Health systems and reform最新文献

Child health outcomes vary between Parliamentary Constituencies (PCs) in India. There are a total of 543 PCs in India, each of which is a geographical unit represented by a Member of Parliament (MP). MP characteristics, such as age, gender, education, the number of terms they have served, and whether they belong to a Scheduled Caste or Scheduled Tribe, might be associated with indicators of child malnutrition and child mortality. The purpose of this paper was to examine the associations between MP characteristics and measures of child malnutrition and mortality. We did not find any meaningful associations between MP characteristics and child anthropometry, anemia, and mortality. Future research should consider the size of a constituency served by an MP along with MP party affiliations as these factors might help explain between-PC variations in child health outcomes. Our findings also underscore the need to better support female MPs and MPs from marginalized caste and tribal groups.

In 2013, the Government of The Gambia implemented a novel results-based financing (RBF) intervention designed to improve maternal and child nutrition and health through a combination of community, facility and individual incentives. In a mixed-methods study, we used a randomized 2 × 2 study design to measure these interventions' impact on the uptake of priority maternal health services, hygiene and sanitation. Conditional cash transfers to individuals were bundled with facility results-based payments. Community groups received incentive payments conditional on completion of locally-designed health projects. Randomization occurred separately at health facility and community levels. Our model pools baseline, midline and endline exposure data to identify evidence of the interventions' impact in isolation or combination. Multivariable linear regression models were estimated. A qualitative study was embedded, with data thematically analyzed. We analyzed 5,927 household surveys: 1,939 baseline, 1,951 midline, and 2,037 endline. On average, community group interventions increased skilled deliveries by 11 percentage points, while the facility interventions package increased them by seven percentage points. No impact was found, either in the community group or facility intervention package arms on early ANC. The community group intervention led to 49, 43 and 48 percentage point increases in handwashing stations, soaps at station and water at station, respectively. No impact was found on improved sanitation facilities. The qualitative data help understand factors underlying these changes. No interaction was found between the community and facility interventions. Where demand-side barriers predominate and community governance structures exist, community group RBF interventions may be more effective than facility designs.

Expanding service coverage and achieving universal health coverage (UHC) is a priority for many low- and middle-income countries. Though UHC is a long-term goal, its importance and relevance have only increased since the start of the COVID-19 pandemic. The first step on the road to UHC is to define and develop essential packages of health services (EPHSs), a list of clinical and public health services that a government has deemed a priority and is to provide. However, the nature of these lists of services in low- and lower-middle-income countries is largely unknown. This study examines the contents of 45 countries' EPHSs to determine the inclusion of essential UHC (EUHC) services as defined by the Disease Control Priorities, which comprises 21 specific essential packages of interventions. EPHSs were collected from publicly available sources and their contents were analyzed in two stages, firstly, to determine the level of specificity and detail of the content of EPHSs and, secondly, to determine which essential UHC services were included. Findings show that there are large variations in the level of specificity among EPHSs and that though EUHC services are included to a large extent, variations exist regarding which services are included between countries. The results provide an overview of how countries are designing EPHSs as a policy tool and are progressing toward providing a full range of EUHC services. Additionally, the study introduces new tools and methods for UHC policy analysts and researchers to study the contents of EPHSs in future investigations.

As Mexico's government restructures the health system, a comprehensive assessment of Seguro Popular's Fund for Protection against Catastrophic Expenses (FPGC) can help inform decision makers to improve breast cancer outcomes and health system performance. This study aimed to estimate the treatment gap for breast cancer patients treated under FPGC and assess changes in this gap between 2007 (when coverage started for breast cancer treatment) and 2016. We used a nationwide administrative claims database for patients whose breast cancer treatment was financed by FPGC in this period (56,847 women), Global Burden of Disease breast cancer incidence estimates, and other databases to estimate the population not covered by social security. We compared the observed number of patients who received treatment under FPGC to the expected number of breast cancer cases among women not covered by social security to estimate the treatment gap. Nationwide, the treatment gap was reduced by more than half: from 0.71, 95% CI (0.69, 0.73) in 2007 to 0.15, 95%CI (0.09, 0.22) in 2016. Reductions were observed across all states . This is the first study to assess the treatment gap for breast cancer patients covered under Seguro Popular. Expanded financing through FPGC sharply increased access to treatment for breast cancer. This was an important step toward improving breast cancer care, but high mortality remains a problem in Mexico. Increased access to treatment needs to be coupled with effective interventions to assure earlier cancer diagnosis and earlier initiation of high-quality treatment.

