Inadequate health financing is one of the major challenges health systems in low-income countries currently face. Health financing reforms are being implemented with an increasing interest in policies that abolish user fees. Data from three nationally representative surveys conducted in Uganda in 1999/2000, 2002/03 and 2005/06 were used to investigate the impact of user fee abolition on the attainment of universal coverage objectives. An increase in illness reporting was noted over the three surveys, especially among the poorer quintiles. An increase in utilization was registered in the period immediately following the abolition of user fees and was most pronounced in the poorest quintile. Overall, there was an increase in utilization in both public and private health care delivery sectors, but only at clinic and health centre level, not at hospitals. Our study shows important changes in health-care-seeking behaviour. In 2002/03, the poorest population quintile started using government health centres more often than private clinics whereas in 1999/2000 private clinics were the main source of health care. The richest quintile has increasingly used private clinics. Overall, it appears that the private sector remains a significant source of health care. Following abolition of user fees, we note an increase in the use of lower levels of care with subsequent reductions in use of hospitals. Total annual average expenditures on health per household remained fairly stable between the 1999/2000 and 2002/03 surveys. There was, however, an increase of US$21 in expenditure between the 2002/03 and 2005/06 surveys. Abolition of user fees improved access to health services and efficiency in utilization. On the negative side is the fact that financial protection is yet to be achieved. Out-of-pocket expenditure remains high and mainly affects the poorer population quintiles. A dual system seems to have emerged where wealthier population groups are switching to the private sector.
Inadequate health financing is one of the major challenges health systems in low-income countries currently face. Health financing reforms are being implemented with an increasing interest in policies that abolish user fees. Data from three nationally representative surveys conducted in Uganda in 1999/2000, 2002/03 and 2005/06 were used to investigate the impact of user fee abolition on the attainment of universal coverage objectives. An increase in illness reporting was noted over the three surveys, especially among the poorer quintiles. An increase in utilization was registered in the period immediately following the abolition of user fees and was most pronounced in the poorest quintile. Overall, there was an increase in utilization in both public and private health care delivery sectors, but only at clinic and health centre level, not at hospitals. Our study shows important changes in health-care-seeking behaviour. In 2002/03, the poorest population quintile started using government health centres more often than private clinics whereas in 1999/2000 private clinics were the main source of health care. The richest quintile has increasingly used private clinics. Overall, it appears that the private sector remains a significant source of health care. Following abolition of user fees, we note an increase in the use of lower levels of care with subsequent reductions in use of hospitals. Total annual average expenditures on health per household remained fairly stable between the 1999/2000 and 2002/03 surveys. There was, however, an increase of US$21 in expenditure between the 2002/03 and 2005/06 surveys. Abolition of user fees improved access to health services and efficiency in utilization. On the negative side is the fact that financial protection is yet to be achieved. Out-of-pocket expenditure remains high and mainly affects the poorer population quintiles. A dual system seems to have emerged where wealthier population groups are switching to the private sector.
In a fragmented health care system, without a garanteed reference provider to guide patients in their journey to better health, it can become difficult to search for appropriate care. This is especially the case when confronted with chronic illness, comorbidities, or frailty and receiving care from different health care settings. Therefore, Belgium started in 2015 a nationwide program aimed at improving integration of care for people with chronic diseases, called Integreo. This includes 12 integrated care projects (ICPs), who have all engaged in co-creation and progressive loco-regional governance development to restructure care organization. Each locoregional governance consortium came up with an action plan. This plan requires constant adaptation in order to improve care integration and possibly have an effect on the triple aim. Decisions on locoregional level are made with a population based perspective on value of care. Value driven health care is defined on the base of mean effects of care and its mean cost for specific groups of the population. However, so far, it hardly takes into account the individual specificities of experiencing care. Question: How can we include individual patient experience in value driven care as part of the governance process in order to improve care integration? Why is it important to include individual patient perspectives in valuing care? There are several reasons: • The health care system is a public good, therefore it is politically mandated that the people get a say in what is done and how it is delivered. • Including patient perspectives has the potential to improve the quality of care and subsequently the efficiency of care. • Health professionals (HPs) are experiencing tensions • To deliver the best possible care, customized to each individual patient • To taking into account population effects of care. • This tension should not stay a problem of the HPs, but it should be taken into account in each decision on loco-regional governance. • This need to balance statistical and narrative approach in evidence generation.
