Health policy and planning最新文献

Diabetes prevalence is rising globally, especially in low- and middle-income countries like Mexico, posing challenges for healthcare systems that require efficient primary care to manage the disease. However, healthcare efficiency is influenced by factors beyond decision-makers, including socioeconomic and political conditions. This study aims to evaluate the technical efficiency of primary healthcare for diabetes patients in Mexico over a 12-year period and explore the impact of contextual variables on efficiency. A longitudinal analysis was conducted using administrative and socio-demographic data from 242 health jurisdictions between 2009 and 2020. Data envelopment analysis with bootstrapping and output orientation was used to measure the technical efficiency; health resources in infrastructure and human resources were used as inputs. As outcome, the number of patients receiving treatment for diabetes and the number of patients with controlled diabetes were considered. Machine learning algorithms were employed to analyse multiple factors affecting the provision of diabetes health services and assess heterogeneity and trends in efficiency across different health jurisdictions. The average technical efficiency in primary healthcare for diabetes patients was 0.44 (CI: 0.41-0.46) in 2009, reaching a peak of 0.71 (CI: 0.69-0.72) in 2016, and moderately declining to 0.60 (CI: 0.57-0.62) in 2020; these differences were statistically significant. The random forest analysis identified the marginalization index, primary healthcare coverage, proportion of indigenous population and demand for health services as the most influential variables in predicting efficiency levels. This research underscores the crucial need for the formulation of targeted public policies aimed at extending the scope of primary healthcare services, with a particular focus on addressing the unique challenges faced by marginalized and indigenous populations. According to our results, it is necessary that medical care management adjust to the specific demands and needs of these populations to guarantee equitable care in Mexico.

The burden of sexually transmitted infections (STIs) continues to increase in developing countries like China, but the access to STI care is often limited. The emergence of direct-to-consumer (DTC) telemedicine offers unique opportunities for patients to directly access health services when needed. However, the quality of STI care provided by telemedicine platforms remains unknown. After systemically identifying the universe of DTC telemedicine platforms providing on-demand consultations in China in 2019, we evaluated their quality using the method of unannounced standardized patients (SPs). SPs presented routine cases of syphilis and herpes. Of the 110 SP visits conducted, physicians made a correct diagnosis in 44.5% (95% CI: 35.1% to 54.0%) of SP visits, and correctly managed 10.9% (95% CI: 5.0% to 16.8%). Low rates of correct management were primarily attributable to the failure of physicians to refer patients for STI testing. Controlling for other factors, videoconference (vs SMS-based) consultation mode and the availability of public physician ratings were associated with higher-quality care. Our findings suggest a need for further research on the causal determinants of care quality on DTC telemedicine platforms and effective policy approaches to promote their potential to expand access to STI care in developing countries while limiting potential unintended consequences for patients.

The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.

The advent of the COVID-19 pandemic and the establishment of a new transitional government in Sudan with rejuvenated relations with the international community paved the way for external assistance to the EU COVID-19 response project, a project with a pioneering design within the region. The project sought to operationalize the humanitarian-development-peace nexus, perceiving the nexus as a continuum rather than sequential due to the protracted nature of emergencies in Sudan and their multiplicity and contextual complexity. It went further into enhancing peace through engaging with conflict and post-conflict-affected states and communities and empowering local actors. Learning from this experience, external assistance models to low- or middle-income countries (LMICs) should apply principles of flexibility and adaptability, while maintaining trust through transparency in exchange, to ensure sustainable and responsive action to domestic needs within changing contexts. Careful selection and diverse project team skills, early and continuous engagement with stakeholders, and robust planning, monitoring and evaluation processes were the project highlights. Yet, the challenges of political turmoil, changing Ministry of Health leadership, competing priorities and inactive coordination mechanisms had to be dealt with. While applying such an approach of a health system lens to health emergencies in LMICs is thought to be a success factor in this case, more robust technical guidance to the nexus implementation is crucial and can be best attained through encouraging further case reports analysing context-specific practices.

