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  • 1.

    【2hr】Who benefits from healthcare spending in Cambodia? Evidence for a universal health coverage policy

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    机译 谁可以从柬埔寨的医疗保健支出中受益？普遍健康保险政策的证据
    摘要：Cambodia’s healthcare system has seen significant improvements in the last two decades. Despite this, access to quality care remains problematic, particularly for poor rural Cambodians. The government has committed to universal health coverage (UHC) and is reforming the health financing system to align with this goal. The extent to which the reforms have impacted the poor is not always clear. Using a system-wide approach, this study assesses how benefits from healthcare spending are distributed across socioeconomic groups in Cambodia. Benefit incidence analysis was employed to assess the distribution of benefits from health spending. Primary data on the use of health services and the costs associated with it were collected through a nationally representative cross-sectional survey of 5000 households. Secondary data from the 2012–14 Cambodia National Health Accounts and other official documents were used to estimate the unit costs of services. The results indicate that benefits from health spending at the primary care level in the public sector are distributed in favour of the poor, with about 32% of health centre benefits going to the poorest population quintile. Public hospital outpatient benefits are quite evenly distributed across all wealth quintiles, although the concentration index of −0.058 suggests a moderately pro-poor distribution. Benefits for public hospital inpatient care are substantially pro-poor. The private sector was significantly skewed towards the richest quintile. Relative to health need, the distribution of total benefits in the public sector is pro-poor while the private sector is relatively pro-rich. Looking across the entire health system, health financing in Cambodia appears to benefit the poor more than the rich but a significant proportion of spending remains in the private sector which is largely pro-rich. There is the need for some government regulation of the private sector if Cambodia is to achieve its UHC goals.
  • 2.

    【2hr】Exploring the determinants of distress health financing in Cambodia

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    机译 探索柬埔寨遇险健康筹资的决定因素
    摘要：Borrowing is a common coping strategy for households to meet healthcare costs in countries where social health protection is limited or non-existent. Borrowing with interest, hereinafter termed distress health financing or distress financing, can push households into heavy indebtedness and exacerbate the financial consequences of healthcare costs. We investigated distress health financing practices and associated factors among Cambodian households, using primary data from a nationally representative household survey of 5000 households. Multivariate logistic regression was used to determine factors associated with distress health financing. Results showed that 28.1% of households consuming healthcare borrowed to pay for that healthcare with 55% of these subjected to distress financing. The median loan was US$125 (US$200 for loans with interest and US$75 for loans without interest). Approximately 50.6% of healthcare-related loans were to pay for the costs of outpatient care in the past month, 45.8% for inpatient care and 3.6% for preventive care in the past 12 months. While the average period to pay off the loan was 8 months, 78% of households were still indebted from loans taken over 12 months before the survey. Distress financing is strongly associated with household poverty—the poorer the household the more likely it is to borrow, fall into debt and unable to pay off the debt—even for members of the health equity funds, a national scheme designed to improve financial access to health services for the poor. Other determinants of distress financing were household size, use of inpatient care and outpatient consultations with private providers or with both private and public providers. In order to ensure effective financial risk protection, Cambodia should establish a more comprehensive and effective social health protection scheme that provides maximum population coverage and prioritizes services for populations at risk of distress financing, especially poorer and larger households.
  • 3.

    【2hr】Determinants of health insurance enrolment in Ghana: evidence from three national household surveys

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    机译 加纳健康保险注册的决定因素：来自三项全国家庭调查的证据
    摘要：In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) to move towards Universal Health Coverage. NHIS enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%. The evidence on the relationship between socio-economic characteristics and NHIS enrolment is mixed, and comes mainly from studies conducted in a few areas. Therefore, in this study we investigate the socio-economic determinants of NHIS enrolment using three recent national household surveys. We used data from the Ghanaian Demographic and Health Survey conducted in 2014, the Multiple Indicator Cluster Survey conducted in 2011 and the sixth wave of the Ghana Living Standard Survey conducted in 2012–13. Given the multilevel nature of the three databases, we use multilevel logistic regression models to estimate the probability of enrolment for women and men separately. We used three levels of analysis: geographical clusters, household and individual units. We found that education, wealth, marital status—and to some extent—age were positively associated with enrolment. Furthermore, we found that enrolment was correlated with the type of occupation. The analyses of three national household surveys highlight the challenges of understanding the complex dynamics of factors contributing to low NHIS enrolment rates. The results indicate that current policies aimed at identifying and subsidizing underprivileged population groups might insufficiently encourage health insurance enrolment.
  • 4.