In a fragmented health care system, without a garanteed reference provider to guide patients in their journey to better health, it can become difficult to search for appropriate care. This is especially the case when confronted with chronic illness, comorbidities, or frailty and receiving care from different health care settings. Therefore, Belgium started in 2015 a nationwide program aimed at improving integration of care for people with chronic diseases, called Integreo. This includes 12 integrated care projects (ICPs), who have all engaged in co-creation and progressive loco-regional governance development to restructure care organization. Each locoregional governance consortium came up with an action plan. This plan requires constant adaptation in order to improve care integration and possibly have an effect on the triple aim. Decisions on locoregional level are made with a population based perspective on value of care. Value driven health care is defined on the base of mean effects of care and its mean cost for specific groups of the population. However, so far, it hardly takes into account the individual specificities of experiencing care. Question: How can we include individual patient experience in value driven care as part of the governance process in order to improve care integration? Why is it important to include individual patient perspectives in valuing care? There are several reasons: • The health care system is a public good, therefore it is politically mandated that the people get a say in what is done and how it is delivered. • Including patient perspectives has the potential to improve the quality of care and subsequently the efficiency of care. • Health professionals (HPs) are experiencing tensions • To deliver the best possible care, customized to each individual patient • To taking into account population effects of care. • This tension should not stay a problem of the HPs, but it should be taken into account in each decision on loco-regional governance. • This need to balance statistical and narrative approach in evidence generation.
Abstract Background Use of evidence in health policymaking plays an important role, especially in resource-constrained settings where informed decisions on resource allocation are paramount. Several knowledge translation (KT) models have been developed, but few have been applied to health policymaking in low income countries. If KT models are expected to explain evidence uptake and implementation, or lack of it, they must be contextualized and take into account the specificity of low income countries for example, the strong influence of donors. The main objective of this research is to elaborate a Middle Range Theory (MRT) of KT in Uganda that can also serve as a reference for other low- and middle income countries. Methods This two-step study employed qualitative approaches to examine the principal barriers and facilitating factors to KT. Step 1 involved a literature review and identification of common themes. The results informed the development of the initial MRT, which details the facilitating factors and barriers to KT at the different stages of research and policy development. In Step 2, these were further refined through key informant interviews with policymakers and researchers in Uganda. Deductive content and thematic analysis was carried out to assess the degree of convergence with the elements of the initial MRT and to identify other emerging issues. Results Review of the literature revealed that the most common emerging facilitating factors could be grouped under institutional strengthening for KT, research characteristics, dissemination, partnerships and political context. The analysis of interviews, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. New factors emphasized by respondents were the use of mainstreamed structures within MoH to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of the community and civil society in KT. Conclusions This study refined an initial MRT on KT in policymaking in the health sector in Uganda that was based on a literature review. It provides a framework that can be used in empirical research of the process of KT on specific policy issues.
BACKGROUND: Use of evidence in health policymaking plays an important role, especially in resource-constrained settings where informed decisions on resource allocation are paramount. Several knowledge translation (KT) models have been developed, but few have been applied to health policymaking in low income countries. If KT models are expected to explain evidence uptake and implementation, or lack of it, they must be contextualized and take into account the specificity of low income countries for example, the strong influence of donors. The main objective of this research is to elaborate a Middle Range Theory (MRT) of KT in Uganda that can also serve as a reference for other low- and middle income countries. METHODS: This two-step study employed qualitative approaches to examine the principal barriers and facilitating factors to KT. Step 1 involved a literature review and identification of common themes. The results informed the development of the initial MRT, which details the facilitating factors and barriers to KT at the different stages of research and policy development. In Step 2, these were further refined through key informant interviews with policymakers and researchers in Uganda. Deductive content and thematic analysis was carried out to assess the degree of convergence with the elements of the initial MRT and to identify other emerging issues. RESULTS: Review of the literature revealed that the most common emerging facilitating factors could be grouped under institutional strengthening for KT, research characteristics, dissemination, partnerships and political context. The analysis of interviews, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. New factors emphasized by respondents were the use of mainstreamed structures within MoH to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of the community and civil society in KT. CONCLUSIONS: This study refined an initial MRT on KT in policymaking in the health sector in Uganda that was based on a literature review. It provides a framework that can be used in empirical research of the process of KT on specific policy issues.
