lack of funding, equipment and human resources for implementing and expanding access to abortion services. The inadequacy of indicators and reporting systems hindered accountability and made it difficult to give priority to abortion services among the series of health programmes and priorities that local health authorities had to implement. The situation was further challenged by the contested nature of the abortion issue itself, both in the general population, but also amongst health bureaucrats and hospital leaders. This study casts a light on the complex and entangled processes of turning national-level priorities into on-the-ground practice and highlights the real-life challenges of setting and implementing health priorities.

Organizations that perform Health Policy and Systems Research (HPSR) need robust capacities, but it remains unclear what these organizations should look like in practice. We sought to define 'HPSRIs' (pronounced as 'hip-srees', i.e. 'Health Policy and Systems Research Institutions') as organizational models and developed a conceptual framework for assessing their capacities based on a set of attributes. We implemented a multi-method study in the Philippines that comprised: a qualitative analysis of perspectives from 33 stakeholders in the HPSR ecosystem on the functions, strengths and challenges of HPSRIs; a workshop with 17 multi-sectoral representatives who collectively developed a conceptual framework for assessing organizational capacities for HPSRIs based on organizational attributes; and a survey instrument development process that determined indicators for assessing these attributes. We defined HPSRIs to be formally constituted organizations (or institutions) with the minimum essential function of research. Beyond the research function, our framework outlined eight organizational attributes of well-performing HPSRIs that were grouped into four domains, namely: 'research expertise' (1) excellent research, (2) capacity-building driven; 'leadership and management' (3) efficient administration, (4) financially sustainable; 'policy translation' (5) policy orientation, (6) effective communication; and 'networking' (7) participatory approach, (8) convening influence. We developed a self-assessment instrument around these attributes that HPSRIs could use to inform their respective organizational development and collectively discuss their shared challenges. In addition to developing the framework, the workshop also analysed the positionality of HPSRIs and their interactions with other institutional actors in the HPSR ecosystem, and recommends the importance of enhancing these interactions and assigning responsibility to a national/regional authority that will foster the community of HPSRIs. When tailored to their context, HPSRIs that function at the nexus of research, management, policy and networks help achieve the main purpose of HPSR, which is to 'achieve collective health goals and contribute to policy outcomes'.

Providing social support to tuberculosis (TB) patients is a recommended strategy as households having TB patients find themselves in a spiral of poverty because of high cost, huge income loss and several other economic consequences associated with TB treatment. However, there are few examples of social support globally. The Indian government introduced the 'Nikshay Poshan Yojana' scheme in 2018 to provide nutritional support for all registered TB patients. A financial incentive of 500 Indian Rupee (6 United States Dollars) per month was proposed to be transferred directly to the registered beneficiaries' validated bank accounts. We examined the reach, timing, amount of benefit receipt and the extent to which the benefit alleviated catastrophic costs (used as a proxy to measure the impact on permanent economic welfare as catastrophic cost is the level of cost that is likely to result in a permanent negative economic impact on households) by interviewing 1482 adult drug-susceptible TB patients from 16 districts of four states during 2019 to 2023, using the methods recommended by the World Health Organization for estimating household costs of TB nationally. We also estimated the potential amount of social support required to achieve a zero catastrophic cost target. At the end of treatment, 31-54% of study participants received the benefit. In all, 34-60% of TB patients experienced catastrophic costs using different estimation methods and the benefit helped 2% of study participants to remain below the catastrophic cost threshold. A uniform benefit amount of Indian Rupee 10 000 (127 United States Dollars) for 6 months of treatment could reduce the incidence of catastrophic costs by 43%. To improve the economic welfare of TB patients, levels of benefit need to be substantially increased, which will have considerable budgetary impact on the TB programme. Hence, a targeted rather than universal approach may be considered. To maximize impact, at least half of the revised amount should be given immediately after treatment registration.

The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.