Health systems and reform最新文献

Progress toward Universal Health Coverage (UHC) remains a priority for low- and middle-income countries (LMICs). For countries that have adopted Social Health Insurance (SHI) as a strategy, expanding coverage among informal sector households presents an important pathway to this goal. This scoping review examines strategies and interventions employed in LMICs to improve the enrollment and retention of informal sector households in SHI schemes. The review highlights common barriers, including irregular incomes, limited awareness, administrative challenges, and trust deficits. Potential strategies include designing flexible contribution mechanisms, simplified registration processes, targeted awareness campaigns, leveraging existing community structures, and designing comprehensive benefit packages that balance coverage goals with fiscal sustainability. Our findings emphasize the importance of context-specific and innovative approaches that could include tiered premiums, mobile payment platforms, and partnerships with microfinance institutions to address financial and logistical barriers. However, there is also evidence to suggest that net revenue gains from contributory mechanisms are typically modest, with enrollment expansion often requiring substantial public subsidies and incurring additional administrative costs. For Zambia, integrating some of these lessons into the National Health Insurance Scheme (NHIS) offers a pathway to enhancing coverage among the informal sector and advancing equitable access to healthcare, while acknowledging the fiscal constraints.

Previous studies have shown that facility autonomy, especially control over budget allocation, and management practices can have a modest positive effect on health facility performance, but the evidence is limited and often qualitative. Data from the evaluation of the Nigeria States Health Investment Project (NSHIP), a study that examined the effects of direct facility and performance-based financing, offers a novel opportunity to quantitatively examine these relationships in the context of a lower middle-income country. We utilize non-parametric statistics and regression methods to test the hypothesis that autonomy, supervision, and management affected facility performance. Results show that facilities with greater autonomy, more budget control, and better management practices generally outperform their peers on a range of facility readiness and service delivery measures. For example, regressions show that facilities with high autonomy held an additional 2.1 outreach sessions per month and facilities with a business plan offered 1.8 additional outreach services (p < 0.05). Supervision practices, including visit frequency and a quantitative checklist, are associated with 26% higher productivity and up to a 29% increase in equipment availability (p < 0.05). Sensitivity analyses validated that results are robust. We conclude that facility-level autonomy and especially budget control can improve primary healthcare facility readiness and service availability. Further, management practices that are reinforced through supportive supervision and routine monitoring can maximize the benefits that accrue from even small amounts of incremental financing. This shows that these policies and practices can contribute critically to efficiently achieving the goals of universal healthcare policies in the context of limited resources.

There are approximately 220 million (about 12% regional prevalence) adults living with diabetes mellitus (DM) with its related complications, and morbidity knowingly or unconsciously in the Western Pacific Region (WP). The estimated healthcare cost in the WP and Malaysia was 240 billion USD and 1.0 billion USD in 2021 and 2017, respectively, with unmeasurable suffering and loss of health quality and economic productivity. This urgently calls for nothing less than concerted and preventive efforts from all stakeholders to invest in transforming healthcare professionals and reforming the healthcare system that prioritizes primary medical care setting, empowering allied health professionals, improvising health organization for the healthcare providers, improving health facilities and non-medical support for the people with DM. This article alludes to challenges in optimal diabetes care and proposes evidence-based initiatives over a 5-year period in a detailed roadmap to bring about dynamic and efficient healthcare services that are effective in managing people with DM using Malaysia as a case study for reference of other countries with similar backgrounds and issues. This includes a scanning on the landscape of clinical research in DM, dimensions and spectrum of research misconducts, possible common biases along the whole research process, key preventive strategies, implementation and limitations toward high-quality research. Lastly, digital medicine and how artificial intelligence could contribute to diabetes care and open science practices in research are also discussed.

It is already a common practice for many health care systems in the world to opt for mixed markets where different types of health care facilities compete against each other to offer high-quality health care to patients. Nevertheless, little is known about the effects of the interaction between hospitals of the same or different type on patient health outcomes. This study estimated the impacts of aggregate and specific types of hospital competition by hospital-type on the quality of inpatient care using an analysis dataset comprising 267,183 individuals from China. The Herfindahl-Hirschman index was employed to measure the degree of hospital competition, with length of stay, readmission and mortality being used to measure the quality of inpatient care. The Poisson and binomial logistic models combined with the instrumental variable approach were constructed to estimate the impacts of hospital competition. This study generated three key findings: 1) aggregate hospital competition reduced the quality of inpatient care, as evidenced by a rise in the odds of readmission and length of stay; 2) intra-type hospital competition reduced the quality of inpatient care and in general had larger effects on reducing the quality of inpatient care than inter-type hospital competition; and 3) the only exception was in the way that competition between private nonprofit hospitals contributed to better quality of inpatient care. The overarching suggestion is that instead of treating competition as a panacea for improving health, a flexible plan tailored to specific conditions is needed.

Following the global health challenge of Ebola, the World Health Organization (WHO) developed a new approach to prioritizing health policy actions when both markets and government fail. The new approach, Common Goods for Health (CGH), is applied in this paper to identify priority actions to tackle failures in addressing the increasing prevalence of type 2 diabetes globally. National governments could realistically implement these actions to efficiently and equitably reduce the prevalence of type 2 diabetes, a non-communicable disease that is growing in every region of the world. The paper identifies three broad categories of CGH actions: (i) earlier risk identification; (ii) better communication for behavior change; and (iii) reforming tax/subsidy policies on food.

