Health policy and planning最新文献

India's economy is among the fastest growing in the world. However, a large share of informal workforce is a common characteristic of country's economy, comprises a significant portion of most of its labour markets. This workforce often receives low wages and lacks benefits such as strong social security and health coverage for all. The majority of healthcare spending in India is private. As India's population ages and the informal sector expands, it is expected that many of these workers will continue to work beyond the retirement age to bear their own healthcare costs due to lack of savings, pensions and the precarious nature of their employment. In this context, this study estimates the burden of Out-of-Pocket (OOP) payments on India's informal older workers compared to their formal counterparts, using data from the first wave of the nationally representative Longitudinal Ageing Study in India. According to estimates from the Two-part regression model, informal older workers pay, on an average, INR 1113 (p<0.01) and INR 55 (p<0.05) less than their formal counterparts for inpatient and outpatient care, respectively. However, probit regression models revealed that the burden of combined (both inpatient and outpatient) OOP payments exceeding (by 40%, 20%, and 10%) of their income is significantly higher among informal older workers compared to formal older workers. The study underscores the need for strengthening of universal health insurance schemes to ensure everyone has access to medical services without experiencing financial hardship. It also advocates for policies specifically tailored towards informal workers, considering their unique challenges with regard to livelihoods and healthcare security. In particular, this encompasses bolstering the existing social security and healthcare system, and related policies for ensuring financial security against OOP payments, especially for informal workers and all the population in general.

New vaccine policy adoption is a complex process, especially in low-and-middle-income countries (LMICs), requiring country policymakers to navigate challenges such as competing priorities, human and financial resource constraints, and limited logistical capacity. Since the Expanded Programme on Immunization's (EPI) beginning, most new vaccine introductions under this structure have not been aimed at adult populations. The majority of adult vaccines offered under the EPI are not typically tested among and tailored for pregnant persons, except those that are specifically recommended for pregnancy. Given that new maternal vaccines, including RSV and GBS 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 by Levine et al., (2010) focused on new vaccine introduction in LMICs. 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 program. Previous shortcomings, in Kenya, and globally during HPV 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, we are at 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.

Many children do not receive a full schedule of childhood vaccines, yet there is limited evidence on the cost-effectiveness of strategies for improving vaccination coverage. Evidence is even scarcer on the cost-effectiveness of strategies for reaching 'zero-dose children', who have not received any routine vaccines. We evaluated the cost-effectiveness of periodic intensification of routine immunization (PIRI), a widely applied strategy for increasing vaccination coverage. We focused on Intensified Mission Indradhanush (IMI), a large-scale PIRI intervention implemented in India in 2017-2018. In 40 sampled districts, we measured the incremental economic cost of IMI using primary data, and used controlled interrupted time-series regression to estimate the incremental vaccination doses delivered. We estimated deaths and disability-adjusted life years (DALYs) averted using the Lives Saved Tool and reported cost-effectiveness from immunization programme and societal perspectives. We found that, in sampled districts, IMI had an estimated incremental cost of 2021US$13.7 (95% uncertainty interval: 10.6 to 17.4) million from an immunization programme perspective and increased vaccine delivery by an estimated 2.2 (-0.5 to 4.8) million doses over a 12-month period, averting an estimated 1413 (-350 to 3129) deaths. The incremental cost from a programme perspective was $6.21 per dose ($2.80 to dominated), $82.99 per zero-dose child reached ($39.85 to dominated), $327.63 ($147.65 to dominated) per DALY averted, $360.72 ($162.56 to dominated) per life-year saved and $9701.35 ($4372.01 to dominated) per under-5 death averted. At a cost-effectiveness threshold of 1× per-capita GDP per DALY averted, IMI was estimated to be cost-effective with 90% probability. This evidence suggests IMI was both impactful and cost-effective for improving vaccination coverage, though there is a high degree of uncertainty in the results. As vaccination programmes expand coverage, unit costs may increase due to the higher costs of reaching currently unvaccinated children.

