Health policy and planning最新文献

Acute malnutrition (AM) causes large loss of life and disability in children in Africa. Researchers are testing innovative approaches to increase the efficiency of treatment programs This paper presents results of a cost-effectiveness analysis of one such program in the Democratic Republic of the Congo (DRC) based on a secondary analysis of a randomized controlled trial Optimizing Treatment for Acute Malnutrition (OptiMA), conducted in DRC in 2018-20. A total of 896 children aged 6-59 months with a mid-upper arm circumference (MUAC) <125 mm or with oedema were treated and followed for 6 months. The cost-effectiveness of OptiMA using ready-to-use therapeutic food (RUTF) at a tapered dose was compared with the standard national program in which severe cases (SAM) received RUTF proportional to weight, and moderate cases (MAM) were referred to another clinic for a fixed dose regimen of ready-to-use supplementary food. Cost analysis from the provider perspective used data collected during the trial and from administrative records. Statistical differences were derived using t-tests. The mean cost per enrolled child under OptiMA was $123 [95% confidence interval (CI): 114-132], not statistically different from the standard group [$127 (95%CI: 118-136), P = 0.549], while treatment success (i.e. recovery to MUAC > 125 mm and no relapse for 6 months) under OptiMA was 9% higher (72 vs 63%, P = 0.004). Among children with SAM at enrollment, there was no significant difference in treatment success between OptiMA and standard care (70 vs 62%, P = 0.12), but OptiMA's mean cost per enrolled child was 23% lower ($128 vs $166, P < 0.0001). OptiMA was more effective at preventing progression to SAM among those enrolled with MAM (5 vs 16%, P < 0.0001), with an incremental cost-effectiveness ratio of $234 per progression to SAM prevented. Overall, OptiMA had significantly better outcomes and was no more expensive than standard care. Its adoption could enable more children to be successfully treated in contexts where therapeutic food products are scarce.

While there is ample evidence of the overall reduction in perinatal and pregnancy-related mortality in Ethiopia, it remains uncertain if geographic disparities have diminished. This study aimed to investigate perinatal and pregnancy-related mortality spatial distributions, trends over time, and factors associated with the distribution in Ethiopia. We used data from Ethiopian Demographic and Health Surveys conducted in 2000, 2005, 2011, and 2016. In each survey, around 15 500 women aged 15-49 years were interviewed from about 550 neighborhoods randomly sampled from across the country. Perinatal and pregnancy-related mortality were used as outcome variables. We carried out an optimized hotspot analysis using the Getis-Ord Gi* statistic in ArcGIS Pro to identify the time trend of geographical clusters with high (hot spot) and low (cold spot) perinatal and pregnancy-related mortality. In addition, we conducted a geographically weighted Poisson regression in R to examine the factors associated with the spatial distribution of perinatal and pregnancy-related mortality. Perinatal and pregnancy-related mortality exhibited a clustering pattern, indicating the presence of geographic inequality, with a decreasing pattern from 2000 to 2016. We detected hotspot areas in developed administrative regions of Amhara, Oromia, and Southern Nations, indicating inequality within large regions. Inequality in perinatal mortality was associated with rural residence, younger age of women, and high birth rate, whereas pregnancy-related mortality was associated with low autonomy, younger age, and anemia. We found that anemia (P-value = .01) has a geographically varying relationship with perinatal mortality, while education (P-value = .03) and wealth (P-value = 0.01) are associated with pregnancy-related mortality. While there has been a reduction during the study period, geographical disparities in perinatal and pregnancy-related mortality still persist. Therefore, targeting intervention programs in areas where spatial inequalities still persist is essential for effectively utilizing scarce resources.

The Republic of Chad has one of the highest rates of maternal mortality in the world. With scarce resources to respond to competing demands, pragmatic evidence-based planning tools are needed to aid planning and support priority setting. This action research aimed to develop a tool to support maternal health (MH) planning and prioritization decisions and identify priority regions/provinces for intervention in Chad based on aggregate MH coverage gap scores (Target-Coverage = Coverage Gap). A rapid review was conducted to identify key indicators and relevant national targets. The 2019 Multiple Indicator Cluster Survey and other national surveys were the data sources for selected indicators at the provincial level. Aggregate MH coverage gaps were calculated and displayed using geographic information system software to visualize variations by province. Eleven key informant interviews (KIIs) and six focus group discussions (FGDs) were conducted with clinicians and administrators to understand existing MH planning, prioritization, and maternal mortality risks in Chad. Wide provincial variation in aggregate MH coverage gaps was identified (mean score 374.3, SD: 77.4). Indicators contributing the most to coverage gaps include emergency obstetric care, adolescent births, tetanus vaccination, and delivery by skilled health personnel. Two weighting scenarios for the coverage gap scores are also considered. KIIs and FGDs revealed that existing MH planning in Chad differs provincially and by health system level, with no clear prioritization processes identified. Main themes regarding MH risks reported by stakeholders included challenges relating to the health system, policy landscape, country and population-specific factors, along with specific MH threats. Current centralized planning approaches may benefit from greater consideration of provincial differences to support more efficient and equitable resource distribution. This multi-indicator assessment offers an adaptable approach for evidence-based MH resource allocation to prioritize subnational areas with worst health indicators in resource-limited settings, although further research is needed to test its impact.