    【2hr】The impacts of decentralization on health system equity, efficiency and resilience: a realist synthesis of the evidence

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    机译 分权化对卫生系统公平性，效率和复原力的影响：证据的现实综合
    摘要：One constant refrain in evaluations and reviews of decentralization is that the results are mixed. But given that decentralization is a complex intervention or phenomenon, what is more important is to generate evidence to inform implementation strategies. We therefore synthesized evidence from the literature to understand why, how and under what circumstances decentralization influences health system equity, efficiency and resilience. In doing this, we adopted the realist approach to evidence synthesis and included quantitative and qualitative studies in high-, low- and middle-income countries that assessed the the impact of decentralization on health systems. We searched the Medline and Embase databases via Ovid, and the Cochrane library of systematic reviews and included 51 studies with data from 25 countries. We identified three mechanisms through which decentralization impacts on health system equity, efficiency and resilience: ‘Voting with feet’ (reflecting how decentralization either exacerbates or assuages the existing patterns of inequities in the distribution of people, resources and outcomes in a jurisdiction); ‘Close to ground’ (reflecting how bringing governance closer to the people allows for use of local initiative, information, feedback, input and control); and ‘Watching the watchers’ (reflecting mutual accountability and support relations between multiple centres of governance which are multiplied by decentralization, involving governments at different levels and also community health committees and health boards). We also identified institutional, socio-economic and geographic contextual factors that influence each of these mechanisms. By moving beyond findings that the effects of decentralization on health systems and outcomes are mixed, this review presents mechanisms and contextual factors to which policymakers and implementers need to pay attention in their efforts to maximize the positive and minimize the negative impact of decentralized governance.
  • 5.

    【2hr】Access to healthcare for children with Congenital Zika Syndrome in Brazil: perspectives of mothers and health professionals

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    机译 巴西患有先天性寨卡综合症儿童的医疗保健：母亲和卫生专业人员的观点
    摘要：The Congenital Zika Syndrome (CZS) epidemic took place in Brazil between 2015 and 2017 and led to the emergence of at least 3194 children born with CZS. We explored access to healthcare services and activities in the Unified Health Service (Sistema Único de Saúde: SUS) from the perspective of mothers of children with CZS and professionals in the Public Healthcare Network. We carried out a qualitative, exploratory study, using semi-structured interviews, in two Brazilian states—Pernambuco, which was the epicentre of the epidemic in Brazil, and Rio de Janeiro, where the epidemic was less intense. The mothers and health professionals reported that healthcare provision was insufficient and fragmented and there were problems with follow-up care. There was a lack of co-ordination and an absence of communication between the various specialized services and between different levels of the health system. We also noted a public–private mixture in access to healthcare services, resulting from a segmented system and related to inequality of access. High reported household expenditure is an expression of the phenomenon of underfunding of the public system. The challenges that mothers and health professionals reported exposes contradictions in the health system which, although universal, does not guarantee equitable and comprehensive care. Other gaps were revealed through the outbreak. The epidemic provided visibility regarding difficulties of access for other children with disabilities determined by other causes. It also made explicit the gender inequalities that had an impact on the lives of mothers and other female caregivers, as well as an absence of the provision of care for these groups. In the face of an epidemic, the Brazilian State reproduced old fashioned forms of action—activities related to the transmitting mosquito and to prevention with an emphasis on the individual and no action related to social determinants.
  • 6.

    【2hr】Assessing scalability of an intervention: why, how and who?

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    机译 评估干预措施的可扩展性：为什么，如何以及谁？
    摘要：Public health interventions should be designed with scale in mind, and researchers and implementers must plan for scale-up at an early stage. Yet, there is limited awareness among researchers of the critical value of considering scalability and relatively limited empirical evidence on assessing scalability, despite emerging methodological guidance. We aimed to integrate scalability considerations in the design of a study to evaluate a multi-component intervention to reduce unnecessary caesarean sections in low- and middle-income countries. First, we reviewed and synthesized existing scale up frameworks to identify relevant dimensions and available scalability assessment tools. Based on these, we defined our scalability assessment process and adapted existing tools for our study. Here, we document our experience and the methodological challenges we encountered in integrating a scalability assessment in our study protocol. These include: achieving consensus on the purpose of a scalability assessment; and identifying the optimal timing of such an assessment, moving away from the concept of a one-off assessment at the start of a project. We also encountered tensions between the need to establish the proof of principle, and the need to design an innovation that would be fit-for-scale. Particularly for complex interventions, scaling up may warrant rigorous research to determine an efficient and effective scaling-up strategy. We call for researchers to better incorporate scalability considerations in pragmatic trials through greater integration of impact and process evaluation, more stringent definition and measurement of scale-up objectives and outcome evaluation plans that allow for comparison of effects at different stages of scale-up.
  • 7.