BACKGROUND: Use of evidence in health policymaking plays an important role, especially in resource-constrained settings where informed decisions on resource allocation are paramount. Several knowledge translation (KT) models have been developed, but few have been applied to health policymaking in low income countries. If KT models are expected to explain evidence uptake and implementation, or lack of it, they must be contextualized and take into account the specificity of low income countries for example, the strong influence of donors. The main objective of this research is to elaborate a Middle Range Theory (MRT) of KT in Uganda that can also serve as a reference for other low- and middle income countries. METHODS: This two-step study employed qualitative approaches to examine the principal barriers and facilitating factors to KT. Step 1 involved a literature review and identification of common themes. The results informed the development of the initial MRT, which details the facilitating factors and barriers to KT at the different stages of research and policy development. In Step 2, these were further refined through key informant interviews with policymakers and researchers in Uganda. Deductive content and thematic analysis was carried out to assess the degree of convergence with the elements of the initial MRT and to identify other emerging issues. RESULTS: Review of the literature revealed that the most common emerging facilitating factors could be grouped under institutional strengthening for KT, research characteristics, dissemination, partnerships and political context. The analysis of interviews, however, showed that policymakers and researchers ranked institutional strengthening for KT, research characteristics and partnerships as the most important. New factors emphasized by respondents were the use of mainstreamed structures within MoH to coordinate and disseminate research, the separation of roles between researchers and policymakers, and the role of the community and civil society in KT. CONCLUSIONS: This study refined an initial MRT on KT in policymaking in the health sector in Uganda that was based on a literature review. It provides a framework that can be used in empirical research of the process of KT on specific policy issues.
Introduction: Interprofessional Collaboration (IPC) has long been considered as an essential principle underpinning effective primary health care, [1]. The Belgian primary care level is characterized by a shortage of General practitioners (GPs), the absence of shared patients list between GPs and home nurses, and a diversity of practices and payment systems. The Belgian population is aging and suffering from chronic diseases [2]. It becomes essential to enable primary healthcare providers to face these sociodemographic changes and increased health and social care needs. We therefore aim at 1) assessing IPC between GPs and nurses; 2) identifying target priorities for improving IPC; and 3) endorsing their improvement projects. Methods: A participatory action research (PAR) was initiated based on the methodological scheme for health systems research of Mercenier [3]. Six groups of GPs and nurses were chosen based on diversity of practices, payment systems, environment, and resources. Researchers met on a monthly basis with participants of each area. The conceptual model of Reeves on teamwork was used as a descriptive model for this PAR[4]. Preliminary results (ongoing research): Each group performed a SWOT analysis of their collaborative practice. Identified strengths were about shared values and objectives, previous positive experiences of IPC, and recognition of each other's competencies and specific roles. Weaknesses revolved around managerial and informational fragmentation, hierarchical relations, lack of trust, lack of consideration, and lack of responsibilities clarification. Opportunities and threats were related to the different financing systems which impeded or facilitated multidisciplinary team meetings and communication, the weak functional integration, the shortage of workforces, the lack of shared patients list, and the lack of of interprofessional education. Two issues were co-identified as common priorities: communication and task delegation. Actions prioritized by each area were related to these two issues and took local needs into account. Discussions Communication could be supported locally by improved ICT tools, and dedicating time for multidisciplinary team meetings. Task delegation is a more challenging issue to address and rises questions related to the nurses training and continuing education, task clarification, restrictive legislation and payment system. IPC seems to be easier to achieve when healthcare professionals belong to the same organization, with shared patients list, spaces and communication tools, and consider themselves as a "team". Conclusions Benefits of interprofessional collaboration are widely agreed upon for the healthcare system in general. However, implementation of collaborative interventions depends of both governmental and local factors and has not yet been fully explored. Lessons learned IPC is more challenging to achieve in a context where healthcare providers don't share a patients population and effective communication tools. Limitations The PAR did not include patients, only a patient organization in the steering committee of this project. Suggestions for future research Future research should address patient's acceptance of task delegation. References 1. Morgan, S, Pullon, S and McKinlay, E. Observation of interprofessional collaborative practice in primary care teams: An integrative literature review. International Journal of Nursing Studies 2015; 52(7): 1217-30. DOI: https://doi.org/10.1016/j.ijnurstu.2015.03.008 2. Institut Scientifique de Santé Publique ISP. Enquête de santé belge par interview 2013. [Scientific Institute of Public Health. Health Interview Survey 2013]. Rapport I: Etat de santé et bien-etre. [in French]. [cited 2016 20 April]. Available from: https://his.wiv-isp.be/fr/Documents%20partages/SH_FR_2013.pdf 3. Grodos, D and Mercenier, P. La recherche sur les systèmes de santé: mieux comprendre la méthodologie pour mieux agir. Antwerpen: ITGPress, 2000. 114 p. (Studies in Health Services Organisation & Policy; 14). 4. Reeves, S, Lewin, S, Espin, S and Zwarenstein, M. Interprofessional Teamwork for Health and Social Care: Promoting partnership for health. UK: Chichester. Wiley-Blackwell. 2010. 191p.
