Public Health Action最新文献

Setting: The BUDS (not an acronym) institutions comprise a community-based rehabilitation initiative for children and families affected by developmental disabilities in Kerala, India.

Objective: To explore the role of local governments in the establishment and functioning of BUDS institutions.

Design: We used qualitative approaches comprising document review and in-depth interviews with trainers, parents of children with developmental disabilities and elected representatives.

Results: BUDS was created by Kudumbasree, a decentralised women empowerment and poverty alleviation initiative. Our findings illustrate the role of local governments in facilitating expansion through the establishment of infrastructure, therapy equipment, transportation and financial allocation for these, as well as through the development of human resources, assistance with enrolment for financial assistance and insurance programmes, and coordination with education and health sectors. Programme implementation varied considerably regarding available infrastructure, staffing and services among the institutions studied. The institutions were physically closed during the COVID-19 pandemic but continued to function in alternative ways.

Conclusion: Despite variable implementation, local governments have supported the expansion of BUDS institutions, thereby creating more spaces for inclusive and integrated education and rehabilitation of persons with disabilities in Kerala. The expansion over the past two decades and measures during the COVID-19 pandemic suggest resilience and sustainability of the model.

Setting: The community-based primary palliative care programme in Kerala, India, has received international acclaim. Programme functioning is supported through Palliative Care Management Committees (PMCs) at the local government (LG) level.

Objective: To study the functioning of the PMCs within the decentralised governance space to identify achievements, gaps and notable innovations.

Design: This qualitative study included seven key informant interviews (KIIs), 28 in-depth interviews and a review of relevant publicly available policies and documents. Major themes were recognised from the KII transcripts. Codes emerging from the document review and in-depth interview transcripts were mapped into the identified thematic areas.

Results: Successful PMCs raised resources like money, human resource, equipment, had good skilled care options for symptom relief and facilitated reduced out-of-pocket expenditure by providing home care and free medicines, and improved access to interventions that addressed the social determinants of suffering like poverty. PMCs had varying managerial and technical capacities. In some LGs, the programme was weak and mostly limited to the supply of medicines, basic aids and appliances to patients' homes.

Conclusion: Despite varied implementation patterns, PMCs in Kerala are examples of state-supported, community-owned care initiatives, that can potentially address medical and social determinants of suffering.

Background: The use of molecular amplification as-says for TB diagnosis is limited by their costs and cartridge stocks. Pooling multiple samples to test them together is reported to have similar accuracy to individual testing and to save costs.

Methods: Two surveys of individuals with presumptive TB were conducted to assess the performance of pooled testing using Xpert® MTB/RIF (MTB/RIF) and Xpert® Ultra (Ultra).

Results: A total of 500 individuals were tested using MTB/RIF, with 72 (14.4%) being MTB-positive. The samples were tested in 125 pools, with 50 pools having ⩾1 MTB-positive and 75 only MTB-negative samples: 46/50 (92%, 95% CI 80.8-97.8) MTB-positive pools tested MTB-positive and 71/75 (94.7%, 95% CI 86.9-98.5) MTB-negative pools tested MTB-negative in the pooled test (agreement: 93.6%, κ = 0.867). Five hundred additional samples were tested using Ultra, with 60 (12%) being MTB-positive. Samples were tested in 125 pools, with 42 having ⩾1 MTB-positive and 83 only MTB-negative samples: 35/42 (83.6%, 95% CI 68.6-93.0) MTB-positive pools tested MTB-positive and 82/83 (98.8%, 95% CI 93.5-100.0) MTB-negative pools tested MTB-negative in the pooled test (agreement: 93.6%, κ = 0.851; P > 0.1 between individual and pooled testing). Pooled testing saved 35% (MTB/RIF) and 46% (Ultra) of cartridges.

Conclusions: Pooled and individual testing has a high level of agreement and improves testing efficiency.

Setting: The Kerala health system in India has more than 25 years of decentralised implementation experience. Decentralization could assist in addressing health disparities such as gender, disability, and migration.

