Health policy and planning最新文献

Understanding how an integrated rehabilitation workforce can be supported and strengthened is crucial to address gaps in access and quality of rehabilitation below tertiary hospitals. We explored how physiotherapists in two provinces in Pakistan perceive enablers and constraints to their rehabilitation performance at individual, workplace, health systems, socio-cultural, and political levels. Using a qualitative approach based on social ecological theories of health-worker performance and semi-structured interviews, 31 in-depth interviews with physiotherapists were conducted at secondary care hospitals in Khyber Pakhtunkhwa and Sindh provinces. Four intersecting themes were generated. (i) The capacity to perform as a rehabilitation professional is mediated by factors operating at different levels of the worker ecology. The experience of these factors has implications for (ii) the livelihoods and wellbeing of rehabilitation workers and (iii) the quality of care these workers perceive is delivered. (iv) Respondents' insightful and diverse suggestions for positive opportunities for change, towards strengthening and expanding integration of rehabilitation services within the health system, have policy and practice implications. Findings suggest an interdependence between context, rehabilitation workers, and the quality of care they deliver. The perspectives of these workers draw attention, beyond staff numbers and distribution, to the real-world challenges of practicing effectively in the context of local and systemic constraints and facilitators. These insights will be valuable to current efforts to integrate rehabilitation into health care settings beyond tertiary hospitals.

Efforts to strengthen knowledge translation (KT) for policy-making often call for greater engagement with the policy process and its actors. Yet, existing KT approaches often focus on communication and dissemination of evidence and undertheorise the role and influence of policy actors on KT. As such, this study examines how, why, and to what effect policy actors shape KT. Our findings address a critical gap in the KT literature regarding the relational dimensions of KT for policy-making in low-middle-income countries. We utilised purposive and snowball sampling to identify participants who are involved in health policy-making and KT in Kenya. This included policy-makers, academics/researchers, knowledge intermediaries, and external partners (development and implementation partners). Data were collected through in-depth interviews (n = 32), observations (n = 52 h), and document reviews (n = 34). Data analysis was informed by a theoretical framework that combined perspectives from actor-centred institutionalism, Gaventa's PowerCube, boundary work, and coproduction. Our findings reveal how actor influence in KT is shaped by institutional mandates and roles, which, in turn, shape how actors perceive their position and authority in KT processes. While some actors viewed themselves as constrained to the role of evidence provision, others acted as boundary spanners across policy spaces, enabled by their institutional flexibility and financial resources. In addition, actor interests shaped when and how they exercised power to support or resist KT. Furthermore, access to policy spaces determined whose evidence was visible and perceived as legitimate, reflecting deeper power structures. These dynamics frame KT as a relational process mediated by political and institutional structures. As such, this study highlights the need to reconceptualise KT to integrate relational and structural dimensions, moving beyond evidence dissemination to addressing actor and power dynamics. It contributes novel insights into the interplay between actors, context, and power in shaping KT outcomes.

The underutilization of primary care (PC) presents a substantial challenge in enhancing the people-centeredness, quality, and efficiency of health services for patients with chronic diseases. Pharmaceutical copayments have been considered a key barrier to patient access in low- and middle-income countries. It is unclear whether the removal of pharmaceutical copayment can lead to better care and management of chronic diseases. This study sought to evaluate the impact on healthcare utilization and spending of a policy that waived fees for essential pharmaceuticals at PC facilities, piloted county-wide from 2014 in rural China. Using individual claims data from 2010 to 2017, we applied a synthetic difference-in-difference approach to estimate the policy's effects. Our sample included 9115 patients with hypertension and/or diabetes from the pilot county and 30 675 patients from the other counties in the same municipality. The policy led to a significant increase of 0.69 in the number of PC visits per patient per year (95% CI: 0.46-0.91), equivalent to a rise of 44.1%. Annual spending per person on outpatients at PC facilities increased significantly due to the policy, by 58 yuan (95% CI: 36-80), equivalent to a rise of 40.5%. As for outpatient visits at hospitals, there was a 25.8% significant reduction in the number of visits per year (-0.56; 95% CI: -0.95 to -0.16) and a nonsignificant increase in spending (45 yuan; 95% CI: -111 to 21). The annual number of admissions and spending on inpatients per person in all facilities remained stable. Using claims data, we have demonstrated that targeted removal of copayment for essential medicines successfully shifted outpatient visits and expenditure from hospitals to PC facilities but did not affect hospitalization and inpatient expenditure. Further research may be attempted to see if removing pharmaceutical copayments on people with less severe NCDs could reduce hospitalizations.

