Health policy and planning最新文献

Case management of malaria in Africa has evolved markedly over the past twenty 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%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.

Type 2 diabetes (T2D) represents a growing disease burden in South Africa. While glycated haemoglobin (HbA1c) testing is the gold standard for long-term blood glucose management, recommendations for HbA1c monitoring frequency are based on expert opinion. This study investigates the effectiveness and cost-effectiveness of alternative HbA1c monitoring intervals in the management of T2D. A Markov model with three health states (HbA1c <7%, HbA1c ≥ 7%, Dead) was used to estimate lifetime costs and quality-adjusted life years (QALYs) of alternative HbA1c monitoring intervals among patients with T2D, using a provider's perspective and a 3% discount rate. HbA1c monitoring strategies (three-monthly, four-monthly, six-monthly and annual tests) were evaluated with respect to the incremental cost-effectiveness ratio (ICER) assessing each comparator against a less costly, undominated alternative. The scope of costs included the direct medical costs of managing diabetes. Transition probabilities were obtained from routinely collected public sector HbA1c data, while health service utilization and health-related-quality-of-life (HRQoL) data were obtained from a local cluster randomized controlled trial. Other parameters were obtained from published studies. Robustness of findings was evaluated using one-way and probabilistic sensitivity analyses. A South African indicative cost-effectiveness threshold of USD2665 was adopted. Annual and lifetime costs of managing diabetes increased with HbA1c monitoring, while increased monitoring provides higher QALYs and life years. For the overall cohort, the ICER for six-monthly vs annual monitoring was cost-effective (USD23 22.37 per QALY gained), whereas the ICER of moving from six-monthly to three-monthly monitoring was not cost effective (USD6437.79 per QALY gained). The ICER for four-monthly vs six-monthly monitoring was extended dominated. The sensitivity analysis showed that the ICERs were most sensitive to health service utilization rates. While the factors influencing glycaemic control are multifactorial, six-monthly monitoring is potentially cost-effective while more frequent monitoring could further improve patient HrQoL.

Burkina Faso has implemented a nationwide free healthcare policy (gratuité) for pregnant and lactating women and children under 5 years since April 2016. Studies have shown that free healthcare policies can increase healthcare service use. However, the emerging coronavirus disease 2019 pandemic, escalating insecurity and the political situation in recent years might have affected the implementation of such policies. No studies have looked at whether the gratuité maintained high service use under such changing circumstances. Our study aimed to assess the effects of gratuité on the utilization of facility-based delivery and curative care of children under 5 years in light of this changing context. We employed a controlled interrupted time series analysis using data from the Health Management Information System and annual statistical reports of 2560 primary health facilities from January 2013 to December 2021. We focused on facility-based deliveries and curative care for children under 5 years, with antenatal care and curative care for children over 5 years as non-equivalent controls. We employed segmented regression with the generalized least square model, accounting for autocorrelation and monthly seasonality. The monthly utilization rate among children under 5 years compared to those above 5 years (controls) immediately increased by 111.19 visits per 1000 children (95% CI: 91.12, 131.26) due to the gratuité. This immediate effect declined afterwards with a monthly change of 0.93 per 1000 children (95% CI: -1.57, -0.29). We found no significant effects, both immediate and long-term, on the use of maternal care services attributable to the gratuité. Our findings suggest that free healthcare policies can be instrumental in improving healthcare, yet more comprehensive strategies are needed to maintain healthcare utilization. Our findings reflect the overall situation in the country, while localized research is needed to understand the effect of insecurity and the pandemic at the local level and the effects of gratuité across geographies and socioeconomic statuses.