UNAIDS Fast-Track goals for 2025 include ensuring that 95% of the people with HIV know their HIV status. In 2019, the Malawi Ministry of Health introduced its approach for achieving this: an active index testing (AIT) policy with assisted partner notification services (APNS). Under this policy, health centers can actively reach out to a contact of newly-diagnosed HIV positive client (the index) to offer voluntary HIV testing services. However, APNS uptake has been sub-optimal at many health facilities. This qualitative study considers strategies to optimize the uptake of APNS among newly-diagnosed HIV positive clients at Ndirande Health Center in Blantyre, Malawi. We conducted in-depth interviews, between February and April 2020, with 24 participants, including new HIV positive index clients, their sexual partners, and key health workers. We employ a maximum variation purposive sampling technique. Thematic inductive and deductive data analysis was done manually according to the social-ecological model. Interviewees discussed various strategies for optimizing APNS uptake among newly diagnosed HIV-infected clients. Interpersonal strategies included maximizing the use of client profiling techniques and sensitization on APNS to create demand. Institutional-level strategies were also suggested, such as providing transportation for home visits, strengthening referral notification approaches, and additional training for health workers. Policy-level recommendations included introducing home-based partner testing and intensifying use of partner notification slips. APNS is a key strategy to maximize HIV case identification. However, achieving optimal APNS in Malawi requires strengthening existing strategies and conducting additional research to identify other APNS strategies tailored to the local context.

During the last two decades, Mexico adopted policies intended to increase the efficiency and effectiveness of medicines procurement in its nationally fragmented health system. In this policy report, we review Mexico's efforts to guarantee access to medicines during three national administrations (from 2000 to 2018), and then examine major health system changes introduced by the current government (2018-2024), which have created significant setbacks in guaranteeing access to medicines in Mexico. These recent changes are having important consequences in the levels of satisfaction of health care users and citizens, household expenditure on health, and health conditions. We suggest key lessons for Mexico and other countries seeking to improve pharmaceutical procurement as part of guaranteeing access to medicines.

India has recently implemented several major health care reforms at national and state levels, yet the nation continues to face significant challenges in achieving better health system performance. These challenges are particularly daunting in India's poorer states, like Odisha. The first step toward overcoming these challenges is to understand their root causes. Toward this end, the Harvard T.H. Chan School of Public Health conducted a comprehensive study in Odisha based on ten new field surveys of the system's performance to provide a multi-perspective analysis. This article reports on the assessment of the performance of Odisha's health system and the preliminary diagnosis of underlying causes of the strengths and challenges. This comprehensive health system assessment is aimed toward the overarching goals of informing and supporting efforts to improve the performance of health systems in Odisha and other similar contexts.

Universal Health Coverage (UHC) is a widespread policy goal in the 21st century. The aim is to protect people from financial risk while promoting their access to good-quality care. This study examined the social insurance systems of South Korea and Taiwan to explore the critical challenges of achieving effective UHC. By assessing the impact of UHC on financial risk protection (measured by out-of-pocket payment share and catastrophic payment headcount), we found that when South Korea inaugurated its National Health Insurance (NHI) program with a limited benefits package and high cost sharing, it did not reduce the financial burden. Meanwhile, we observed a drop of 5 to 6 percentage points in the catastrophic payment headcount in Taiwan, which offered a universal and rather comprehensive benefits package with a modest cost-sharing design under its single-payer NHI system. The political-economic context of the UHC policy evolution was further explored through an in-depth discussion. We conclude that to provide sufficient financial risk protection against unexpected medical expenses, the design of the insurance scheme, in particular the risk-sharing mechanism, not only matters but is also the key to success.

Improving the quality of primary care is essential for achieving universal health coverage in low- and middle-income countries. This study examined the level and variation in primary care provider knowledge and effort in Cambodia, using cross-sectional data collected in 2014-2015 from public sector health centers in nine provinces. The data included clinical vignettes and direct observations of processes of antenatal care, postnatal care, and well-child visits and covered between 290-495 health centers and 370-847 individual providers for each service and type of data. The results indicate that provider knowledge and observed effort were generally low and varied across health centers and across individual providers. In addition, providers' effort scores were generally lower than their knowledge scores, indicating the presence of a "know-do gap." Although higher provider knowledge was correlated with higher levels of effort during patient encounters, knowledge only explained a limited fraction of the provider-level variation in effort. Due to low baseline performance and the know-do gap, improving provider adherence to clinical guidelines through training and practice standardization alone may have limited impact. Overall, the findings suggest that raising the low quality of care provided by Cambodia's public sector will require multidimensional interventions that involve training, strategies that increase provider motivation, and improved health center management. The authors reported there is no funding associated with the work presented in this article.

There is no universal understanding of what defines urban or rural areas nor criteria for differentiating within these. When assessing access to health services, traditional urban-rural dichotomies may mask substantial variation. We use geospatial methods to link household data from the 2015-2016 Malawi Demographic Health Survey to health facility data from the Malawi Service Provision Assessment and apply a new proposed four-category classification of geographic area (urban major metropolitan area, urban township, rural, and remote) to evaluate households' distance to, and choice of, primary, secondary, and tertiary health care in Malawi. Applying this new four-category definition, approximately 3.8 million rural- and urban-defined individuals would be reclassified into new groups, nearly a quarter of Malawi's 2015 population. There were substantial differences in distance to the nearest facility using this new categorization: remote households are (on average) an additional 5 km away from secondary and tertiary care services versus rural households. Health service choice differs also, particularly in urban areas, a distinction that is lost when using a simple binary classification: those living in major metropolitan households have a choice of five facilities offering comprehensive primary care services within a 10-km zone, whereas urban township households have no choice, with only one such facility within 10 km. Future research should explore how such expanded classifications can be standardized and used to strengthen public health and demographic research.