Cervical cancer is a significant public health issue in Nigeria and a major cause of cancer-related morbidity and mortality among women. Equitable implementation of cervical cancer control programs alongside relevant policies and strategic plans is vital to reducing the burden of cervical cancer and improving the quality of life. Considering the role of policies in guiding program implementation, we reviewed Nigeria's cervical cancer policy landscape to identify strengths, limitations, and opportunities for improvement. This policy appraisal involved a literature review to understand related policy review frameworks, developing a modified framework containing six domains, systematically searching key databases and websites to identify relevant policy documents, data extraction and analysis, and synthesizing findings from reviewed documents. A total of five documents were reviewed in this study-three integrated cancer control plans, a cervical cancer policy, and a strategic plan for cervical cancer prevention and control. Two of the reviewed documents are current (2023-7), one is outdated, and two are expired. Key strengths identified in these documents include (i) a clear articulation of goals, (ii) a collaborative development process, (iii) the adoption of a phased implementation approach for proposed interventions, (iv) detailed intervention plans, and (v) monitoring and evaluation plans with performance indicators. In contrast, key limitations include (i) poor participation of subnational level stakeholders, (ii) absence of costing and funding approach in some plans, (iii) lack of baseline data on unmet needs and outcomes of previous plans, and (iv) absence of health system resource mapping. Addressing identified limitations is critical to improving the quality of policy and policy-informing documents, strengthening implementation across all levels, lowering the cervical cancer burden, and improving women's health outcomes.

Infertility, a widely prevalent condition globally, incurs high economic burdens. Assisted reproductive technologies (ARTs) are effective treatments, but public health financing in low- and middle-income countries (LMICs) rarely covers ART services. In China, where birth rates are declining, willingness to pay (WTP) can inform insurance reimbursement policies by reducing out-of-pocket expenses. However, there is no consensus on WTP thresholds for assessing the cost-effectiveness of fertility treatments in LMICs. This study aimed to assess WTP for ART among individuals with infertility in China. Data were obtained from a cross-sectional survey conducted at five hospitals across different geographical and socioeconomic regions in China. Individuals with infertility were recruited using a quota sampling method. A contingent valuation method was employed, with three hypothetical WTP scenarios developed to present detailed information on the success rates, costs, and the treatment processes of in vitro fertilization (IVF), artificial insemination (AI), and preimplantation genetic testing (PGT). A total of 570 individuals with infertility participated in the survey [94.4% female; mean (standard deviation) age: 33.0 (4.7) years]. The sampled respondents were willing to pay renminbi (RMB) 30 163 [$4259, 95% confidence interval (CI): RMB 29 650-30 675] for IVF, RMB 6046 ($854, 95% CI: RMB 5987-6106) for AI, and RMB 47 234 ($6669, 95% CI: RMB 46 435-48 033) for PGT. These WTPs were equivalent to 0.34, 0.07, and 0.53 times the GDP per capita in China, respectively. Older age and male-factor or unexplained infertility were significantly associated with lower WTP (P < .05), while higher education and patient-physician communication about costs were positively associated with WTP (P < .05). These findings suggest that public health insurance schemes should establish appropriate cost-effectiveness thresholds and reimbursement ceilings for ART to improve affordability and access. Incorporating patient-physician communication about cost into clinical practice may facilitate shared decision-making and potentially increase patients' perceived value of ART.

A hierarchical medical system anchored in primary healthcare is a critical mechanism for global healthcare systems to alleviate financing pressures and enhance health outcomes. Leveraging panel data from Zhejiang Province (2017-2022), this study evaluates how regional global budget payment reforms, implemented within county medical communities, influence the progression of the hierarchical medical system. The reforms were associated with a 3.0% (90% CI: -6.3 to 0.3, P < 0.1) reduction in patient volumes at county-level hospitals and a 30.2% (95% CI: 3.1-57.4, P < 0.05) surge in downward referrals to primary institutions. Concurrently, primary facilities saw an 8.3% (95% CI: 0.56-16.0, P < 0.05) increase in outpatient visits and 6.9% (95% CI: 0.15-13.7, P < 0.05) revenue growth. From the perspective of health performance, there was a 1.33% (95% CI: -2.57 to -0.09, P < 0.05) reduction in premature mortality from major chronic diseases. Mechanism analysis reveals that the regional global budget payment reshapes the incentives for both county-level hospitals and primary healthcare institutions. Under cost-containment pressures, county-level hospitals strategically redirect non-critical patients to primary healthcare institutions through formal referral protocols, while the latter are financially incentivized to provide healthcare services. These findings demonstrate how payment reforms can recalibrate provider behavior in vertically integrated systems, offering an explorable pathway for building people-centered, integrated healthcare systems through health insurance leverage.