    【2hr】Institutional barriers and enablers to implementing and complying with internationally accepted quality standards in the local pharmaceutical industry of Pakistan: a qualitative study

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    机译 在巴基斯坦当地制药业中实施和遵守国际公认的质量标准的制度障碍和促成因素：定性研究
    摘要：Complying with good manufacturing practices (GMP) and ensuring a quality system is integral to production and supply of quality medicines and achieving universal health coverage. This study focus on the local production of medicines in Pakistan, a lower middle-income country that has observed considerable growth in the number of pharmaceutical companies over the past two decades. Against this background, we investigated: (1) How is quality assurance (QA) and GMP compliance understood and acted upon by local pharmaceutical manufacturers?; (2) What are the institutional barriers and enablers for QA and GMP compliance in the local pharmaceutical sector from the perspective of key stakeholders?; and (3) What are the institutional barriers and enablers for strengthening local regulatory capacity to improve QA in the industry in the long term? We used a qualitative study design involving 22 interviews of the drug regulatory bodies (n = 9), academia (n = 3) and local manufacturers (n = 10), identifying key themes in data by thematic analysis. Document analysis was used to collect additional information and supplement the interview data. We identified that manufacturing facilities operated under different GMP standards and interpretations, pointing towards an absence of harmonization in quality standards across the industry. Views diverged about the status of GMP compliance, with interviewees from academia presenting a more critical view compared with regulators who promoted a more positive story. Among the barriers explaining why companies struggled with quality standards, the lack of a mindset promoting quality and safety among profit-oriented manufacturers was prominent. At the federal level, DRAP’s establishment represented an institutional improvement aiming to promote QA through inspections and guidance. While some positive measures to promote quality have been observed, the need for DRAP to strengthen its technical and regulatory capacity, enhance its engagement in international collaboration and learning, and improve transparency and accountability were highlighted. Overall, since the challenges in Pakistan are shared with other low- and middle-income countries with local production, there is a need to commit to international collaborative mechanisms, such as those lead by WHO, on this issue.
  • 8.

    【2hr】Counting the cost of not breastfeeding is now easier, but women’s unpaid health care work remains invisible

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    机译 现在更容易计算不母乳喂养的费用，但是女性无偿的医疗保健工作仍然不可见
    • 作者：Julie P Smith
    • 刊名：Health Policy and Planning
    • 2019年第6期
    摘要：
  • 9.

    【2hr】Incorporating costing study results into district and service planning to enhance immunization programme performance: a Zambian case study

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    机译 将成本核算研究结果纳入地区和服务规划以提高免疫计划的绩效：赞比亚案例研究
    摘要：Donors, researchers and international agencies have made significant investments in collection of high-quality data on immunization costs, aiming to improve the efficiency and sustainability of services. However, improved quality and routine dissemination of costing information to local managers may not lead to enhanced programme performance. This study explored how district- and service-level managers can use costing information to enhance planning and management to increase immunization outputs and coverage. Data on the use of costing information in the planning and management of Zambia’s immunization programme was obtained through individual and group semi-structured interviews with planners and managers at national, provincial and district levels. Document review revealed the organizational context within which managers operated. Qualitative results described managers’ ability to use costing information to generate cost and efficiency indicators not provided by existing systems. These, in turn, would allow them to understand the relative cost of vaccines and other resources, increase awareness of resource use and management, benchmark against other facilities and districts, and modify strategies to improve performance. Managers indicated that costing information highlighted priorities for more efficient use of human resources, vaccines and outreach for immunization programming. Despite decentralization, there were limitations on managers’ decision-making to improve programme efficiency in practice: major resource allocation decisions were made centrally and planning tools did not focus on vaccine costs. Unreliable budgets and disbursements also undermined managers’ ability to use systems and information. Routine generation and use of immunization cost information may have limited impact on managing efficiency in many Zambian districts, but opportunities were evident for using existing capacity and systems to improve efficiency. Simpler approaches, such as improving reliability and use of routine immunization and staffing indicators, drawing on general insights from periodic costing studies, and focusing on maximizing coverage with available resources, may be more feasible in the short-term.
  • 10.

