Health policy and planning最新文献

Crowdsourcing strategies are useful in the development of public health interventions. Crowdsourcing engages end users in a co-creation process through challenge contests, designathons or online collaborations. Drawing on our experience of crowdsourcing in four African countries, we provide guidance on designing crowdsourcing strategies across seven steps: deciding on the type of crowdsourcing strategy, convening a steering committee, developing the content of the call for ideas, promotion, evaluation, recognizing finalists and sharing back ideas or implementing the solutions.

This study explores the effect of the transformation of paediatric healthcare through the implementation of the Family Mutual Aid System (FMAS) for personal medical insurance accounts, among paediatric patients at a children's hospital (Hospital A in Shanghai, China). We conducted a cohort study in the endocrinology department of Hospital A from August 2021 to July 2023 to assess the impact of the FMAS enrolment on patients' annual outpatient visits, annual outpatient expenditures, and the allocation of these costs among the Basic Medical Insurance Pooling Fund and patients' out-of-pocket (OOP) expenses, with a further subdivision into online and offline consultations. Analysis employed a weighted Difference-in-Differences approach within a fixed-effects model following Propensity Score Matching. The study encompassed 10,975 paediatric patients, divided into those enrolled in the FMAS (observation group) and those not (control group). Enrolment in FMAS was associated with a statistically significant increase in annual outpatient visits by an average of 1.107, predominantly attributed to an uptick in offline consultations. Additionally, there was a substantial 38.9% rise in annual outpatient costs. Detailed analysis revealed a 52.5% increase in costs covered by the medical insurance pooling fund, while patients' OOP expenses decreased by an average of 69.2%. These findings highlight the beneficial effects of FMAS enrolment on healthcare service utilization and risk-sharing mechanisms of medical insurance.

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 hospitalisation services. Conversely, as the ratio of cost-sharing for outpatient services to that for inpatient services increases, the likelihood of patients forgoing doctor-initiated hospitalisation 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.

Person-centered long-term care systems, integral to healthy ageing, should empower older people to achieve ageing in place. Yet evidence on the impact of the design of long-term care systems on older people's choice of places of ageing, especially that from developing countries, is limited. Taking the introduction of Long-Term Care Insurance (LTCI) in City X of China as a policy shock, we examined the impact of becoming eligible for LTCI on program beneficiaries' choice of places of ageing-institution or home-before they started to receive any actual benefit. Based on our analysis of the administrative data of all LTCI applicants between July 2017 and September 2020 from City X, we found that becoming eligible for LTCI increased an older-person's probability of choosing home as her place of ageing even before she received any benefit by around 16 percentage points, and this positive impact was larger for those insured of higher education level or of higher disability grade. By bring more ageing in place, the LTCI in City X promoted healthy ageing. Our study suggests that the specifics of the LTCI program like who could receive subsidies, family values, and family members' engagement in labor market could all work together to shape the substitution pattern between home and institutional care.

Acute malnutrition (AM) causes large loss of life and disability in children in Africa. Researchers are testing innovative approaches to increase 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. 896 children aged 6-59 months with a mid-upper arm circumference (MUAC) <125 mm or with oedema were treated and followed for six months. 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 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%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 > 125mm and no relapse for 6 months) under OptiMA was 9 percentage points 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 (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 (ICER) 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.

Generic substitutions are globally considered to contain health expenditures. Yet it is uncertain whether the costs would spill over to other medicines or health services. Contextualizing China's National Volume-Based Procurement (NVBP) policy, which promoted generic substitution, this study tests the changes in patients' utilisation of generic medicines and whether the costs shift to other pharmaceutics or health services post-policy. This population-based, matched, cohort study uses claims data from Tianjin, China in 2018-2020. We focus on Amlodipine, the most commonly used calcium channel blocker with the largest volume. We build comparable post-policy cohorts: Non-switchers who kept using originator Amlodipine, Pure-switchers who loyally switched to generic Amlodipine, and Back-switchers who switched back-and-forth; and compare between each matched pair, respectively, of their annual healthcare costs and that broken down by components, and patients' use of and adherence to Amlodipine post-policy. 1185 Pure-switchers, 1398 Back-switchers, and 2330 Non-switchers are identified (mean age: 63.0 years; 58.5% men). For the matched pairs, Pure-switchers (N=772) incurred an annual total medical costs of CNY 9213.5, 12.2% lower than Non-switchers (N=1544, absolute difference CNY -1309.3, 95%CI: [-2645.8, -19.6]). The cost reduction only results from Amlodipine prescriptions in outpatient encounters, and are equally born on health plans and the enrolees. Pure-switchers and Non-switchers are not different in costs from other medicines, nor from other items including tests, surgeries, beds, and medical consumables for hypertension-related encounters/admissions. Pure-switchers had higher daily dosage and better adherence to Amlodipine than Non-switchers as well. The differences between Back-switchers and Non-switchers show similar trends but are less profound. China's NVBP policy is effective to control pharmaceutical costs. No unintended cost effects have yet been identified in the short run. Other countries may learn from China on the comprehensive sets of auxiliary policies, including listing, bidding, purchasing, and reimbursing, to better promote generic substitutions.

