Health policy and planning最新文献

The need for leadership within district health systems is critical for the effective delivery of services and for inter-sectoral collaboration for health. Leadership capacity development (LCD) has not, however, been prioritized within health systems, and the systemic capacity (i.e. roles, structures and processes) that is needed to develop managers who can lead is not always in place. This paper aims to contribute to understanding how to build such capacity, considering a relevant bottom-up innovation. We observed, in the period 2013-15, the emergent implementation of this innovation (a 'Leadership Commission') in a South African health district. What started out as an effort to train individual leaders evolved into the development of systemic capacity for LCD. We adopted realist evaluation as the main methodological approach, as well as case study design, and we first developed a programme theory of the internally driven LCD initiative, through a round of interviews with senior managers. We then tested the programme theory drawing on 14 in-depth interviews and field notes of meetings and processes. Our analysis suggests that building systemic capacity for LCD requires leadership to be expressed as a strategic priority by those with positional authority and that bottom-up LCD requires institutional commitment through strengthening routine structures or creating new ones. The ability to leverage existing resources is another key element of systemic capacity. The mechanisms that enable bottom-up capacity development include tacit and experiential knowledge, sensemaking, systems thinking and trust between, and motivation of, those tasked with leading LCD. Leadership development is constrained by increased workloads for those involved as the prioritization of leadership becomes simply an additional task, and sustainability challenges are likely in the absence of additional resources for bottom-up innovation.

Two billion people globally lack access to a basic toilet, and sanitation is a critical determinant of health and well-being. Evaluations of sanitation programmes typically measure disease or behaviour, and visual analogue scales (VASs) 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 hypothesized 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 hypothesized 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.

Farm workers are vulnerable working populations who face significant inequalities in accessing health services, including those for human immunodeficiency virus (HIV) prevention, treatment and care. This descriptive phenomenological study aimed to explore farm workers' experiences when accessing HIV services and was conducted in Limpopo province, South Africa. Eighteen in-depth interviews were conducted in four health facilities from two districts, and two focus group discussions were conducted in one of the farms within the province. Purposive sampling and systematic random sampling were used to select study participants. A deductive thematic approach was used to analyse data, informed by the social-ecological model of health. The results reveal that farm workers perceive multiple interdependent factors that inhibit or enable their access to HIV healthcare services. Key barriers to HIV healthcare were transport affordability, health worker attitudes, stigma and discrimination, models of HIV healthcare delivery, geographic location of health facilities and difficult working conditions. Key facilitators to HIV healthcare included the availability of mobile health services, the presence of community health workers and a supportive work environment. The findings suggest disparities in farm workers' access to HIV services, with work being the main determinant of access. We, therefore, recommend a review of HIV policies and programmes for the agricultural sector and models of HIV healthcare delivery that address the unique needs of farm workers.

A realist review is a theory-driven approach to synthesizing evidence based on the realist philosophy of science. Realist reviews are conducted to provide the policy and practice community with a rich, detailed and practical understanding of complex social interventions that will likely be of much more use to them when planning and implementing programmes. Robust realist reviews must balance philosophical engagement, methodological rigour and relevance to practice. Nevertheless, they have been criticized for being more philosophically inclined and less methodologically robust, with findings that have little implication for practice. Using the philosophy/epistemology➔ methodology➔ theory➔ practice concept flow, we report how we balanced philosophical principles and practical insights in a recently conducted realist review on participatory practices that impact the benefits of non-communicable disease research and interventions in low- and middle-income countries. If realist reviews are not comprehensible enough for these practitioners, their utility and relevance may suffer from being limited to a specialist cohort of academics. We propose that realist review findings and outputs must be framed and communicated to meaningfully engage practitioners without undertaking translational efforts.