Diabetes mellitus, once a rare diagnosis in precolonial and early post-colonial Nigeria, now has the highest prevalence and fatality rates in sub-Saharan Africa. This increased prevalence is attributed to rising population affluence characterized by sedentary lifestyles and higher consumption of processed and ultra-processed foods. The burden is further exacerbated by a poorly responsive healthcare system. Currently, less than 50% of affected individuals are aware of their condition. Factors such as misconceptions about the disease, a preference for unproven traditional herbal treatments, and the high cost of treatment hinder effective secondary responses. Health system challenges in diabetes management in Nigeria include inadequate implementation of existing policies and guidelines, high out-of-pocket payments, poor quality of healthcare, and limited public education about the disease. To address these issues, we recommend a policy focus on:  1) Implementing actionable policies and guidelines for diabetes prevention and care; 2) Improving the pre-paid care system to reduce out-of-pocket payments; 3) Enhancing the quality of services at all healthcare levels, with the establishment of centers of excellence for specialized diabetes management; 4) Continuing the training, retraining, motivation, and expansion of the workforce responsible for diabetes care; and 5) Health promotion and health awareness aimed at the public to address inaccurate beliefs and practices about diabetes. Addressing these multifaceted factors will help to reduce the rising incidence of diabetes in Nigeria.

Health systems in low- and middle-income countries face the challenge of addressing the growing burden of non-communicable diseases (NCDs) with scarce resources to do so. There are cost-effective interventions that can improve management of the most common NCDs, but many remain poorly implemented. One example is fixed dose combinations (FDCs) of medications for hypertension. Included in WHO's Essential Medicines List, FDCs combine two or more blood pressure lowering agents into one pill and can reduce burden on patients and the health system. However, implementation of FDCs globally is poor. We aimed to identify health systems factors affecting implementation of evidence-based interventions for NCDs, and opportunities to address these, using the case study of FDCs in Kenya. We conducted semi-structured interviews with 39 policy-makers and healthcare workers involved in hypertension treatment policy and identified through snowball sampling. Interview data were analyzed thematically, using the Access Framework to categorize themes. Our interviews identified factors operating at the global, national, county, and provider levels. These include lack of global implementation guidance, context specific cost-effectiveness data, or prioritization by procurement agencies and clinical guidelines; perceived high cost; poor data for demand forecasting; insufficient budget for procurement of NCD medications; absence of prescriber training and awareness of clinical guidelines; and habitual prescribing behavior and understaffing limiting capacity for change. We propose specific strategies to address these. The findings of this work can inform efforts to improve implementation of other evidence-based interventions for NCDs in low-income settings.

Diabetes and other chronic NCDs pose a major public health threat in Ghana, and where health systems are less developed and there are numerous competing societal priorities. This qualitative study examines the barriers hindering domestic financing and prioritization of diabetes and other NCDs in Ghana. The study applied Kingdon's multiple stream framework using document reviews and face-to-face interviews with 29 key informants/stakeholders in the diabetes or NCD landscape in Ghana. Data from the document review and key informant interviews were thematically analyzed. The study revealed that at the problem stream level, diabetes and other NCDs are not yet sufficiently perceived by the general population and policy makers as major societal issues. Donors are also focusing on different health priorities. On the policy solution stream, many solutions are being initiated and developed by a rich array of policy entrepreneurs. The recent introduction of an excise tax bill on sugar-sweetened, alcoholic beverages and tobacco products suggests positive developments in the politics stream. The health financing system is advanced institutionally, and the country could rapidly convert a higher prioritization of diabetes into resource allocation if the macro-fiscal context permits it. The study concludes that applying Kingdon's framework provides a nuanced understanding of the barriers, enablers, and opportunities for prioritizing NCDs in Ghana, and finds that policy prioritization will require political commitment from the upper echelon of government. Higher public awareness on the determinants and costs of NCDs would contribute to broad citizen support and the sustainability of the political commitment across successive governments.

Non-communicable diseases (NCDs) represent the largest burden of disease, even in low-and middle-income countries (LMICs). The long latency period, chronicity, and common environmental, behavioral and genetic etiologies of NCDs-as shown through the example of Type 2 diabetes mellitus (T2DM)-expose health system failures to undertake multi-sectoral public health actions, address early detection, and provide integrated care. Development assistance for health (DAH), with its focus on donor priorities, often exacerbates such health system challenges. DAH has mainly focused on infectious diseases along with conditions related to reproductive health. Some programs show how DAH could help LMICs reorient health systems by focusing on neglected areas like economic and social policies, along with environmental and behavioral drivers of diseases like T2DM. Furthermore, in an era of declining resources for DAH, external support needs to be catalytic, supporting reforms more than financing services. Orienting limited DAH to address NCDs could support the necessary transformation of service organization, financial allocation criteria, data generation and use, health promotion, and training of care providers. DAH could also strengthen the public institutions and policies that prevent NCDs like T2DM through economic policies, environmental regulation, and health promotion interventions that address social and behavioral risk factors. Four broad categories of actions can guide DAH to better orient health systems to address NCDs: "First, do no harm," help transform health systems, think outside the box, and match tools to needs. Several existing assistance modalities are also presented to show specific ways that this reorientation can be implemented.