Health policy and planning最新文献

The highly decentralized nature of global health governance presents significant challenges to conceptualizing and systematically measuring the agenda status of diseases, injuries, risks and other conditions contributing to the collective disease burden. An arenas model for global health agenda setting was recently proposed to help address these challenges. Further developing the model, this study aims to advance more robust inquiry into how and why priority levels may vary among the array of stakeholder arenas in which global health agenda setting occurs. We analyse order and the magnitude of changes in priority for eight infectious diseases in four arenas (international aid, scientific research, pharmaceutical industry and news media) over a period of more than two decades in relation to five propositions from scholarship. The diseases vary on burden and prominence in United Nations Sustainable Development Goal 3 for health and well-being, including four with specific indicators for monitoring and evaluation (HIV/AIDS, tuberculosis, malaria, hepatitis) and four without (dengue, diarrhoeal diseases, measles, meningitis). The order of priority did not consistently align with the disease burden or international development goals in any arena. Additionally, using new methods to measure the scale of annual change in resource allocations that are indicative of priority reveals volatility at the disease level in all arenas amidst broader patterns of stability. Insights around long-term patterns of priority within and among arenas are integral to strengthening analyses that aim to identify pivotal causal mechanisms, to clarify how arenas interact, and to measure the effects they produce.

At present, the world is off-track to meet the World Health Assembly global nutrition targets for 2025. Reducing the prevalence of stunting and low birthweight (LBW) in children, and anaemia in women, and increasing breastfeeding rates are among the prioritized global nutrition targets for all countries. Governments and development partners need evidence-based data to understand the true costs and consequences of policy decisions and investments. Yet there is an evidence gap on the health, human capital, and economic costs of inaction on preventing undernutrition for most countries. The Cost of Inaction tool and expanded Cost of Not Breastfeeding tool provide country-specific data to help address the gaps. Every year undernutrition leads to 1.3 million cases of preventable child and maternal deaths globally. In children, stunting results in the largest economic burden yearly at US$548 billion (0.7% of global gross national income [GNI]), followed by US$507 billion for suboptimal breastfeeding (0.6% of GNI), US$344 billion (0.3% of GNI) for LBW and US$161 billion (0.2% of GNI) for anaemia in children. Anaemia in women of reproductive age (WRA) costs US$113 billion (0.1% of GNI) globally in current income losses. Accounting for overlap in stunting, suboptimal breastfeeding and LBW, the analysis estimates that preventable undernutrition cumulatively costs the world at least US$761 billion per year, or US$2.1 billion per day. The variation in the regional and country-level estimates reflects the contextual drivers of undernutrition. In the lead-up to the renewed World Health Assembly targets and Sustainable Development Goals for 2030, the data generated from these tools are powerful information for advocates, governments and development partners to inform policy decisions and investments into high-impact low-cost nutrition interventions. The costs of inaction on undernutrition continue to be substantial, and serious coordinated action on the global nutrition targets is needed to yield the significant positive human capital and economic benefits from investing in nutrition.

Gender impacts exposure and vulnerability to TB, evidenced by a higher prevalence of both TB disease and missed TB diagnoses among men, who significantly contribute to new TB infections. We present the formative research phase of a study which used participatory methods to identify gender-specific interventions for systematic screening of TB among men in Uganda. Health facility level data was collected at four Ugandan general hospitals (Kawolo, Gombe, Mityana, and Nakaseke) among 70 TB stakeholders, including healthcare workers, TB survivors, policymakers, and researchers. Using health seeking pathways, they delineated and compared men's ideal and actual step-by-step TB health seeking processes to identify barriers to TB care. The stepping stones method, depicting barriers as a 'river' and each 'steppingstone' as a solution, was employed to identify interventions which would help link men with TB symptoms to care. These insights were then synthesized in a co-analysis meeting with 17 participants including representatives from each health facility to develop a consensus on proposed interventions. Data across locations revealed the actual TB care pathway diverted from the ideal pathway due to health system, community, health worker and individual level barriers such as delayed health seeking, unfavourable facility operating hours and long waiting times that conflicted with men's work schedules. Stakeholders proposed to address these barriers through the introduction of male-specific services; integrated TB services that prioritize X-ray screening for men with cough; healthcare worker training modules on integrated male-friendly services; training and supporting TB champions to deliver health education to people seeking care; and engagement of private practitioners to screen for TB. In conclusion, our participatory co-design approach facilitated dialogue, learning, and consensus between different health actors on context-specific, person-centred TB interventions for men in Uganda. The acceptability, effectiveness and cost effectiveness of the package will now be evaluated in a pilot study.