Despite being the most cost-effective tobacco control policy, tobacco taxation is the least implemented component of the World Health Organization MPOWER package to reduce smoking worldwide. In Mexico, both smoking prevalence and taxation have remained stable for more than a decade. This study aims to provide evidence about the potential effects of taxation to reduce the burden of tobacco-related diseases and the main attributable social costs in Mexico, including informal (unpaid) care costs, which are frequently ignored. We employ a first-order Monte Carlo microsimulation model that follows hypothetical population cohorts considering the risks of an adverse health event and death. First, we estimate tobacco-attributable morbidity and mortality, direct medical costs and indirect costs, such as labour productivity losses and informal care costs. Then, we assess the potential effects of a 50% cigarette price increase through taxation and two alternative scenarios of 25% and 75%. The inputs come from several sources, including national surveys and vital statistics. Each year, 63 000 premature deaths and 427 000 disease events are attributable to tobacco in Mexico, while social costs amount to MX$194.6 billion (US$8.5)-MX$116.2 (US$5.1) direct medical costs and MX$78.5 (US$3.4) indirect costs-representing 0.8% of gross domestic product. Current tobacco tax revenue barely covers 23.3% of these costs. Increasing cigarette prices through taxation by 50% could reduce premature deaths by 49 000 over the next decade, while direct and indirect costs averted would amount to MX$87.9 billion (US$3.8) and MX$67.6 billion (US$2.9), respectively. The benefits would far outweigh any potential loss even in a pessimistic scenario of increased illicit trade. Tobacco use imposes high social costs on the Mexican population, but tobacco taxation is a win-win policy for both gaining population health and reducing tobacco societal costs.

Gender-responsive monitoring and evaluation (M&E) for health and health systems interventions and programs is vital to improve health, health systems, and gender equality outcomes. It can be used to identify and address gender disparities in program participation, outcomes and benefits, as well as ensure that programs are designed and implemented in a way that is inclusive and accessible for all. While gender-responsive M&E is most effective when interventions and programs intentionally integrate a gender lens, it is relevant for all health systems programs and interventions. Within the literature, gender-responsive M&E is defined in different and diverse ways, making it difficult to operationalize. This is compounded by the complexity and multi-faceted nature of gender. Within this methodological musing, we present our evolving approach to gender-responsive M&E which we are operationalizing within the Monitoring for Gender and Equity project. We define gender-responsive M&E as intentionally integrating the needs, rights, preferences of, and power relations among, women and girls, men and boys, and gender minority individuals, as well as across social, political, economic, and health systems in M&E processes. This is done through the integration of different types of gender data and indicators, including: sex- or gender-specific, sex- or gender-disaggregated, sex- or gender-specific/disaggregated which incorporate needs, rights and preferences, and gender power relations and systems indicators. Examples of each of these are included within the paper. Active approaches can also enhance the gender-responsiveness of any M&E activities, including incorporating an intersectional lens and tailoring the types of data and indicators included and processes used to the specific context. Incorporating gender into the programmatic cycle, including M&E, can lead to more fit-for-purpose, effective and equitable programs and interventions. The framework presented in this paper provides an outline of how to do this, enabling the uptake of gender-responsive M&E.

Nigeria accounts for a substantial cholera burden globally, particularly in its northeast region, where insurgency is persistent and widespread. We used participatory group model building workshops to explore enablers and barriers to implementing known cholera interventions, including water, sanitation and hygiene, surveillance and laboratory, case management, community engagement, oral cholera vaccine, and leadership and coordination, as well as exploring leverage points for interventions and collaboration. The study engaged key cholera stakeholders in the northeastern States of Adamawa and Bauchi, as well as national stakeholders in Abuja. Adamawa and Bauchi States' group modes building participants comprised 49 community members and 43 healthcare providers, while the 23 national participants comprised government ministry, department and agency staff, and development partners. Data were analysed thematically and validated via consultation with selected participants. The study identified four overarching themes regarding the enablers and barriers to implementing cholera interventions: (1) political will, (2) health system resources and structures, (3) community trust and culture, and (4) spill-over effect of COVID-19. Specifically, inadequate political will exerts its effect directly (e.g. limited funding for prepositioning essential cholera supplies) or indirectly (e.g. overlapping policies) on implementing cholera interventions. The healthcare system structure (e.g. centralization of cholera management in a State capital) and limited surveillance tools weaken the capacity to implement cholera interventions. Community trust emerges as integral to strengthening the healthcare system's resilience in mitigating the impacts of cholera outbreaks. Lastly, the spill-over effects of COVID-19 helped promote interventions similar to cholera (e.g. water, sanitation and hygiene) and directly enhanced political will. In conclusion, the study offers insights into the complex barriers and enablers to implementing cholera interventions in Nigeria's cholera-endemic settings. Strong political commitment, strengthening the healthcare system, building community trust and an effective public health system can enhance the implementation of cholera interventions in Nigeria.