The maldistribution of physicians, especially in rural areas, remains a global public health challenge. The internship programme for medical doctors is one of the efforts undertaken to address this issue. However, evidence aiming to disentangle this persistent challenge in the Indonesian context has been scant. This study aims to identify factors influencing medical doctors' intentions to practise in rural areas and how these factors affect their decisions. We adopted a sequential explanatory mixed-method design using a validated questionnaire. Then, focus group discussions were conducted with medical doctors from three different regions (West, Central, and East) to gain in-depth understanding of motivations, intentions, and barriers to practicing in rural areas. Participants were intern doctors who had been practising for at least 6 months in their internship locations. Quantitative analysis was based on a questionnaire addressing each factor, rated using five-point Likert scales, with bivariate and multivariate logistic regression analyses. The qualitative results were analysed using thematic analysis. In total, 498 respondents completed the questionnaire where 9.6%, 49%, and 40.9% intend to practise in rural, suburban, and urban areas, respectively. Three factors were positively associated with a preference for rural practice: prior living experience in rural areas, accessibility to cultural centres and events, and personal savings as funding resources during medical school. However, the importance of 'internet accessibility' was negatively associated with a preference for rural practice. Furthermore, the qualitative study involving 18 participants resulted in four main themes: the role of the internship programme in enhancing motivation as medical doctors, factors generally influencing the intention to practise, factors influencing the intention to practise in rural areas, and policy recommendations to increase the intention to practise in rural areas. Addressing the challenge of attracting and retaining medical doctors in rural areas requires multisectoral approaches involving both personal and professional factors.

The emergence of 'resilience' as a concept for analysing health systems-especially in low- and middle-income countries-has been trailed by debates on whether 'resilience' is a process or an outcome. This debate poses a methodological challenge. What 'health system resilience' is interpreted to mean shapes the approach taken to its analysis. To address this methodological challenge, we propose 'learning' as a concept versatile enough to navigate the 'process versus outcome' tension. Learning-defined as 'the development of insights, knowledge, and associations between past actions, the effectiveness of those actions, and future actions'-we argue, can animate features that tend to be silenced in analyses of resilience. As with learning, the processes involved in resilience are cyclical: from absorption to adaptation, to transformation, and then to anticipation of future disruption. Learning illuminates how resilience occurs-or fails to occur-interactively and iteratively within complex systems while acknowledging the contextual, cognitive, and behavioural capabilities of individuals, teams, and organizations that contribute to a system's emergence from or evolution given shocks/stress. Learning analysis can help to resist the pull towards framing resilience as an outcome-as resilience is commonly used to mean or suggest a state or an attribute, rather than a process that unfolds, whether the outcomes are deemed positive or not. Analysing resilience as a learning process can help health systems researchers better systematically make sense of health system responses to present and future stress/shocks. In qualitative or quantitative analyses, seeing what is to be analysed as 'learning' rather than the more nebulous 'resilience' can refocus attention on what is to be measured, explained, and how-premised on the understanding that a health system with the ability to learn is the one with the ability to be resilient, regardless of the outcome of such a process.