    【2hr】A cost-effectiveness analysis of maternal and neonatal health interventions in Ethiopia

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    机译 埃塞俄比亚孕产妇和新生儿保健干预措施的成本效益分析
    摘要：Ethiopia is one of the sub-Saharan African countries contributing to the highest number of maternal and neonatal deaths. Coverage of maternal and neonatal health (MNH) interventions has remained very low in Ethiopia. We examined the cost-effectiveness of selected MNH interventions in an Ethiopian setting. We analysed 13 case management and preventive MNH interventions. For all interventions, we used an ingredients-based approach for cost estimation. We employed a static life table model to estimate the health impact of a 20% increase in intervention coverage relative to the baseline. We used disability-adjusted life years (DALYs) as the health outcome measure while costs were expressed in 2018 US$. Analyses were based on local epidemiological, demographic and cost data when available. Our finding shows that 12 out of the 13 interventions included in our analysis were highly cost-effective. Interventions targeting newborns such as neonatal resuscitation (institutional), kangaroo mother care and management of newborn sepsis with injectable antibiotics were the most cost-effective interventions with incremental cost-effectiveness ratios of US$7, US$8 and US$17 per DALY averted, respectively. Obstetric interventions (induction of labour, active management of third stage of labour, management of pre-eclampsia/eclampsia and maternal sepsis, syphilis treatment and tetanus toxoid during pregnancy) and safe abortion cost between US$100 and US$300 per DALY averted. Calcium supplementation for pre-eclampsia and eclampsia prevention was the least cost-effective, with a cost per DALY of about US$3100. Many of the MNH interventions analysed were highly cost-effective, and this evidence can inform the ongoing essential health services package revision in Ethiopia. Our analysis also shows that calcium supplementation does not appear to be cost-effective in our setting.
  • 11.

    【2hr】Value and effectiveness of National Immunization Technical Advisory Groups in low- and middle-income countries: a qualitative study of global and national perspectives

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    机译 中低收入国家国家免疫技术咨询小组的价值和有效性：对全球和国家观点的定性研究
    摘要：The Global Vaccine Action Plan proposes that every country establish or have access to a National Immunization Technical Advisory Group (NITAG) by 2020. The NITAG role is to produce evidence-informed recommendations that incorporate local context, to guide national immunization policies and practice. This study aimed to explore the value and effectiveness of NITAGs in low- and middle-income countries (LMICs), identifying areas in which NITAGs may require further support to improve their functionality and potential barriers to global investment. A multi-methods study design was used, comprising 134 semi-structured interviews and 82 literature review sources that included 38 countries. Interviews were conducted with 53 global/regional and 81 country-level participants able to provide insight into NITAG effectiveness, including NITAG members, national immunization programme staff, and global agency representatives (e.g. the World Health Organisation, the Bill and Melinda Gates Foundation, Gavi the Vaccine Alliance). The review, including published and unpublished sources on NITAGs in LMICs, was conducted to supplement and corroborate interview findings. Data were analysed thematically. NITAGs were described as valuable in promoting evidence-informed vaccination decision-making, with NITAG involvement enhancing national immunization programme strength and sustainability. Challenges to NITAG effectiveness included: (1) unreliable funding; (2) insufficient diversity of member expertise; (3) inadequate conflicts of interest management procedures; (4) insufficient capacity to access and use evidence; (5) lack of transparency; and (6) limited integration with national decision-making processes that reduced the recognition and incorporation of NITAG recommendations. LMIC NITAGs have developed significantly in the past decade. Well-functioning NITAGs were trusted national resources that enhanced country ownership of immunization provision. However, many LMIC NITAGs require additional technical and funding support to strengthen quality and effectiveness, while maintaining impartiality and ensuring sufficient integration with national decision-making processes. Barriers to sustainable global support need to be addressed for LMIC NITAGs to both continue and develop further.
  • 12.