Introduction: Interprofessional Collaboration (IPC) has long been considered as an essential principle underpinning effective primary health care, [1]. The Belgian primary care level is characterized by a shortage of General practitioners (GPs), the absence of shared patients list between GPs and home nurses, and a diversity of practices and payment systems. The Belgian population is aging and suffering from chronic diseases [2]. It becomes essential to enable primary healthcare providers to face these sociodemographic changes and increased health and social care needs. We therefore aim at 1) assessing IPC between GPs and nurses; 2) identifying target priorities for improving IPC; and 3) endorsing their improvement projects. Methods: A participatory action research (PAR) was initiated based on the methodological scheme for health systems research of Mercenier [3]. Six groups of GPs and nurses were chosen based on diversity of practices, payment systems, environment, and resources. Researchers met on a monthly basis with participants of each area. The conceptual model of Reeves on teamwork was used as a descriptive model for this PAR[4]. Preliminary results (ongoing research): Each group performed a SWOT analysis of their collaborative practice. Identified strengths were about shared values and objectives, previous positive experiences of IPC, and recognition of each other's competencies and specific roles. Weaknesses revolved around managerial and informational fragmentation, hierarchical relations, lack of trust, lack of consideration, and lack of responsibilities clarification. Opportunities and threats were related to the different financing systems which impeded or facilitated multidisciplinary team meetings and communication, the weak functional integration, the shortage of workforces, the lack of shared patients list, and the lack of of interprofessional education. Two issues were co-identified as common priorities: communication and task delegation. Actions prioritized by each area were related to these two issues and took local needs into account. Discussions Communication could be supported locally by improved ICT tools, and dedicating time for multidisciplinary team meetings. Task delegation is a more challenging issue to address and rises questions related to the nurses training and continuing education, task clarification, restrictive legislation and payment system. IPC seems to be easier to achieve when healthcare professionals belong to the same organization, with shared patients list, spaces and communication tools, and consider themselves as a "team". Conclusions Benefits of interprofessional collaboration are widely agreed upon for the healthcare system in general. However, implementation of collaborative interventions depends of both governmental and local factors and has not yet been fully explored. Lessons learned IPC is more challenging to achieve in a context where healthcare providers don't share a patients population and effective communication tools. Limitations The PAR did not include patients, only a patient organization in the steering committee of this project. Suggestions for future research Future research should address patient's acceptance of task delegation. References 1. Morgan, S, Pullon, S and McKinlay, E. Observation of interprofessional collaborative practice in primary care teams: An integrative literature review. International Journal of Nursing Studies 2015; 52(7): 1217-30. DOI: https://doi.org/10.1016/j.ijnurstu.2015.03.008 2. Institut Scientifique de Santé Publique ISP. Enquête de santé belge par interview 2013. [Scientific Institute of Public Health. Health Interview Survey 2013]. Rapport I: Etat de santé et bien-etre. [in French]. [cited 2016 20 April]. Available from: https://his.wiv-isp.be/fr/Documents%20partages/SH_FR_2013.pdf 3. Grodos, D and Mercenier, P. La recherche sur les systèmes de santé: mieux comprendre la méthodologie pour mieux agir. Antwerpen: ITGPress, 2000. 114 p. (Studies in Health Services Organisation & Policy; 14). 4. Reeves, S, Lewin, S, Espin, S and Zwarenstein, M. Interprofessional Teamwork for Health and Social Care: Promoting partnership for health. UK: Chichester. Wiley-Blackwell. 2010. 191p.