South Africa has a high burden of drug-resistant tuberculosis (DR-TB). A policy to decentralize DR-TB treatment from specialized central hospitals to more accessible district facilities was introduced in 2011, but to date implementation has been suboptimal, with variable pace, coverage and models of care emerging. This study explored multilevel policy implementation of DR-TB decentralization in two provinces of South Africa, Western Cape and KwaZulu-Natal. Applying interpretive policy analysis, this paper describes how actors across health system levels and geographies made sense of the DR-TB policy and how this shaped implementation. In an embedded qualitative case study, districts of the two provinces were compared, through data collected in 94 in-depth interviews, and analysed using Vickers' framework of reality, value and action judgements. Five district cases characterise variation in the pace of implementation and models of DR-TB care that emerged. Individual and collective attitudes for and against the policy were underpinned by different systems of meaning for interpreting policy problems and making decisions. These meaning systems were reflected in actor stances on whether DR-TB care needed to be specialized or generalized, nurse- or doctor-led, and institutionalized or ambulatory. Actors' stances influenced their actions and implementation strategies adopted. Resistance to decentralized DR-TB care related to perceived threats of budget cuts to and loss of authority of central facilities, and was often justified in fears of increased transmission, poor quality of care and inadequate resources at lower levels. New advances in diagnosis and treatment to address the growing burden of DR-TB in South Africa will have little impact unless implementation dynamics are better understood, and attention paid to the mindsets, interests and interpretations of policy by actors tasked with implementation. Deliberative policy implementation processes will enhance the quality of discourse, communication and cross-learning between policy actors, critical for reaching synthesis of meaning systems.

Low- and middle-income countries (LMIC) are rapidly urbanizing, and in response to this, there is an expansion in the body of scholarship and significant policy interest in urban healthcare provision. The idea and the reality of 'urban advantage' has meant that health research in low- and middle-income countries (LMICs) has disproportionately focused on health and healthcare provision in rural contexts and is yet to sufficiently engage with urban health as actively. We contend that this research and practice can benefit from a more explicit engagement with the rich conceptual understandings that have emerged in other disciplines around the urban condition. Our critical review included publications from four databases (MEDLINE, EMBASE, CINAHL and Social Sciences Citation Index) and two CHW resource hubs. We draw upon scholarship anchored in sociology to unpack the nature and features of the urban condition; we use these theoretical insights to critically review the literature on urban community health worker programs, as a case to reflect on community health practice and urban health research in LMIC contexts. Through this analysis, we delineate key features of the urban - such as heterogeneity, secondary spaces and ties, size and density, visibility and anonymity, precarious work and living conditions, crime, and insecurity, and specifically the social location of the urban CHWs and present their implications for community health practice. We propose a conceptual framework for a distinct imagination of the urban to guide health research and practice in urban health and community health programs in the LMIC context. The framework will enable researchers and practitioners to better engage with what entails a 'community' and a 'community health program' in urban contexts.

Poverty is associated with poorer mental health in early adulthood. Cash transfers (CTs) have been shown to improve child health and education outcomes, but it is unclear whether these effects may translate into better mental health outcomes as children reach young adulthood. Using a quasi-experimental approach that exploits variation across countries in the timing of national CT programme introduction, we examine whether longer exposure to CTs during childhood (0-17 years) reduces depressive symptoms in early adulthood (18-30 years). Based on harmonized data from Colombia, Mexico and South Africa (N= 14 431) we applied logistic regression models with country- and birth-cohort fixed effects to estimate the impact of cumulative years of CT exposure on mental health, educational attainment and employment outcomes. Our findings indicate that each additional year of CT exposure during childhood is associated with a 4% reduction in the odds of serious depressive symptoms in early adulthood (OR = 0.96, 95% CIs: 0.93 to 0.98). We find no consistent effect of years of exposure on completion of secondary school (OR = 1.01, 95% CIs: 0.99, 1.03), and a negative effect on the probability of employment in early adulthood (OR = 0.90, 95% CIs: 0.88, 0.91). These results suggest that longer exposure to CTs may contribute to modest but meaningful reductions in population level depressive symptoms during early adulthood.

The capacity of government agencies to develop effective policy responses to external shocks is an important area of focus for health policy processes, as illustrated by the COVID-19 pandemic. However, few empirical studies exploring sub-national capacity of governments and the influence of institutional, organizational and political factors in shaping the policy response to complex emergencies have been conducted. The purpose of this study is to examine the governance capacity to develop and implement a policy response to a major health emergency-COVID-19-in Tamil Nadu, India, and to understand the factors shaping governance capacity during the first and second waves (2020-2021). Tamil Nadu offers a useful case for exploring governance capacity due to its longstanding public health institutions and previous experiences with disaster and outbreak response. We utilized three sources of data: (1) a review of key policy documents (n = 164); (2) a review of English-language media articles in the Indian press (n = 336); and (3) in-depth interviews with senior decision-makers, technical experts and other stakeholders (n = 10). We present four key findings from this analysis. First, Tamil Nadu's institutional framework enabled state-level governance capacity during an emergency of massive complexity, allowing for flexibility and nimbleness to adapt to evolving dynamics of centralization and decentralization over the course of the pandemic. Second, the ability to integrate public health expertise was circumscribed at important phases. Third, while coordination with external experts was utilized extensively, engagement with civil society groups was perceived as limited. Fourth, the electoral cycle was perceived by some to have constrained governance capacity at a critical point in the pandemic. By analysing the dynamics of state-level capacity in Tamil Nadu during a complex emergency, this study provides important learnings for other contexts globally regarding the drivers shaping capacity to develop and implement policy responses to crises.