The Maternal Death Surveillance and Response (MDSR) system is designed to continuously identify and review all maternal deaths. It aims to help countries understand the scale and distribution of maternal deaths, identify their causes, and inform corrective measures to address the challenge. Despite the growing adoption of the MDSR by numerous low- or middle-income countries, its implementation faces various challenges, including legal ones. This scoping review was conducted to map legal issues and challenges that arise during the implementation of the MDSR. It adapted the Bain and Kongnyuy framework, categorizing legal issues into data, people, use of findings, and legal regulation. Literature was retrieved from seven databases, complemented by additional online searches. We included studies published in English between 2010 and November 2022 that report on legal issues arising during the implementation of MDSR. Out of 1174 studies screened, 31 were selected for review. The review highlighted the limited attention given to the legal dimension of the MDSR by the research community. It also documented the lack of adequate legal framework essential for the system's effective implementation. Inadequate safeguards for informational privacy and the lack of confidentiality reinforce a prevalent sense of being blamed, mainly among health workers. Consequently, widespread under-reporting and intentional misattribution of causes of maternal death, defensive referrals, and disengagement from the MDSR process were reported. We recommend that implementing countries regulate the gathering and use of MDSR data through appropriate laws and legally ensure that the MDSR data are only used for the intended purpose. Appropriate complaint-handling mechanisms are needed in health systems to prevent the misuse of the MDSR. Future studies on MDSR implementation would benefit from involving legal experts, considering the multifaceted legal dimensions of the MDSR.

Breastfeeding is important for women and children's health, but less than half of infants worldwide begin life with optimal breastfeeding. A growing literature shows consistently large economic costs of not breastfeeding, with global studies showing economic losses of around US$300 billion globally. However, existing studies are highly diverse in approaches, methods, data sources and country results. Building on a landmark 2012 UNICEF UK review focused on high-income countries, we conducted a scoping review to map and characterize the expanding literature and identify future research directions in this research area. We included studies (n = 36) in diverse country settings and outcomes for women and children. We used PubMed, Web of Science, EMBASE, MEDLINE, ProQuest and manual searches of cost of not breastfeeding studies published between 1996 and 2023. Articles were excluded if they were macroeconomic evaluations, did not assign monetary values or only evaluated breastfeeding or formula feeding costs and not outcomes or were cost of programs studies. We found considerable diversity in disciplinary approaches and differences in methodologies. Though there were different cost measurement perspectives (societal, institutional/payer and individual), all but two excluded the costs of unpaid care. Studies typically measured costs of medical treatment, with more recent studies using dynamic simulation models. The largest economic costs were derived from lifetime estimates of human capital losses, namely cost of premature death and loss of intelligence quotient points. Medical and death costs varied widely depending on method of calculation, but total costs consistently exceeded $US100 billion annually for the USA, and around $US300 billion in global studies. Our findings suggest that greater interdisciplinary collaboration is needed particularly to better define infant feeding exposures, and advance comprehensive measurement of costs and outcomes across lifetimes, in order to prioritize breastfeeding as a public health strategy of economic importance.

The role of the emergency medical service (EMS) is changing globally as ambulance crews respond to a shifting burden of disease, as well as societal stressors such as violence and inequality. New ways of thinking about how to provide emergency care are required to shift EMS from a role primarily focused on clinical care and transporting patients to hospital. In this paper, we present the experience of the Philippi Project (PP), an innovative community-based model of care developed by front line ambulance crews in a low-income neighbourhood in Cape Town, South Africa. Our insights were developed through observational, interview and document review work, within an overall embedded research approach. Our analysis draws on the everyday health systems resilience (EHSR) framework, which sees resilience as an emergent process that may be stimulated through response to stress and shock. Responses take the form of absorptive, adaptive or transformative strategies and are underpinned by system capacities (cognitive, behavioural and contextual). We consider the PP as a potentially transformative resilience strategy, defined as a new way of working that offered the promise of long-term health system gains. We found that the PP's initial development was supported by a range of system capacity attributes (such as the intentional development of relationships, a sense of collective purpose and creating spaces for constructive sense-making). However, the PP was hard to sustain over time because emergent ways of working were undermined both by other capacity attributes rooted in pre-existing organizational routines and two contextual shocks (Coronavirus and a violent incident). The paper adds a new empirical contribution to the still-small EHSR literature. In addition, the PP experience offers globally relevant lessons for developing community-based models of EMS care. It demonstrates that front line staff can develop creative solutions to their stressful daily realities, but only if space is created and protected.