Objective: To explore how inequity issues comprising gender, disability and internal migrations were being addressed at present by the decentralised Kerala health system.

Design: Our approach was qualitative, using document review, key informant interviews and in-depth interviews with policy makers, health staff and other stakeholders.

Results: Gender aspects were incorporated into planning and budgeting, with 10% funds earmarked for women. Projects were gender-specific to women, and within conventional social roles of livelihood, welfare or reproductive health. Recently, transgender focused projects were also initiated. Schemes for people with disabilities remained welfare-centric and driven by top-down policies. The local governments performed beneficiary identification and benefit disbursal. Migrant health aspects were focused on infectious diseases surveillance and later living conditions of migrant workers.

Conclusion: The importance that health systems place on socioeconomic determinants of health and fundamental human rights is reflected in the health interventions for marginalised communities. In Kerala, there is now a passive application of central rules and a reluctance to utilise local platforms. Changing this is a necessary condition for achieving equal development.

Objective: To study the involvement and influence of local participatory governments consisting of Panchayat Raj institutions (PRIs) in implementing evidence-based interventions for eliminating maternal and child undernutrition in the state of Kerala, India.

Methods: In-depth interviews were carried out among stakeholders in six selected local governments using a semi-structured questionnaire. Transcribed interviews were coded and thematically analysed.

Results: PRIs facilitated nutrition interventions through additional resource mobilisation, nutrition monitoring and surveillance, acting as a more approachable point of governance, utilising general acceptance to mobilise volunteers to tackle local challenges, enabling formal and informal platforms for community participation and spaces of co-creation. Changes in the attitude of different stakeholders, timely policy backing and support, and interconnections at the local level aided the process. Gaps exist in awareness creation, dietary diversification, feeding behaviours, maternal mental health, infrastructure development, monitoring of anthropometric indicators and planning for nutrition interventions during emergencies.

Conclusion: Results illustrate complex linkages PRIs have within the health system and how these linkages help in the implementation of interventions. The study explored previously identified pathways from the literature and identified additional pathways through which local participatory governance contributes to the successful implementation of nutrition interventions.

Setting: The Union of the Comoros has experienced a persistent notification gap in TB cases despite several strategic changes, including molecular diagnosis and contact investigation. We therefore performed a TB patient pathway analysis (PPA) under the National Tuberculosis Programme (NTP).

Objective: To assess the alignment of healthcare-seeking behaviour and TB service availability to clarify the reasons for these missing cases.

Design: Three primary data sources, including a national list of health facilities, TB surveillance data and care-seeking behaviour data, were analysed at the national and regional levels to determine access to TB diagnosis and the initial point of care-seeking. Summary data were visualised using the standardised PPA Wizard programme, and the analysis was completed using demographic and socio-economic data.

Results: At the initial point of care-seeking, 18% of patients had access to TB services, available only in nine centralised public health facilities. Furthermore, 30% of patients initially consulted in the informal sector and 45% in the formal public or private sector in health facilities, both of which lacked the capacity for TB diagnosis or first-line treatment.

Conclusion: The concentration of and limited access to TB services at the intermediate and central levels of care indicate a need for decentralisation efforts.

Setting: Kerala State, India, implemented decentralising reforms of healthcare institutions 25 years ago through transfer of administrative control and a sizeable share of the financial allocation.

Objective: To describe the main impacts of decentralisation in Kerala on local policy formulation, programme implementation and service delivery for sustainable health systems.

Design: This was part of a broader qualitative study on decentralisation and health in Kerala. We conducted 25 in-depth interviews and reviewed 31 government orders or policy documents, five related transcripts and five thematic reports from the main study.

Results: Liaising between health system and local governments has improved over time. A shift from welfare-centric projects to infrastructure, human resources and services was evident. Considerable heterogeneity existed due to varying degrees of involvement, capacity, resources and needs of the community. State-level discourse and recent augmentation efforts for moving towards the UN Sustainable Development Goals (SDGs) strongly uphold the role of local governments in planning, financing and implementation.