There is a growing interest in studying and unpacking implementation of policies and programmes as it provides an opportunity to reduce the policy translation time lag taken for research findings to translate to policies and get implemented and understand why policies may fail. Realist evaluation is a theory-driven approach that embraces complexity and helps to identify the mechanisms generating the observed policy outcomes in given context. We aimed to study facilitators and barriers while implementing the Cigarettes and Other Tobacco Products Act, 2003 (COTPA) a comprehensive national tobacco control policy, and the National Tobacco Control Programme (NTCP), 2008 using realist evaluation. We developed an initial program theory (IPT) based on a realist literature review of tobacco control policies in Low- and Middle-Income Countries (LMICs). Three diverse states -Kerala, West Bengal, and Arunachal Pradesh- with varying degree of implementation of tobacco control law and program were chosen as case studies. Within the three selected states, we conducted in-depth interviews with 48 state and district-level stakeholders and undertook non-participant observations to refine the IPT. Following this, we organized two regional consultations covering stakeholders from 20 Indian states for a second iteration to further refine the program theory. A total of 300 Intervention-Context-Actor-Mechanism-Outcome (ICAMO) configurations were developed from the interview data, which were later synthesized into state-specific narrative program theories for Kerala, West Bengal and Arunachal Pradesh. We identified five mechanisms: collective action, felt accountability, individual motivation, fear, and prioritization that were (or were not) triggered leading to diverse implementation outcomes. We identified facilitators and barriers to implementing the COTPA and the NTCP, which have important research and practical implications for furthering the implementation of these policies as well as implementation research in India. In the future, researchers could build on the refined program theory proposed in this study to develop a middle-range theory to explain tobacco control policy implementation in India and other LMICs.

Setting reimbursement rates in national insurance schemes requires robust cost data. Collecting provider-generated cost accounting information is a potential mechanism for improving the cost evidence. To inform strategies for obtaining cost data to set reimbursement rates, this analysis aims to describe the role of cost accounting in public and private health sectors in India and describe the importance, perceived barriers and facilitators to improving cost accounting systems. In-depth interviews were conducted with 11 key informants. The interview tool guide was informed by a review of published and grey literature and government websites. The interviews were recorded as both audio and video and transcribed. A thematic coding framework was developed for the analysis. Multiple discussions were held to add, delete, classify or merge the themes. The themes identified were as follows: the status of cost accounting in the Indian hospital sector, legal and regulatory requirements for cost reporting, challenges to implementing cost accounting and recommendations for improving cost reporting by health care providers. The findings indicate that the sector lacks maturity in cost accounting due to a lack of understanding of its benefits, limited capacity and weak enforcement of cost reporting regulations. Providers recognize the value of cost analysis for investment decisions but have mixed opinions on the willingness to gather and report cost information, citing resource constraints and a lack of trust in payers. Additionally, heterogeneity among providers will require tailored approaches in developing cost accounting reporting frameworks and regulations. Health care cost accounting systems in India are rudimentary with a few exceptions, raising questions about how to source these data sustainably. Strengthening cost accounting systems in India will require standardized data formats, integrated into existing data management systems, that both meet the needs of policy makers and are acceptable to hospital providers.