Time spent on family care of frail older people is difficult to substantiate because of its complex nature. The aim of this study is to check the content validity of existing questionnaires measuring the time spent on caring. Comparing the activities mentioned in the questionnaires with those from other data sources (three validated scales measuring the functional limitations in day-to-day activities and a qualitative study) enabled identification of important drawbacks in the questionnaires reviewed. A comprehensive list of activities was built in order to help future researchers to conduct effective data collection and thereby enable an in-depth analysis of family care supply.
Background: In the Democratic Republic of Congo (DRC), healthcare services are still focused on disease control and mortality reduction in specific groups. The need to broaden the scope from biomedical criteria to bio-psychosocial (BPS) dimensions has been increasingly recognized. Aim: The objective of this study was to identify the barriers and facilitators to providing healthcare at the health centre (HC) level to enable BPS care. Settings: This qualitative study was conducted in six HCs (two urban and four rural) in SouthKivu (eastern DRC) which were selected based on their accessibility and their level of primary healthcare organization. Methods: Seven focus group discussions (FGDs) involving 29 healthcare workers were organized. A data synthesis matrix was created based on the Rainbow Model framework. We identified themes related to plausible barriers and facilitators for BPS approach. Results: Our study reports barriers common to a majority of HCs: misunderstanding of BPS care by healthcare workers, home visits mainly used for disease control, solidarity initiatives not locally promoted, new resources and financial incentives expected, accountability summed up in specific indicators reporting. Availability of care teams and accessibility to patient information were reported as facilitators to change. Conclusion: This analysis highlighted major barriers that condition providers' mindset and healthcare provision at the primary care level in South-Kivu. Accessibility to the information regarding BPS status of individuals within the community, leadership of HC authorities, dynamics of HC teams and local social support initiatives should be considered in order to develop an effective BPS approach in this region. ; SCOPUS: ar.j ; info:eu-repo/semantics/published
Background It is well documented that treatment for severe acute malnutrition (SAM) is effective. However, little is known about the long-term outcomes for children treated for SAM. We sought to trace former SAM patients 11 to 30 years after their discharge from hospital, and to describe their longer-term survival and their growth to adulthood. Methods A total of 1,981 records of subjects admitted for SAM between 1988 and 2007 were taken from the archives of Lwiro hospital, in South Kivu, DRC. The median age on admission was 41 months. Between December 2017 and June 2018, we set about identifying these subjects (cases) in the health zones of Miti-Murhesa and Katana. For deceased subjects, the cause and year of death were collected. A Cox proportional hazards multivariate regression analysis was used to identify the death-related factors. For the cases seen, age- and gender-matched community controls were selected for a comparison of anthropometric indicators. Results A total of 600 subjects were traced, and 201 subjects were deceased. Of the deceased subjects, 65·6% were under 10 years old at the time of their death. Of the deaths, 59·2% occurred within 5 years of discharge from hospital. The main causes of death were malaria (14·9%), kwashiorkor (13·9%), respiratory infections (10·4%), and diarrhoeal diseases (8·9%). The risk of death was higher in subjects with SAM, MAM combined with CM, and in male subjects, with HRs* of 1·83 (p = 0·043), 2.35 (p = 0·030) and 1.44 (p = 0·013) respectively. Compared with their controls, the cases had a low weight (-1·7 kg, p = 0·001), short height [sitting (-1·3 cm, p = 0·006) and standing (-1·7 cm, p = 0·003)], short legs (-1·6 cm, p = 0·002), and a small mid-upper arm circumference (-3·2mm, p = 0·051). There was no difference in terms of BMI, thoracic length, or head and thoracic circumference between the two groups. Conclusion SAM during childhood has lasting negative effects on growth to adulthood. In addition, these adults have characteristics that may place them at risk ...