    【2hr】Initiation and continuity of maternal healthcare: examining the role of vouchers and user-fee removal on maternal health service use in Kenya

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    机译 孕产妇保健的启动和连续性：检查代金券和用户费用的去除在肯尼亚孕产妇保健服务使用中的作用
    摘要：This study explores the relationship between two health financing initiatives on women’s progression through the maternal health continuum in Kenya: a subsidized reproductive health voucher programme (2006–16) and the introduction of free maternity services in all government facilities (2013). Using cross-sectional survey data, we ran three multivariable logistic regression models examining the effects of the voucher programme, free maternity policy, health insurance and other determinants on (1) early antenatal care (ANC) initiation (first visit within the first trimester of pregnancy), (2) receiving continuous care (1+ ANC, facility birth, 1+ post-natal care (PNC) check) and (3) completing the maternal health pathway as recommended (4+ ANC, facility birth, 1+ PNC, with first check occurring within 48 h of delivery). Full implementation of the voucher programme was positively associated with receiving continuous care among users of 1+ ANC [interaction term adjusted odds ratio (aOR): 1.33, P = 0.014]. Early ANC initiation (aOR: 1.32, P = 0.001) and use of private sector ANC (aOR: 1.93, P < 0.001) were also positively associated with use of continuous care among ANC users. Among continuous care users, early ANC was associated with increased odds of completing the maternal health pathway as recommended (aOR: 3.80, P < 0.001). Higher parity was negatively associated with all three outcomes, while having health insurance was positively associated with each outcome. The impact of other sociodemographic factors such as maternal age, education, wealth quintile, urban residence, and employment varied by outcome; however, the findings generally suggest that marginalized women faced greater barriers to early ANC initiation and continuity of care. Health financing and women’s timing and source of ANC are strongly related to their subsequent progression through the maternal health pathway. To increase continuity of care and improve maternal health outcomes, policymakers must therefore focus on equitably reducing financial and other barriers to care seeking and improving quality of care throughout the continuum.
  • 13.

    【2hr】Transforming health systems financing in Lower Mekong: making sure the poor are not left behind

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    机译 改变湄公河下游的卫生系统筹资：确保不让穷人落伍
    摘要：
  • 14.

    【2hr】A new hope: from neglect of the health sector to aspirations for Universal Health Coverage in Myanmar

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    机译 一个新的希望：从对卫生部门的忽视到对缅甸全民健康覆盖的渴望
    摘要：Myanmar’s health sector has received low levels of public spending since 1975. Combined with the country’s historic political and economic isolation, poor economic management and multiple internal armed conflicts, these limited resources have translated into low coverage of even the most basic services and into poor health outcomes with wide disparities. They have also resulted in out-of-pocket payments for health as a proportion of total health spending being among the highest in the world. The Government of Myanmar has now affirmed its commitment to moving toward Universal Health Coverage. This commitment is reflected in the National Health Plan 2017–2021. Drawing upon analysis of data from the Myanmar Poverty and Living Conditions Survey 2015 and using the country’s revised methodology to estimate poverty, this paper explores some of the consequences of Myanmar’s excessive reliance on out-of-pocket funding as the main source of health financing. Around 481 000 households in Myanmar experienced catastrophic health spending in 2015. Of this group, 185 000 households lived below the national poverty line. Households that experienced catastrophic health spending spent, on average, 54.7% of their total capacity to pay on health. Of all Myanmar households that went to a health facility in 2015, ∼28% took loans and ∼13% sold their assets to cover health spending. In that same year, ∼1.7 million people fell below the national poverty line due to health spending. The paper then discusses how ongoing reforms could help alleviate the financial hardship associated with care-seeking. With current political will to reform the health system, a conducive macro-economic environment, and the relatively limited vested interests, Myanmar has a window of opportunity to achieve significant progress towards UHC. Continued high-level political support and strong leadership will be needed to keep reforms on track.
  • 15.

    【2hr】Financial protection and equity of access to health services with the free maternal and child health initiative in Lao PDR