New vaccine policy adoption is a complex process, especially in low-and-middle-income countries, requiring country policymakers to navigate challenges such as competing priorities, human and financial resource constraints, and limited logistical capacity. Since the beginning of the Expanded Programme on Immunization, most new vaccine introductions under this structure have not been aimed at adult populations. The majority of adult vaccines offered under the Expanded Programme on Immunization are not typically tested among and tailored for pregnant persons, except those that are specifically recommended for pregnancy. Given that new maternal vaccines, including respiratory syncytial virus and group B streptococcus vaccines, are on the horizon, it is important to understand what barriers may arise during the policy development and vaccine introduction process. In this study, we sought to understand information needs among maternal immunization policymakers and decision-makers in Kenya for new vaccine maternal policy adoption through in-depth interviews with 20 participants in Nakuru and Mombasa, counties in Kenya. Results were mapped to an adapted version of an established framework focused on new vaccine introduction in low-and-middle-income countries. Participants reported that the policy process for new maternal vaccine introduction requires substantial evidence as well as coordination among diverse stakeholders. Importantly, our findings suggest that the process for new maternal vaccines does not end with the adoption of a new policy, as intended recipients and various actors can determine the success of a vaccine programme. Previous shortcomings, in Kenya, and globally during human papillomavirus vaccine introduction, show the need to allocate adequate resources in education of communities given the sensitive target group. With maternal vaccines targeting a sensitive group-pregnant persons-in the pipeline, it is an opportune time to understand how to ensure successful vaccine introduction with optimal acceptance and uptake, while also addressing vaccine hesitancy to increase population benefit.

Effective leadership and management has been identified as critical in enabling health systems to respond adequately to their population needs. The changing nature of low- and middle-income countries' health systems, given resource scarcity, a high disease burden and other contextual challenges, has also led to learning-including workplace-based learning (WPBL)-being recognized as a key process supporting health system reform and transformation. This review used a framework synthesis approach in addressing the question: 'What forms of WPBL, support leadership and management development; and how does such learning impact district health leadership and management strengthening?'. A search for English language empirical qualitative, mixed-methods and quantitative studies and grey literature published from January 1990 to May 2024 was conducted using four electronic databases (PubMed, EBSCOhost, Scopus and Web of Science). Twenty-five articles were included in the synthesis. The findings reveal that over the last decade, WPBL has received consideration as an approach for leadership and management development. While WPBL interventions differed in type and nature, as well as length of delivery, there was no conclusive evidence about which approach had a greater influence than others on strengthening district health leadership and management. However, the synthesis demonstrates the need for a focus on the sustainability and institutionalization of interventions, including the need to integrate WPBL interventions in health systems. To support sustainability and institutionalization, there should be flexibility in the design and delivery of such interventions and they are best supported through national or regional institutions.

During the past two decades, the Afghan government, along with international community, has developed a system aimed at improving access to essential health services under Afghanistan's challenging socio-political and geographical circumstances. In 31 provinces, non-state actors competed for fixed-term contracts to implement a predefined package of health services. In three provinces, the government organised the provision of health services. An independent third party monitored service provision, including access to medicines. This study examines the availability of essential medicines in Afghanistan's public health facilities and how this is shaped by socio-political challenges, geographical barriers, and the organisation of the health system. Between March and July 2021, enumerators collected data at 885 health facilities across Afghanistan. For our analysis, we combined data about medicine availability and the functioning of the health system with publicly available information about geographical and socio-political factors, including security incidents. Using regression analysis, we identified facility, district, and province-level factors related to medicines availability in public health facilities. On average, 70% of 31 selected essential medicines were available in 2021. The availability of medicines varies significantly between provinces and was considerably higher in those where services were contracted out to non-state actors (n=34; 91%) compared to provinces where service provision was organised by the government (n=3; 9%). The most important drivers of variation in medicine availability included geographical barriers, securing and allocating funds on the provincial level, and organising and sustaining physical capacity on the facility level. Insecurity was not a key factor driving variation in medicine availability. Despite the socio-political challenges in 2021, the availability of essential medicines in public health facilities was relatively high. The results suggest that decentralized procurement of medicines by non-state actors and timely payment of funds contribute to medicines availability. Strategies to improve medicines availability should target hard-to-reach areas and lower-level facilities.

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 Ethiopia in 2000, 2005, 2011, and 2016. In each survey, around 15,500 women aged 15-49 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 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 = 0.01) has a geographically varying relationship with perinatal mortality, while education (p-value = 0.03) and wealth (p-value = 0.01) 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.