Since 2007 to address a high burden, integration of acute malnutrition has been promoted in Niger. This paper studies factors that influenced the integration process of acute malnutrition into the Niger national health system.We used qualitative methods of observation, key informant interviews and focus group discussions at national level, two districts and nine communities selected through convenience sampling, as well as document review. A framework approach constructed around the problem, intervention, adoption system, health system characteristics and broad context guided the analysis. Data were recorded on paper, transcribed in a descriptive record, coded by themes deduced by building on the framework and triangulated for comprehensiveness.Key facilitating factors identified were knowledge and recognition of the problem helped by accurate information; effectiveness of decentralized continuity of care; compatibility with goals, support and involvement of health actors; and leadership for aligning policies and partnerships and mobilizing resources within a favourable political context driven by multisectoral development goals. Key hindering factors identified were not fully understanding severity, causes and consequences of the problem; limited utilization and trust in health interventions; high workload, and health worker turnover and attrition; and high dependence on financial and technical support based on short-term emergency funding within a context of high demographic pressure.The study uncovered influencing factors of integrating acute malnutrition into the national health system and their complex dynamics and relationships. It elicited the need for goal-oriented strategies and alignment of health actors to achieve sustainability, and systems thinking to understand pathways that foster integration. We recommend that context-specific learning of integrating acute malnutrition may expand to include causal modelling and scenario testing to inform strategy designs. The method may also be applied to monitor progress of integrating nutrition by the multisectoral nutrition plan to guide change.
Since 2007 to address a high burden, integration of acute malnutrition has been promoted in Niger. This paper studies factors that influenced the integration process of acute malnutrition into the Niger national health system.We used qualitative methods of observation, key informant interviews and focus group discussions at national level, two districts and nine communities selected through convenience sampling, as well as document review. A framework approach constructed around the problem, intervention, adoption system, health system characteristics and broad context guided the analysis. Data were recorded on paper, transcribed in a descriptive record, coded by themes deduced by building on the framework and triangulated for comprehensiveness.Key facilitating factors identified were knowledge and recognition of the problem helped by accurate information; effectiveness of decentralized continuity of care; compatibility with goals, support and involvement of health actors; and leadership for aligning policies and partnerships and mobilizing resources within a favourable political context driven by multisectoral development goals. Key hindering factors identified were not fully understanding severity, causes and consequences of the problem; limited utilization and trust in health interventions; high workload, and health worker turnover and attrition; and high dependence on financial and technical support based on short-term emergency funding within a context of high demographic pressure.The study uncovered influencing factors of integrating acute malnutrition into the national health system and their complex dynamics and relationships. It elicited the need for goal-oriented strategies and alignment of health actors to achieve sustainability, and systems thinking to understand pathways that foster integration. We recommend that context-specific learning of integrating acute malnutrition may expand to include causal modelling and scenario testing to inform strategy designs. The method may also be applied to monitor progress of integrating nutrition by the multisectoral nutrition plan to guide change.
Au Burkina Faso, la prise en charge de la co-infection TB/VIH est un défi à relever pour les acteurs des politiques et systèmes de santé et présente des enjeux psychologiques, socioculturels et biomédicaux. L'objet de cet article est de montrer les soucis causés par la co-infection TB/VIH et de proposer une modalité de prise en charge des malades. Il s'agit d'une approche qualitative pour des analyses socioanthropologiques accompagnant un projet de santé publique dans trois districts sanitaires de 2006 à 2008. Nous avons aussi procédé à l'observation des pratiques de soins dans les centres de santé. Les malades font face à une double crainte : l'image sociale négative des deux maladies et la lourdeur des traitements. Il y a un problème d'intégration sociale puisque leurs relations sociales sont mises en difficulté par des humiliations et la marginalisation sociale. L'expérience douloureuse des prises quotidiennes d'antirétroviraux et d'antituberculeux crée une amertume face aux médicaments, en plus des services de soins capricieux. Outre la précarité économique, la stigmatisation sociale et les marginalisations subies par les malades chroniques dans leur environnement débouchent sur une mise en difficulté de l'estime de soi des malades.