A long-standing concern suggests that performance-based financing (PBF) may undermine the intrinsic motivation of health workers by heightening extrinsic motivation concerns via the novel introduction of financial incentives. However, the theoretical effect of PBF on worker motivation and job satisfaction is ambiguous as these programs may also improve working conditions, staff engagement, and other factors that determine health worker morale. We use data from six evaluations of national pilots to empirically assess the effect of PBF on worker motivation and job satisfaction. In these six pilots (in Cameroon, Kyrgyz Republic, Nigeria, Tajikistan, Zambia, and Zimbabwe), geographical units (or health facilities) were either randomized or quasi-experimentally assigned to receive PBF or the alternatives of direct facility financing (DFF), enhanced supervision (ES), or business-as-usual comparison arms. Baseline and endline health worker surveys were carried out in the context of these national pilots. The primary outcomes investigated here are health worker motivation and job satisfaction. Secondary outcomes include subconstructs of health worker motivation and job satisfaction extracted using exploratory factor analysis. For two countries out of six-Nigeria and Kyrgyz Republic-we find increases in overall worker motivation and null effects in the other four when contrasting PBF with the business-as-usual comparison. For five countries out of six (all but Cameroon), we find increases in job satisfaction. Further, PBF did not have any systematic motivating or demotivating effects when compared with the health system intervention alternatives of DFF and ES (each in a subset of countries), except in Nigeria where satisfaction in the PBF arm was lower when compared with DFF. All told, these results contain practically no evidence of an adverse effect of PBF on overall health worker motivation or job satisfaction and indeed suggest a beneficial impact in some country settings.

This study examines the substitution effects and complementary dynamics between outpatient and inpatient services across different levels of hospital care in China's tiered healthcare system. The data of this study originated from official administrative medical insurance reimbursement records from 2013 to 2019, with a final sample size of 1 520 263 patients. Using individual-level data and controlling for regional variations through fixed-effects models, we identify significant patterns in healthcare utilization that provide actionable insights for enhancing system efficiency. We have found a notable substitution effect: increased utilization of primary care services was negatively associated with the demand for secondary and tertiary care, thereby supporting ongoing health policy reforms. Additionally, outpatient services at primary care facilities could reduce the demand for both outpatient and inpatient services at higher-level hospitals. The homogeneity of outpatient services further facilitated substitution across care levels, allowing primary and secondary care to increasingly manage clinical cases previously handled by tertiary hospitals. Finally, we explored the complementary relationship between outpatient and inpatient services within the same care level, emphasizing highlighting how financial incentives contribute to induced hospitalization in China's healthcare system. These findings suggest that healthcare policies must be adjusted to address systemic inefficiencies and realign financial incentives in order to improve resource allocation and patient care.

Cambodia is experiencing a growing burden of non-communicable diseases (NCDs) as it undergoes an epidemiological transition. This qualitative study investigates the health-seeking behaviors of Cambodians in the context of hypertension and diabetes, focusing on the utilization of both formal healthcare and alternative medical practices. Data are from 20 in-depth interviews with participants without social health protection and 6 focus groups (n = 48), involving beneficiaries of the Health Equity Fund (HEF) and National Social Security Fund (NSSF). The research explores personal experiences with NCD management, perceptions of social health protection schemes, and perceived barriers to accessing healthcare. Data were collected in urban and rural settings in Cambodia, with thematic analysis facilitated by NVivo 14 software. Many participants delayed seeking biomedical advice due to economic constraints, cultural beliefs, and perceived inadequacies in the healthcare system. Traditional remedies and self-medication were commonly reported, often due to their accessibility and lower cost compared to biomedical healthcare services. Despite the availability of HEF and NSSF, structural challenges within the healthcare system, such as shortages of medications and trained staff at public health centers, emerged as significant barriers. Pharmacy workers and village healers are insufficiently utilized human resources. Formalizing their role in the secondary prevention of NCDs could contribute to the early detection of diabetes and hypertension. The findings suggest the need for an integrated health system that strengthens the capacity of primary care facilities to manage NCDs effectively and utilizes the semi-professional sector more systematically. Strengthening primary care, expanding service availability, and improving social health protection schemes are essential to reduce health disparities and improve access to quality care for NCDs in Cambodia.

Subjective well-being (SWB) is increasingly recognized as a critical indicator of healthy ageing. While prior studies highlight the importance of health behaviours, few examine how multidimensional health investments influence SWB across different levels of well-being. This paper explores the relationship between health investment and SWB among older adults in China, using data from the 2018 Chinese Longitudinal Healthy Longevity Survey. Health investment is categorized into 4 domains: nutrition, healthcare access (insurance coverage and health product use), lifestyle behaviours (including exercise, smoking, and drinking), and living environment (access to clean drinking water). Quantile regression models are applied to assess heterogeneous effects across the SWB distribution, while mediation analysis investigates the role of self-rated health and functional health (activities of daily living) as potential pathways. Results show that the positive effects of nutrition and exercise are the most pronounced among individuals with lower SWB, while smoking and drinking exhibit stronger negative associations in this group. Mediation results suggest that perceived health plays a more consistent role than functional status in translating health investment into higher well-being. The impact of insurance is observed primarily through interaction effects, magnifying benefits from healthy behaviours and buffering risks from harmful ones. These findings point to the need for equity-sensitive ageing policies that target both health behaviours and social protection. Specifically, integrating social work and behavioural counselling into primary health outreach may help address substance-related risks and psychological vulnerabilities among the elderly. This evidence has wider relevance for ageing societies, particularly in low- and middle-income countries aiming to align health system goals with subjective well-being outcomes.