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    机译 老挝人民民主共和国通过免费的母婴保健计划提供财政保护和获得保健服务的公平性
    摘要：Though Lao People’s Democratic Republic (Lao PDR) has made considerable progress in improving maternal and child health (MCH), significant disparities exist nationwide, with the poor and geographically isolated ethnic groups having limited access to services. In its pursuit of universal health coverage, the government introduced a Free MCH initiative in 2011, which has recently been subsumed within the new National Health Insurance (NHI) programme. Although this was a major national health financing reform, there have been few evaluations of the extent to which it improved equitable access to MCH services. We analyse surveys that provide information on demand-side and supply-side factors influencing access and utilization of free MCH services, especially for vulnerable groups. This includes two rounds of household surveys (2010 and 2013) in southern Lao PDR involving, respectively 2766 and 2911 women who delivered within 24 months prior to each survey. These data have been analysed according to the socio-economic status, geographic location and ethnicity of women using the MCH services as well as any associated out-of-pocket expenses and structural quality of these services. Two other surveys analysed here focused on human resources for health and structural quality of health facilities. Together, these data point to persistent large inequities in access and financial protection that need to be addressed. Significant differences were found in the utilization of health services by both economic status and ethnicity. Relatively large costs for institutional births were incurred by the poor and did not decline between 2010 and 2013 whereby there was no significant impact on financial protection. The overall benefit incidence of the universal programme was not pro-poor. The inequity was accentuated by issues related to distribution and nature of human resources, supply-side readiness and thus quality of care provided across different geographical areas.
  • 16.

    【2hr】Patient-experience during delivery in public health facilities in Uttar Pradesh, India

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    机译 印度北方邦公共卫生机构分娩期间的患者体验
    摘要：In India, most women now delivery in hospitals or other facilities, however, maternal and neonatal mortality remains stubbornly high. Studies have shown that mistreatment causes delays in care-seeking, early discharge and poor adherence to post-delivery guidance. This study seeks to understand the variation of women’s experiences in different levels of government facilities. This information can help to guide improvement planning. We surveyed 2018 women who gave birth in a representative set of 40 government facilities from across Uttar Pradesh (UP) state in northern India. Women were asked about their experiences of care, using an established scale for person-centred care. We asked questions specific to treatment and clinical care, including whether tests such as blood pressure, contraction timing, newborn heartbeat or vaginal exams were conducted, and whether medical assessments for mothers or newborns were done prior to discharge. Women delivering in hospitals reported less attentive care than women in lower-level facilities, and were less trusting of their providers. After controlling for a range of demographic attributes, we found that better access, higher clinical quality, and lower facility-level, were all significantly predictive of patient-centred care. In UP, lower-level facilities are more accessible, women have greater trust for the providers and women report being better treated than in hospitals. For the vast majority of women who will have a safe and uncomplicated delivery, our findings suggest that the best option would be to invest in improvements mid-level facilities, with access to effective and efficient emergency referral and transportation systems should they be needed.
  • 17.

    【2hr】Are health workers reduced to being drug dispensers of antiretroviral treatment? A randomized cross-sectional assessment of the quality of health care for HIV patients in northern Uganda

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    机译 医务人员是否沦为抗逆转录病毒治疗的药物分配器？乌干达北部艾滋病毒患者医疗质量的随机横断面评估
    摘要：High quality of care (QoC) for antiretroviral treatment (ART) is essential to prevent treatment failure. Uganda, as many sub-Saharan African countries, increased access to ART by decentralizing provision to districts. However, little is known whether this rapid scale-up maintained high-quality clinical services. We assess the quality of ART in the Acholi and Lango sub-regions of northern Uganda to identify whether the technical quality of critical ART sub-system needs improvement. We conducted a randomized cross-sectional survey among health facilities (HF) in Acholi (n = 11) and Lango (n = 10). Applying lot quality assurance sampling principles with a rapid health facility assessment tool, we assessed ART services vis-à-vis national treatment guidelines using 37 indicators. We interviewed health workers (n = 21) using structured questionnaires, directly observed clinical consultations (n = 126) and assessed HF infrastructure, human resources, medical supplies and patient records in each health facility (n = 21). The district QoC performance standard was 80% of HF had to comply with each guideline. Neither sub-region complied with treatment guidelines. No HF displayed adequate: patient monitoring, physical examination, training, supervision and regular monitoring of patients’ immunology. The full range of first and second line antiretroviral (ARV) medication was not available in Acholi while Lango had sufficient stocks. Clinicians dispensed available ARVs without benefit of physical examination or immunological monitoring. Patients reported compliance with drug use (>80%). Patients’ knowledge of preventing HIV/AIDS transmission concentrated on condom use; otherwise it was poor. The poor ART QoC in northern Uganda raises major questions about ART quality although ARVs were dispensed. Poor clinical care renders patients’ reports of treatment compliance as insufficient evidence that it takes place. Further studies need to test patients’ immunological status and QoC in more regions of Uganda and elsewhere in sub-Saharan Africa to identify topical and geographical areas which are priorities for improving HIV care.
  • 18.

