Health systems and reform最新文献

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.

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.

For over 50 years, health systems the world over have failed people with type 2 diabetes mellitus (T2DM). The WHO documents a quadrupling of people with diabetes in a 34-year period to 422 million in 2014, the overwhelming majority of whom were T2DM. This happened despite extensive scientific literature on the causes of, as well as proven treatments for, this disease. Using a health systems prism to review the extensive medical and nutritional T2DM published research, we identified three main shortcomings of health systems in T2DM: (i) failure in early detection; (ii) failure in understanding the actionable lifestyle drivers; and (iii) subsidizing the causes of the disease. Although small-scale success stories in T2DM control exist, the lack of documented evidence of any country-wide health system's successful attempt to address this epidemic is alarming. The immense and ever-growing health and economic burdens of T2DM should provide all the motivation needed for national and global efforts to counteract the political-economy constraints standing in the way of successful whole-of-system approaches to T2DM.

Trust in government has emerged as one of the strongest predictors of national performance in fighting COVID-19. This commentary aims to take stock of the vast literature on trust and compliance with public health measures that has emerged during the pandemic to synthesize policy-relevant recommendations about: 1) How to conceptualize trust; 2) Whether trust is always deserved; and 3) How governments can earn (appropriate levels of) trust. Based on a critical reading of the literature, we develop a framework that conceptualizes trust as falling along a continuum ranging from extreme distrust to blind trust with the ideal point- "informed" or "basic" trust-falling in the mid-point of the continuum. We illustrate the continuum with examples and provide recommendations regarding how governments can build more nuanced disease responses that account for individuals and sub-groups at different rungs on the continuum while (re)building trust. We conclude that trust-building is a long-term project that must continue in non-crisis times.

This commentary examines the resilience of primary health care in Ukraine amidst the ongoing war, drawing a few reflections relevant for other fragile and conflict-affected situations. Using personal observations and various published and unpublished reports, this article outlines five reflections on the strengths, challenges, and necessary adaptations of Primary Health Care (PHC) in Ukraine. It underscores the concerted efforts of the government to maintain public financing of PHC, thereby averting system collapse. The research also highlights the role of strategic adaptations during the COVID-19 pandemic in fostering resilience during the war, including the widespread use of digital communication and skills training. The commentary emphasizes the role of managerial and financial autonomy in facilitating quick and efficient organizational response to crisis. It also recognizes emerging challenges, including better access to PHC services among the internally displaced persons, shifting patient profiles and service needs, and challenges related to reliance on local government financing. Finally, the authors advocate for a coordinated approach in humanitarian response, recovery efforts, and development programs to ensure the sustainability and effectiveness of PHC in Ukraine.

Reducing the price of expensive medical products through centralized procurement is generally considered an effective way to save public medical resources. Against this background, this paper presents an analysis of the impact of centralized procurement in China by comparing the treatment costs and patterns for acute myocardial infarction (AMI) patients before and after the introduction of this method of purchasing, with specific reference to the use of coronary stents. We found that, after the implementation of centralized procurement for coronary stents, the total expenditure of AMI cases receiving percutaneous coronary interventions with stent implantation (PCI with stents) dropped by 23.4%. The use rate of PCI with stents decreased by 32.5%, with the most significant decrease being evident in cases in which two stents were used simultaneously (32.9%). Meanwhile, percutaneous coronary interventions with balloon implantation (PCI with balloons) increased by 31.5% and coronary artery bypass grafting (CABG) increased by 80.3%. Based on these patterns, it can be observed that the use of centralized procurement significantly reduced the profits of the relevant medical manufacturers, forcing them to decrease their marketing investments, weakening their influence on providers, and ultimately resulting in a more principled use of coronary stents. We therefore conclude that, with reference to the data cited, the centralized procurement program led not only to a reduction in procurement prices but also to decreased overuse of these expensive medical products.

Public financial management (PFM) theory suggests that improvements in the allocation, execution, and monitoring of public funds can result in improved sectoral outcomes, including in health. However, the existing literature on the relationship between PFM quality and health outcomes provides limited empirical documentation and insufficient explanation of the mechanics of that relationship. This paper contributes to the literature by estimating the correlation between PFM quality and health outcomes from a sample of sub-Saharan African countries over the period 2005-2018, using a pooled ordinary least squares (OLS) estimator. The analysis uses Public Expenditure and Financial Accountability (PEFA) scores as proxies for PFM quality. The findings indicate that countries with high-quality PFM tended to have the lowest maternal, under-five and noncommunicable diseases (NCDs) mortality. Among the standard PFM dimensions, the one associated with the higher correlation with maternal and under-five mortality was "predictability and control in budget execution." Better PFM quality was significantly associated with a drop in maternal and under-five mortality in countries which allocated a higher proportion of their budget to the health sector. In countries allocating a lower proportion of their budget to health, the correlations between PFM quality and the three mortality indicators were not significant. The negative correlations between PFM quality and maternal and under-five mortality were significant only in countries with more effective governance. These findings support an emphasis on strengthening PFM as a means of improving health service provision and health outcomes.

Cross-programmatic inefficiencies are duplications or misalignments that arise from undue fragmentation of health systems by vertical health programs. Identifying and addressing the root causes of cross-programmatic inefficiencies in a health system can ensure more efficient use of resources to make progress toward Universal Health Coverage. This paper examines the root causes of cross-programmatic inefficiencies related to governance and financing in the state health system of Anambra in southeast Nigeria. Data were collected from 38 in-depth interviews and four focus group discussions and analyzed thematically. The governance- and finance-related cross-programmatic inefficiencies identified were duplicative and misaligned roles within and between state and federal agencies, functions, and activities within and across health programs; misaligned donor priorities with that of the state; and poor formulation and implementation of the approved annual state health budget. The root causes of governance and financing cross-programmatic inefficiencies included weak policy development, communication, and enforcement; excessive influence of external donors and the federal government; weak accountability mechanisms affecting program coordination and service delivery; and a disharmony between state priorities and objectives with planning, budgeting, and execution of the budget. Addressing the root causes of cross-programmatic inefficiencies has the potential to significantly improve the overall efficiency and performance of the health system to contribute to improved health outcomes in Anambra state. This approach can serve as a model for other states and regions facing similar challenges.