The vital role of healthcare financing in achieving universal health coverage is indisputable. However, most countries, including Malaysia, face challenges in establishing an equitable and sustainable healthcare financing system due to escalating healthcare costs, an ageing population and a growing disease burden. With desirable pre-payment and risk pooling features, private health insurance (PHI) is considered an alternative financing option to reduce out-of-pocket (OOP) medical expenditure. However, ongoing theoretical and empirical debates persist regarding the adequacy of financial risk protection provided by PHI largely because it depends on its role, the benefit design and the regulations in place. Our study aimed to investigate the effect of supplementary PHI on OOP inpatient medical expenditure in Malaysia. Secondary data analysis was conducted using the Malaysian National Health and Morbidity Survey 2019 dataset. A total of 983 respondents with a history of inpatient hospitalization in the past 12 months were included in the study. Instrumental variable analysis using a two-stage residual inclusion was performed to address endogeneity bias, with wealth status and education level as the instrumental variables. Tobit regression model was used in the second stage considering the censored distribution of the outcome variable. Missing data were handled using multiple imputation. About one-fifth of the respondents had PHI. In this study, we found that having PHI significantly increased OOP inpatient medical expenditure in all three marginal effects. Additionally, age, residential location, ethnicity (citizenship), being covered by government guarantee letter, government funding and employer-sponsored health insurance were other significant factors associated with OOP inpatient medical expenditure. Our findings undermine a key justification to advocate PHI uptake among the population, with a need for the Malaysian government to reassess the role of PHI in healthcare financing and reconsider PHI subsidization policy. Regulations should also be strengthened to enhance the financial risk protection provided by PHI.

Cash transfers (CTs) have been increasingly used in low- and middle-income countries as a poverty reduction and social protection tool. Despite their potential for empowering vulnerable groups (especially women), the evidence for such outcomes remains unclear. Additionally, little is known about how this broad concept fits into and is perceived in such programmes. For example, Lesotho's Child Grants Programme (CGP) is an unconditional CT targeting poor and vulnerable households with children. The CGP has been presented as one of the Lesotho's flagship programmes in developing the country's social safety net system. Using the CGP's early phases as a case study, this research aims to capture how programme stakeholders understood and operationalized the concept of economic empowerment (especially women's) in Lesotho's CGP. The qualitative analysis relied on the triangulation of information from a review of programme documents and semi-structured key informant interviews with programme stakeholders. First, the programme documents were coded deductively, while the interview transcripts were coded inductively, and then both materials were analysed thematically. Finally, differences or disagreements within each theme were explored individually according to the programme's chronology, the stakeholders' affiliation and their role in the CGP. The complexity of economic empowerment was reflected in the diversity of definitions found in the desk review and interviews. Economic empowerment was primarily understood as improving access to economic resources and opportunities and, less so, as agency and social and economic inclusion. There were stronger disagreements on other definitions as they seemed to be a terminology primarily used by specific stakeholders. This diversity of definitions impacted how these concepts were integrated into the programme, with particular gaps between the strategic vision and operational units as well as between the role this concept was perceived to play and the effects evaluated so far.

In 2015, the World Health Assembly adopted a global action plan (GAP) on antimicrobial resistance (AMR). Member states were encouraged to develop their own national action plans (NAPs) in alignment with the GAP. To-date, in systematic assessments of NAPs, the Latin American specific context has not been previously analysed. Here we examined 11 Latin American NAPs published between 2015 and 2021 using content analysis. We focused on two approaches: (1) alignment between the strategic objectives and actions defined in the GAP, and those outlined in the NAPs via a content indicator; and (2) assessment of the NAPs via a governance framework covering 'policy design', 'implementation tools' and 'monitoring and evaluation' areas. We observed a high alignment with the strategic objectives of the GAP; however, the opposite was observed for the corresponding actions. Our results showed that the governance aspects contained within coordination and participation domains were addressed by every Latin American NAP, whereas monitoring and assessment areas, as well as incorporating the environment, would need more attention in subsequent NAPs. Given that AMR is a global health threat and collective efforts across regions are necessary to combat it, our findings can benefit member states by highlighting how to strengthen the AMR strategies in Latin America, while also supporting global policy formulation.