    【2hr】Corruption in Anglophone West Africa health systems: a systematic review of its different variants and the factors that sustain them

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    机译 西非英语卫生系统中的腐败：对其不同变体及其维持因素的系统评价
    摘要：West African countries are ranked especially low in global corruption perception indexes. The health sector is often singled out for particular concern given the role of corruption in hampering access to, and utilization of health services, representing a major barrier to progress to universal health coverage and to achieving the health-related Sustainable Development Goals. The first step in tackling corruption systematically is to understand its scale and nature. We present a systematic review of literature that explores corruption involving front-line healthcare providers, their managers and other stakeholders in health sectors in the five Anglophone West African (AWA) countries: Gambia, Ghana, Liberia, Nigeria and Sierra Leone, identifying motivators and drivers of corrupt practices and interventions that have been adopted or proposed. Boolean operators were adopted to optimize search outputs and identify relevant studies. Both grey and published literature were identified from Research Gate, Yahoo, Google Scholar, Google and PubMed, and reviewed and synthesized around key domains, with 61 publications meeting our inclusion criteria. The top five most prevalent/frequently reported corrupt practices were (1) absenteeism; (2) diversion of patients to private facilities; (3) inappropriate procurement; (4) informal payments; and (5) theft of drugs and supplies. Incentives for corrupt practices and other manifestations of corruption in the AWA health sector were also highlighted, while poor working conditions and low wages fuel malpractice. Primary research on anti-corruption strategies in health sectors in AWA remains scarce, with recommendations to curb corrupt practices often drawn from personal views and experience rather that of rigorous studies. We argue that a nuanced understanding of all types of corruption and their impacts is an important precondition to designing viable contextually appropriate anti-corruption strategies. It is a particular challenge to identify and tackle corruption in settings where formal rules are fluid or insufficiently enforced.
  • 19.

    【2hr】Disrespectful treatment in primary care in rural Tanzania: beyond any single health issue

    包量

    机译 坦桑尼亚农村地区初级保健中不尊重的治疗：除了任何单一的健康问题
    摘要：Knowing how patients are treated in care is foundational for creating patient-centred, high-quality health systems and identifying areas where policies and practices need to adapt to improve patient care. However, little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. We used data from a household survey of 2002 women living in rural Tanzania to describe the extent of disrespectful care during outpatient visits, who receive disrespectful care, and determine the association with patient satisfaction, rating of quality and recommendation of the facility to others. We asked about women’s most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. We report risk ratios with standard errors clustered at the facility level. The most common reasons for seeking care were fever or malaria (33.9%), vaccination (33.6%) and non-emergent check-up (13.4%). Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up [risk ratio (RR): 1.6, 95% confidence interval (CI): 1.1–2.2]. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic (95% CI: 1.6–2.7). While there is currently a lot of attention on disrespectful maternity care, our results suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.
  • 20.

    【2hr】‘Maternal deaths should simply be 0’: politicization of maternal death reporting and review processes in Ethiopia

    包量

    机译 “孕产妇死亡应简单地为0”：埃塞俄比亚将孕产妇死亡报告和审查流程政治化
    摘要：The Maternal Death Surveillance and Response system (MDSR) was implemented in Ethiopia in 2013 to record and review maternal deaths. The overall aim of the system is to identify and address gaps in order to prevent future death but, to date, around 10% of the expected number of deaths are reported. This article examines practices and reasoning involved in maternal death reporting and review practices in Ethiopia, building on the concept of ‘practical norms’. The study is based on multi-sited fieldwork at different levels of the Ethiopian health system including interviews, document analysis and observations, and has documented the politicized nature of MDSR implementation. Death reporting and review are challenged by the fact that maternal mortality is a main indicator of health system performance. Health workers and bureaucrats strive to balance conflicting demands when implementing the MDSR system: to report all deaths; to deliver perceived success in maternal mortality reduction by reporting as few deaths as possible; and to avoid personalized accountability for deaths. Fear of personal and political accountability for maternal deaths strongly influences not only reporting practices but also the care given in the study sites. Health workers report maternal deaths in ways that minimize their number and deflect responsibility for adverse outcomes. They attribute deaths to community and infrastructural factors, which are often beyond their control. The practical norms of how health workers report deaths perpetuate a skewed way of seeing problems and solutions in maternal health. On the basis of our findings, we argue that closer attention to the broader political context is needed to understand the implementation of MDSR and other surveillance systems.
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