In Indonesia, primary health centres (PHCs) are mandated to provide essential medicines to ensure equal access to medication for all Indonesians, as stated in the national medicine policy. However, limited information is available regarding the actual practices of health workers within the context of decentralized governance. This paper investigates the discrepancies between national policies and local practices in two Indonesian districts, shedding light on coping mechanisms employed in each phase of medicine management within PHCs. The mixed-method study began by identifying pertinent policies addressing medicine management in PHCs. Subsequently, panel data on patient visits to tuberculosis, maternal and neonatal health (MNH), and noncommunicable disease (NCD) services were collected from 2019 to 2022. After analysing the panel data, interviews were conducted with 56 health workers including physicians, nurses, pharmacists, midwives, and public health programme managers regarding their views on fluctuations in medicine stocks and the patient visit data. These participants included pharmacists and programme managers specializing in tuberculosis, MNH, and NCD care and were affiliated with PHCs and district health offices. Our findings highlight the occasional unavailability of essential medicines in PHCs, with stockouts being attributed to supplier shortages at provincial and national levels and to variations in the capacity of the local health system. Low-skilled pharmaceutical staff are a contributing factor in each phase of medicine management. Additionally, health workers employ coping mechanisms, such as deviating from policy on the use of capitation funds to purchase medicines, to manage temporary stockouts. To tackle systemic stockouts, central government should prioritize capacity-building among health workers, by establishing a continuous and easily accessible local learning system.

The pro-rich nature of catastrophic health expenditure (CHE) indicators has garnered criticism, inspiring the exploration of the subjective approach as a complementary method. However, no studies have examined the discrepancy between subjective and objective approaches. Employing data from the Chinese Social Survey (CSS) 2013-2021 waves, we analysed the discrepancy between objective and subjective CHE and its associated socioeconomic factors using logit regression modelling. Overall, self-rating generated higher CHE incidence (28.35% to 33.72%) compared to objective indicators (9.92% to 21.97%). Objective indicators did not support 17.57% to 23.90% of self-rated cases of household CHE, while 2.73% to 8.42% of households classified with CHE by objective indicators did not self-rate with CHE. The normative subsistence spending indicator showed the least consistency with self-rating (70.66% to 74.28%), while the budget share method produced the most consistent estimation (72.73% to 76.10%). Living with elderly and young children [adjusted odds ratios (AOR): 1.069 to 1.169, P < 0.1], lower educational attainment (AOR: 1.106 to 1.225, P < 0.1), lower income (AOR: 1.394 to 2.062, P < 0.01), and lower perceived social class (AOR: 1.537 to 2.801, P < 0.05) were associated with higher odds of self-rated CHE without support from objective indicators. Conversely, low socioeconomic status (AOR: 0.324 to 0.819, P < 0.1) was associated with lower odds of missing CHE cases classified by objective indicators in self-rating. The commonly used objective indicators for assessing CHE may attract doubts about their fairness from socioeconomically disadvantaged people. The CHE subjective approach can be adopted as a complementary measure to monitor financial risk protection.

Delphi studies are rapidly gaining prominence in global health research. However, researchers' modifications to the Delphi method are often not well-described or justified, limiting opportunities to systematically learn from these studies when the methods are applied to other topics and settings. This paper aims to describe an approach to implementing a modified Delphi study and reflect on the research process in the context of a multicountry study of implementation science research priorities to advance Universal Health Coverage (UHC). We review trends in the use of the modified Delphi method in global health research, outline our three-phased modified Delphi approach, and share reflections on five decision points for implementing the study: (I) identifying and recruiting participants for the expert panel, (II) addressing participant attrition between rounds, (III) justifying the most appropriate cutoff points, (IV) incorporating new items raised by participants in open-ended survey sections, and (V) ensuring maximum variation in perspective in the panel of experts. Insights from this work foster greater understanding of the underlying assumptions for, and interpretation of, 'modified' in modified Delphi studies. This study will encourage critical dialogue about points of methodological contention in Delphi methodology and thus are relevant for scaling the use of modified Delphi studies in public health, including global health research.

This paper evaluates the relationship between the degree of cost-sharing and the utilization of outpatient and inpatient health services in China. Using data from the 2015 China Health and Retirement Longitudinal Study (CHARLS), we estimated the association between outpatient and inpatient service utilization and cost-sharing levels associated with outpatient and inpatient services, as well as a comparative metric that quantifies the relative cost-sharing burden between the two. We found that patients in areas with higher levels of cost-sharing for outpatient services exhibit a lower propensity to use outpatient care and a higher inclination to utilize costly hospitalization services. Conversely, as the ratio of cost-sharing for outpatient services to that for inpatient services increases, the likelihood of patients forgoing doctor-initiated hospitalization correspondingly increases. This suggests that when cost-sharing for outpatient care rises relative to inpatient care, observed increases in inpatient care utilization reflect an escalation in moral hazard rather than a correction for the underutilization of inpatient services. We conclude that both substitution and complementary roles exist between outpatient and inpatient services. Our findings suggest that a more effective design of cost-sharing is needed to enhance the equity and efficiency of China's health system.