Domestic violence (DV) is a global prevalent health problem leading to adverse health consequences, yet health systems are often unprepared to address it. This article presents a comparative synthesis of the health system's pre-conditions necessary to enable integration of DV in health services in Brazil, Nepal, Sri Lanka and occupied Palestinian Territories (oPT). A cross-country, comparative analysis was conducted using a health systems readiness framework. Data collection involved multiple data sources, including qualitative interviews with various stakeholders; focus-group discussions with women; structured facility observations; and a survey with providers. Our findings highlight deficiencies in policy and practice that need to be addressed for an effective DV response. Common readiness gaps include unclear and limited guidance on DV, unsupportive leadership coupled with limited training and resources. Most providers felt unprepared, lacked guidance and felt unsupported and unprotected by managers and their health system. While in Brazil most providers felt they should respond to DV cases, many in Sri Lanka preferred not to. Such organizational and service delivery challenges, in turn, also affected how health providers responded to DV cases leaving them not confident, uncertain about their knowledge and unsure about their role. Furthermore, providers' personal beliefs and values on DV and gender norms also impacted their motivation and ability to respond, prompting some to become 'activists' while others were reluctant to intervene and prone to blame women. Our synthesis also pointed to a gap in women's use of health services for DV as they had low trust in providers. Our conceptual framework demonstrates the importance of having clear policies and highlights the need to engage leadership across every level of the system to reframe challenges and strengthen routine practices. Future research should also determine the ways in which women's understanding and needs related to DV help-seeking are addressed.

The Integrated Disease Surveillance and Response (IDSR) system was adopted by the Sierra Leone Ministry of Health (MOH) in 2008, which was based on paper-based tools for health data recording and reporting from health facilities to the national level. The Sierra Leone MoH introduced the implementation of electronic case-based disease surveillance reporting of immediately notifiable diseases. This study aimed to document and describe the experience of Sierra Leone in transforming her paper-based disease surveillance system into an electronic disease surveillance system. Retrospective mixed methods of qualitative and quantitative data were reviewed. Qualitative data was collected by reviewing surveillance technical reports, epidemiological bulletins, COVID-19, IDSR technical guidelines, Digital Health strategy, and DHIS2 documentation. Content and thematic data analysis were performed for the qualitative data, while Microsoft Excel and DHIS2 platform were used for the quantitative data analysis to document the experience of Sierra Leone in digitalizing its disease surveillance system. In early 2017, a web-based electronic Case-Based Disease Surveillance (eCBDS) for real-time reporting of immediately notifiable diseases and health threats was piloted using the District Health Information System 2 (DHIS2) software. The eCBDS, integrates case profile, laboratory, and final outcome data. All captured data and information are immediately accessible to users with the required credentials. The system can be accessed via a browser or an Android DHIS2 application. By 2021, there was a significant increase in the proportion of immediately notifiable cases reported through the facility-level electronic platform, and more than 80% of the cases reported through the weekly surveillance platform had case-based data in eCBDS. Case-based data from the platform is analyzed and disseminated to stakeholders for public health decision-making. Several outbreaks of Lassa fever, Measles, vaccine-derived Polio, and Anthrax have been tracked in real-time through the eCBDS.

There is growing scholarly interest in what leads to global or national prioritization of specific health issues. By retrospectively analysing agenda setting for India's national burn programme, this study aimed to better understand how the agenda-setting process influenced its design, implementation and performance. We conducted document reviews and key informant interviews with stakeholders and used a combination of analytical frameworks on policy prioritization and issue framing for analysis. The READ (readying material, extracting data, analysing data and distilling findings) approach was used for document reviews, and qualitative thematic analysis was used for coding and analysis of documents and interviews. The findings suggest three critical features of burns care policy prioritization in India: challenges of issue characteristics, divergent portrayal of ideas and its framing as a social and/or health issue and over-centralization of agenda setting. First, lack of credible indicators on the magnitude of the problem and evidence on interventions limited issue framing, advocacy and agenda setting. Second, the policy response to burns has two dimensions in India: response to gender-based intentional injuries and the healthcare response. While intentional burns have received policy attention, the healthcare response was limited until the national programme was initiated in 2010 and scaled up in 2014. Third, over-centralization of agenda setting (dominated by a few homogenous actors, located in the national capital, with attention focused on the national ministry of health) contributed to limitations in programme design and implementation. We note following elements to consider when analysing issues of significant burden but limited priority: the need to analyse how actors influence issue framing, the particularities of issues, the inadequacy of any one dominant frame and the limited intersection of frames. Based on this analysis in India, we recommend a decentralized approach to agenda setting and for the design and implementation of national programmes from the outset.

