| 61. |
- Tancred, Tara, et al.
(author)
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How people-centred health systems can reach the grassroots : experiences implementing community-level quality improvement in rural Tanzania and Uganda
- 2018
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In: Health Policy and Planning. - : Oxford University Press (OUP). - 0268-1080 .- 1460-2237. ; 33:1, s. e1-e13
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Journal article (peer-reviewed)abstract
- BackgroundQuality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here we share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff.AimTo describe experiences implementing EQUIP’s QI approach at the community level.MethodsA mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. We outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also.ResultsVillage volunteers had the capacity to learn and apply QI techniques to address local maternal and neonatal health problems. Data collection and presentation was a persistent challenge for village volunteers, overcome through intensive continuous mentoring and coaching. Village volunteers complemented health facility staff, particularly to reinforce behaviour change on health facility delivery and birth preparedness. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce.ConclusionsCommunity-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.
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| 62. |
- Xu, Biao, et al.
(author)
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DOTS in China : Removing barriers or moving barriers?
- 2006
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In: Health Policy and Planning. - : Oxford University Press. - 0268-1080 .- 1460-2237. ; 21:5, s. 365-72
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Journal article (peer-reviewed)abstract
- In 1992, China initiated its modern National TB Control Programme (NTP) with DOTS strategy through a project funded by a World Bank loan. Key motives for the revised NTP-DOTS were to reduce financial barriers to patients by removing fee charges for diagnosis and treatment, and to address regressive suppliers' incentives for appropriate referrals. This study aims to assess to what extent China's NTP subsidies are achieving the objective of removing financial barriers to care in terms of patients' expenditure. One county with NTP-DOTS - Jianhu - and one county without - Funing - were selected. A cohort of 493 tuberculosis patients newly diagnosed in 2002 was interviewed by questionnaire. The main outcome measure was tuberculosis patients' expenditure on medical care and transportation/accommodation from the onset of symptoms to treatment completion. During the follow-up period, Funing started implementing NTP-DOTS, which offered a possibility of longitudinal comparison both between counties and within county. Ninety-four per cent (465/493) of subjects were followed-up. The mean total patient's expenditure on TB medical care and transportation/accommodation before TB diagnosis was higher in Jianhu than in Funing (715 vs. 256CNY), whereas it was higher in Funing (835 vs. 157CNY) after diagnosis. After implementing NTP-DOTS in Funing, expenditure after diagnosis decreased slightly whereas expenditure before diagnosis increased remarkably. We found that the market incentive structures in the reformed health system appear to have a stronger regressive effect and may result in prolonged delays before effective treatment can be given. We believe that doctors adapt to new incentive structures, with bonus income being linked to the hospitals' fee-for-service revenue, and find new ways of keeping revenue at the old levels, which reduce or eliminate the intended effect of the subsidies. TB patients suffer a heavy economic burden even in counties where NTP-DOTS treatment is subsidized. The total patient expenditure was reduced only marginally, but shifted substantially from after diagnosis to before diagnosis. The shift could imply delays in diagnosis and treatment with an increased risk of infection transmission.
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| 63. |
- Zamboni, K, et al.
(author)
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Assessing scalability of an intervention: why, how and who?
- 2019
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In: Health policy and planning. - : Oxford University Press (OUP). - 1460-2237 .- 0268-1080. ; 34:7, s. 544-552
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Journal article (peer-reviewed)abstract
- 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.
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| 64. |
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| 65. |
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| 66. |
- Asefa, A, et al.
(author)
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Methodological reflections on health system-oriented assessment of maternity care in 16 hospitals in sub-Saharan Africa: an embedded case study
- 2022
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In: Health policy and planning. - : Oxford University Press (OUP). - 1460-2237. ; 37:10, s. 1257-1266
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Journal article (peer-reviewed)abstract
- Health facility assessments (HFAs) assessing facilities’ readiness to provide services are well-established. However, HFA questionnaires are typically quantitative and lack depth to understand systems in which health facilities operate—crucial to designing context-oriented interventions. We report lessons from a multiple embedded case study exploring the experiences of HFA data collectors in implementing a novel HFA tool developed using systems thinking approach. We assessed 16 hospitals in four countries (Benin, Malawi, Tanzania and Uganda) as part of a quality improvement implementation research. Our tool was organized in 17 sections and included dimensions of hospital governance, leadership and financing; maternity care standards and procedures; ongoing quality improvement practices; interactions with communities and mapping of the areas related to maternal care. Data for this study were collected using in-depth interviews with senior experts who conducted the HFA in the countries 1–3 months after completion of the HFAs. Data were analysed using the inductive thematic analysis approach. Our HFA faced challenges in logistics (accessing key hospital-based respondents, high turnover of managerial staff and difficulty accessing information considered sensitive in the context) and methodology (response bias, lack of data quality and data entry into an electronic platform). Data elements of governance, leadership and financing were the most affected. Opportunities and strategies adopted aimed at enhancing data collection (building on prior partnerships and understanding local and institutional bureaucracies) and enhancing data richness (identifying respondents with institutional memory, learning from experience and conducting observations at various times). Moreover, HFA data collectors conducted abstraction of records and interviews in a flexible and adaptive way to enhance data quality. Lessons and new skills learned from our HFA could be used as inputs to respond to the growing need of integrating the systems thinking approach in HFA to improve the contextual understanding of operations and structure.
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| 67. |
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| 68. |
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| 69. |
- Gurung, SC, et al.
(author)
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How to reduce household costs for people with tuberculosis: a longitudinal costing survey in Nepal
- 2021
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In: Health policy and planning. - : Oxford University Press (OUP). - 1460-2237. ; 36:5, s. 594-605
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Journal article (peer-reviewed)abstract
- The aim of this study was to compare costs and socio-economic impact of tuberculosis (TB) for patients diagnosed through active (ACF) and passive case finding (PCF) in Nepal. A longitudinal costing survey was conducted in four districts of Nepal from April 2018 to October 2019. Costs were collected using the WHO TB Patient Costs Survey at three time points: intensive phase of treatment, continuation phase of treatment and at treatment completion. Direct and indirect costs and socio-economic impact (poverty headcount, employment status and coping strategies) were evaluated throughout the treatment. Prevalence of catastrophic costs was estimated using the WHO threshold. Logistic regression and generalized estimating equation were used to evaluate risk of incurring high costs, catastrophic costs and socio-economic impact of TB over time. A total of 111 ACF and 110 PCF patients were included. ACF patients were more likely to have no education (75% vs 57%, P = 0.006) and informal employment (42% vs 24%, P = 0.005) Compared with the PCF group, ACF patients incurred lower costs during the pretreatment period (mean total cost: US$55 vs US$87, P < 0.001) and during the pretreatment plus treatment periods (mean total direct costs: US$72 vs US$101, P < 0.001). Socio-economic impact was severe for both groups throughout the whole treatment, with 32% of households incurring catastrophic costs. Catastrophic costs were associated with ‘no education’ status [odds ratio = 2.53(95% confidence interval = 1.16–5.50)]. There is a severe and sustained socio-economic impact of TB on affected households in Nepal. The community-based ACF approach mitigated costs and reached the most vulnerable patients. Alongside ACF, social protection policies must be extended to achieve the zero catastrophic costs milestone of the End TB strategy.
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| 70. |
- Kinney, MV, et al.
(author)
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Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors
- 2021
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In: Health policy and planning. - : Oxford University Press (OUP). - 1460-2237. ; 36:6, s. 955-973
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Journal article (peer-reviewed)abstract
- Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.
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