Pakistan is a lower middle-income setting. External assistance for health and development partners play an important role in health sector development. The federal system and health care delivery as a devolved provincial subject warrant regular and effective coordination among federating units and partners. Pakistan was selected as a priority country in 2019 for the implementation of the Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP). Given the ongoing universal health coverage (UHC) reforms, the country prioritized two SDG3 GAP accelerators, related to primary health care (PHC) and sustainable financing for health (SFH). Eight partner agencies representing PHC and SFH accelerators jointly planned and conducted a 'PHC for UHC mission' to Pakistan in 2021. This mission paved the way for setting up an SDG3 GAP Coordination Committee and a 'PHC Service Delivery and Financing working group', which have been regularly coming together through in-person and virtual meetings; the latter was relatively uncommon previously and this new way of working provided a chance to build rapport, share workplans, identify duplications in technical assistance and jointly gauge governments' priorities. This has shifted the focus of reforms deliberations from 'what' to 'how', enabling joint strategic planning and implementation. The joint work by SDG3 GAP partners with the Ministry of National Health Services Regulation & Coordination linked discussions on health financing and service delivery reforms for the first time, and has contributed to advocacy, analysis, strategic policy dialogue, institutional strengthening and implementation of UHC reforms, with a focus on PHC. Even though joint work by SDG3 GAP partners undoubtedly shows the potential for better alignment and collaboration, translation of the commitment to better collaboration into concrete impact has been the result of committed and engaged staff members, rather than institutionalized change, which will require strong incentives for collaboration.

Violence against women (VAW), particularly intimate partner violence (IPV) or domestic violence, is a major public health issue, garnering more attention globally post-coronavirus disease 2019 (COVID-19) lockdown. Health providers often represent the first point of contact for IPV victims. Thus, health systems and health providers must be equipped to address survivors' physical, sexual and mental health care needs. However, there is a notable lack of evidence regarding such readiness in Nepal. This study, utilizing a concurrent triangulation design, evaluated the readiness of public health facilities in Nepal's Madhesh Province in managing VAW, focusing on providers' motivation to offer psychosocial counselling to survivors. A cross-sectional study was conducted across 11 hospitals and 17 primary health care centres, where 46 health care providers were interviewed in February-April 2022. The study employed the World Health Organization's tools for policy readiness and the Physician Readiness to Manage IPV Survey for data collection. Quantitative and qualitative data were collected via face-to-face interviews and analysed using descriptive and content analysis, respectively. Only around 28% of health facilities had trained their staff in the management of VAW. Two out of 11 hospitals had a psychiatrist, and a psychosocial counsellor was available in four hospitals and two out of 17 primary health care centres. Two-thirds of all health facilities had designated rooms for physical examinations, but only a minority had separate rooms for counselling. Though a few health facilities had guidelines for violence management, the implementation of these guidelines and the referral networks were notably weak. Hospitals with one-stop crisis management centres demonstrated readiness in VAW management. Health providers acknowledged the burden of IPV or domestic violence and expressed motivation to deliver psychosocial counselling, but many had limited knowledge. This barrier can only be resolved through appropriate training and investment in violence management skills at all tiers of the health system.

The multiple domains of development covered by the Sustainable Development Goals (SDGs) present a practical challenge for governments. This is particularly acute in highly resource-constrained settings which use a sector-by-sector approach to structure financing and prioritization. One potentially under-prioritized solution is to implement interventions with the potential to simultaneously improve multiple outcomes across sectors, what United Nations Development Programme refer to as development 'accelerators'. An increasing number of accelerators are being identified in the literature. There are, however, challenges associated with the evaluation and implementation of accelerators. First, as accelerators have multiple benefits, possibly in different sectors, they will be undervalued if the priority setting is conducted sector-by-sector. Second, even if their value is recognized, accelerators may not be adopted if doing so clashes with any of the multiple competing interests policymakers consider, of which efficiency/social desirability is but one. To illustrate the first challenge, and outline a possible solution, we conduct a cost-effectiveness analysis comparing the implementation of three sector-specific interventions to an accelerator, first using a sector-by-sector planning perspective, then a whole of government approach. The case study demonstrates how evaluating the cost-effectiveness of interventions sector-by-sector can lead to suboptimal efficiency rankings and overlook interventions that are efficient from a whole of government perspective. We then examine why recommendations based on a whole of government approach to evaluation are unlikely to be heeded. To overcome this second challenge, we outline a menu of existing and novel financing mechanisms that aim to address the mismatch between political incentives and logistical constraints in the priority setting and the economic evaluation evidence for cost-effective accelerators. These approaches to financing accelerators have the potential to improve efficiency, and in doing so, progress towards the SDGs, by aligning political incentives more closely with recommendations based on efficiency rankings.