This article traces the influence of network power on mental health policy in Liberia, a low-income, post-conflict West African country. Based on key informant interviews, focus group discussions and document analysis, the work uses an inductive approach to uncover how a network of civil society groups, government officials, diasporans and international NGOs shaped the passage, implementation and revision of the country's 2009 and 2016 mental health policies. With relations rooted in ties of information, expertise, resources, commitment and personal connections, the network coalesced around a key agent, the Carter Center, which connected members and guided initiatives. Network power was evident when these actors channelled expertise, shared narratives of post-war trauma and mental health as a human right, and financial resources to influence policy. Feedback loops appeared as policy implementation created new associations of mental health clinicians and service users, research entities and training institutes. These beneficiaries offered the network information from lived experiences, while also pressing their own interests in subsequent policy revisions. As the network expanded over time, some network members gained greater autonomy from the key agent. Network power outcomes included the creation of government mental health institutions, workforce development, increased public awareness, civil society mobilization and a line for mental health in the government budget, though concerns about network overstretch and key agent commitment emerged over time. The Liberian case illustrates how networks need not be inimical to development, and how network power may facilitate action on stigmatized, unpopular issues in contexts with low state capacity. A focus on network power in health shows how power can operate not only through discrete resources such as funding but also through the totality of assets that network linkages make possible.

The vision of the African Medicines Agency (AMA) is to ensure that all Africans have access to affordable medical products that meet internationally recognized standards of quality, safety and efficacy for priority diseases/conditions. The AMA is being established by a treaty which had to be ratified by a minimum of 15 African countries. Although there was no deadline, the ratification process has been slower than expected. This study therefore analysed the rationale, perceived benefits, enabling factors and challenges of the AMA's establishment. This study was a qualitative, cross-sectional, census survey of the national medicines regulatory authorities (NRAs) of 45 African countries. The Heads of NRAs and a senior NRA staff member were contacted to complete self-administered questionnaires. The existence of mature NRAs, the desire to have harmonized regulatory systems, the presence of strong political will and appropriate advocacy to expedite treaty signing are all enabling factors for AMA treaty signing. The challenges reported include the fact that the process is slow and there is limited understanding of the process. Competing national priorities, changes in office bearers in the public system and stagnation of the process at the ministerial level were also challenges reported. This study has improved the understanding of the treaty signing and ratification process and the perceived benefits and enabling factors of signing and ratification from African NRAs' perspective. NRAs also highlighted challenges encountered in the process. Addressing these challenges will result in effective medicines regulation by galvanizing technical support, regulatory expertise and resources at a continental level.

Mental health advocacy and activism have been highlighted as important in the effort towards creating environments for better mental health. However, relevant research in low- and middle-income country settings remains limited and lacks critical exploration. We seek to contribute to filling this gap by exploring driving factors behind mental health advocacy and activism efforts in low- and middle-income country settings. This review uses a critically informed thematic analysis employing conceptual frameworks of productive power to analyse peer-reviewed articles on mental health advocacy or activism over the last 20 years. We suggest that the current body of research is marred by superficial explorations of activism and advocacy, partly due to a lack of cohesion around definitions. Based on our findings, we suggest a conceptual framework to guide deeper explorations of mental health advocacy and activism. This framework identifies 'legitimacy', 'context' and 'timing' as the main dimensions to consider in understanding activism and advocacy efforts. The fact that they remain misunderstood and underappreciated creates missed opportunities for meaningful inclusion of lived experience in policy decisions and limits our understanding of how communities envision and enact change.

This study determined the feasibility of investing revenues raised through Nigeria's sugar-sweetened beverage (SSB) tax of 10 Naira/l to support the implementation of the National, Surgical, Obstetrics, Anaesthesia and Nursing Plan, which aims to strengthen access to surgical care in the country. We conducted a mixed-methods political economy analysis. This included a modelling exercise to predict the revenues from Nigeria's SSB tax based on its current tax rate over a period of 5 years, and for several scenarios such as a 20% ad valorem tax recommended by the World Health Organization. We performed a gap analysis to explore the differences between fiscal space provided by the tax and the implementation cost of the surgical plan. We conducted qualitative interviews with key stakeholders and performed thematic analyses to identify opportunities and barriers for financing surgery through tax revenues. At its current rate, the SSB tax policy has the potential to generate 35 914 111 USD in year 1, and 189 992 739 USD over 5 years. Compared with the 5-year adjusted surgical plan cost of 20 billion USD, the tax accounts for ∼1% of the investment required. There is a substantial scope for further increases in the tax rate in Nigeria, yielding potential revenues of up to 107 663 315 USD, annually. Despite an existing momentum to improve surgical care, there is no impetus to earmark sugar tax revenues for surgery. Primary healthcare and the prevention and treatment of non-communicable diseases present as the most favoured investment areas. Consensus within the medical community on importance of primary healthcare, along the recent government transition in Nigeria, offers a policy window for promoting a higher SSB tax rate and an adoption of other sin taxes to generate earmarked funds for the healthcare system. Evidence-based advocacy is necessary to promote the benefits from investing into surgery.