This study contributes to a neglected aspect of health policy analysis: policy formulation processes. Context is central to the policy cycle, yet the influence of crises on policy formulation is underrepresented in the health policy literature in low- and middle-income countries (LMICs). This paper analyses a detailed case study of how the COVID-19 crisis influenced policy formulation processes for the regulation of alcohol in South Africa, as part of COVID-19 control measures, in 2020 and 2021. It provides a picture of the policy context, specifically considering the extent to which the crisis influenced the position and power of actors, and policy content. Qualitative data were collected from nine key informant interviews and 127 documents. Data were analysed using thematic content analysis. A policy formulation conceptual framework was applied as a lens to describe complex policy formulation processes. The study revealed that the perceived urgency of the pandemic prompted a heightened sense of awareness of alcohol-related trauma as a known, preventable threat to public health system capacity. This enabled a high degree of innovation among decision-makers in the generation of alternative alcohol policy content. Within the context of uncertainty, epistemic and experiential policy learning drove rapid, adaptive cycles of policy formulation, demonstrating the importance of historical and emerging public health evidence in crisis-driven decision-making. Within the context of centralization and limited opportunities for stakeholder participation, non-state actors mobilized to influence policy through the public arena. The paper concludes that crisis-driven policy formulation processes are shaped by abrupt redistributions of power among policy actors and the dynamic interplay of evolving economic, political and public health priorities. Understanding the complexity of the local policy context may allow actors to navigate opportunities for public health-oriented alcohol policy reforms in South Africa and other LMICs.

In the aftermath of Russia's military response to the 2014 Revolution of Dignity, the government of Ukraine implemented a package of health financing reforms underpinned by universal health coverage (UHC) principles. By the time of Russia's full-scale invasion of Ukraine in February 2022, the new systems and institutions envisaged in the reforms were largely established. In this Commentary article, we explain how these attributes strengthened the Ukrainian health system's response to the impacts of the war. Ukraine's experience highlights the role that health financing arrangements, designed in accordance with UHC principles, can play in strengthening health system resilience.

Sub-Saharan Africa has fewer medical workers per capita than any region of the world, and that shortage has been highlighted consistently as a critical constraint to improving health outcomes in the region. This paper draws on newly available, systematic, comparable data from 10 countries in the region to explore the dimensions of this shortage. We find wide variation in human resources performance metrics, both within and across countries. Many facilities are barely staffed, and effective staffing levels fall further when adjusted for health worker absences. However, caseloads-while also varying widely within and across countries-are also low in many settings, suggesting that even within countries, deployment rather than shortages, together with barriers to demand, may be the principal challenges. Beyond raw numbers, we observe significant proportions of health workers with very low levels of clinical knowledge on standard maternal and child health conditions. This study highlights that countries may need to invest broadly in health workforce deployment, improvements in capacity and performance of the health workforce, and on addressing demand constraints, rather than focusing narrowly on increases in staffing numbers.

As part of a randomized controlled trial conducted in Myanmar between 2016 and 2019, we explore the performance of a maternal cash transfer program across villages assigned to different models of delivery (by government health workers vs loan agents of a non-governmental organization) and identify key factors of success. Measures include enrolment inclusion and exclusion errors, failures in payment delivery to enrolled beneficiaries (whether beneficiaries received any transfer, fraction of benefits received and whether there were delays and underpayment of benefit amounts) and whether beneficiaries remained in the program beyond eligibility. We find that women in villages where government health workers delivered cash transfers received on average two additional monthly transfers, were 19.7% more likely to receive payments on time and in-full and were 14.6% less likely to stay in the program beyond eligibility. With respect to the primary health objective of the program-child nutrition-we find that children whose mother received cash by government health workers were less likely to be chronically malnourished compared to those whose mother received cash by loan agents. Overall, the delivery of cash transfers to mothers of young children by government health workers outperforms the delivery by loan agents in rural Myanmar. Qualitative evidence suggests two key factors of success: (1) trusted presence and past interactions with targeted beneficiaries and complementarities between government health workers' expertise and the program; and (2) performance incentives based on specific health objectives along with top-down monitoring. We cannot exclude that other incentives or intrinsic motivation also played a role.