Conclusion: The 25-year history of decentralised healthcare administration in Kerala indicates both successes and failures. Central support without disempowering the local governments can be a viable option to allow flexible decision-making consistent with broader system goals.

Background: An international multistakeholder participatory workshop was hosted in the Gambia, West Africa, in November 2021.

Objectives: To explore the experiences, challenges and recommendations of workshop participants on health and wellbeing after TB treatment.

Methods: An exploratory, descriptive, qualitative approach was used for data collection through facilitator-guided group discussions. Workshop participants included adolescent and adult TB survivors, and representatives of TB advocacy groups and the policy sector. Discussions were audio-recorded and transcribed verbatim, and the data were analysed using a deductive thematic approach.

Results: Overall, 38 participants (22 women) from six West African countries participated in the workshop, comprising 33 TB survivors and advocacy group representatives and 5 participants from the policy sector. Although some TB survivors noted improved ability to carry out physical activities, others continued to experience detrimental effects on their family life, social interactions, physical health and ongoing stigma. Policymakers emphasised the lack of data and clear guidelines on post-TB disability.

Conclusions: Some TB survivors continue to suffer detrimental effects of the illness even after treatment completion. However, available data on post-TB disability is inadequate to support policy adoption. Therefore, there is an urgent need for increased advocacy, awareness and research to bridge knowledge gaps.

Setting: In alignment with the UN Sustainable Development Goals (SDGs), Kerala State in India aims to end the HIV/AIDS epidemic, using its strong background in local governance to implement the National AIDS Control Programme (NACP).

Objective: To examine the role of local governments in the implementation of NACP in tune with SDGs.

Design: We conducted a state-wide exploratory study using document reviews, key informant and in-depth interviews, which were analysed thematically.

Results: Four overarching themes that emerged were 1) preparation for programme implementation, 2) positive impact of local government involvement, 3) convergence with other organisations, and 4) barriers to implementation. Local government commitment to implementing the programme was evidenced by their adoption of the HIV/AIDS policy, facilitative interdepartmental coordination and local innovations. Interventions focused on improving awareness about the disease and treatment, and social, financial and rehabilitative support, which were extended even during the COVID-19 pandemic. Fund shortages and poor visibility of the beneficiaries due to preference for anonymity were challenges to achieving the expected outcomes.

Conclusion: The NACP is ably supported by local governments in its designated domains of interventions, prevention, treatment, and care and support. The programme can achieve its target to end the AIDS epidemic by overcoming the stigma factor, which still prevents potential beneficiaries from accessing care.

Background: Zambia has an estimated TB incidence of 319/100,000 population and a HIV prevalence of 11.1%. In 2020, only 49% of new people living with HIV (PLHIV) received TB preventive therapy (TPT) in Zambia. Misconceptions about the reliability of symptom screening and drug resistance among people who develop TB while on TPT are barriers to TPT scale-up. We determined the incidence and predictors of breakthrough TB during TPT among PLHIV in Zambia.

Method: This was a retrospective analysis of routine TPT programme data among PLHIV collected between October 2016 and October 2019 from select primary health facilities in Zambia.

Results: Of 48,581 PLHIV enrolled on TPT, 130 (0.3%) developed breakthrough TB during TPT. Of the 130, 90 client records were accessed. The median age of the breakthrough TB cases was 35 years; 68% were males. Overall, 96% of the breakthrough TB cases had been on antiretroviral therapy (ART) for ⩽3 months; 24% were symptomatic at the beginning of TPT, 22% were asymptomatic and others had missing data. Of the 130 breakthrough TB cases, 79% developed TB in the first month after TPT initiation. The median time to TB diagnosis was 10 days (IQR 4-16).

Conclusion: Breakthrough TB during TPT is rare among PHLIV on ART, and very rare after the first month of TPT initiation. It should therefore not be a barrier to TPT scale-up.