Suchergebnisse

BACKGROUND: The South African government is implementing National Health Insurance (NHI) as a monopsony health care financing mechanism to drive the country towards Universal Health Coverage (UHC). Strategic purchasing, with separation of funder, purchaser and provider, underpins this initiative. The NHI plans Contracting Units for Primary healthcare (PHC) Services (CUPS) to function as either independent sub-district purchasers or public providers and District Health Management Offices (DHMOs) to support and monitor these CUPS. This decentralised operational unit of PHC, the heartbeat of NHI, is critical to the success of NHI. The views of district-level managers, who are responsible for these units, are fundamental to this NHI implementation. This qualitative study aimed to explore district and sub-district managerial views on NHI and their role in its implementation. METHODS: Purposive sampling was used to identify key respondents from a major urban district in Gauteng, South Africa, for participation in in-depth interviews. This study used framework analysis methodology within MaxQDA software. RESULTS: Three main themes were identified: managerial engagement in NHI policy development (with two sub-themes), managerial views on NHI (with three sub-themes) and perceptions of current NHI implementation (with six sub-themes). The managers viewed NHI as a social and moral imperative but lacked clarity and insight into the NHI Bill as well as the associated implementation strategies. The majority of respondents had not had the opportunity to engage in NHI policy formulation. Managers cited several pitfalls in current organisational operations. The respondents felt that national and provincial governments continue to function in a detached and rigid top-down hierarchy. Managers highlighted the need for their inclusion in NHI policy formulation and training and development for them to oversee the implementation strategies. CONCLUSIONS: It appears that strategic purchasing is not being operationalised in PHC. NHI ...

The World Health Organization's Health Promoting Schools (HPS) framework is a whole-school approach to promoting health that recognizes the intrinsic relationship between health and education. Our recent Cochrane systematic review found HPS interventions produced improvements in a number of student health outcomes. Here we reflect on what this review was not able to tell us: in other words, what evidence is missing with regard to the HPS approach. Few HPS interventions engage with schools' "core business" by examining impacts on educational outcomes. Current evidence is dominated by obesity interventions, with most studies conducted with children rather than adolescents. Evidence is lacking for outcomes such as mental or sexual health, substance use, and violence. Activities to engage families and communities are currently weak and unlikely to prompt behavioral change. The HPS approach is largely absent in low-income settings, despite its potential in meeting children's basic health needs. Intervention theories are insufficiently complex, often ignoring upstream determinants of health. Few studies provide evidence on intervention sustainability or cost-effectiveness, nor in-depth contextual or process data. We set out an agenda for future school health promotion research, considering implications for key stakeholders, namely, national governments, research funders, academics, and schools.

Background: Pragmatic trials of public health interventions outside the NHS are relatively scarce, much needed and face particular challenges. These include funding, of intervention costs in particular; trial implementation in professional and organisational cultures unused to randomised trial procedures, including randomisation, maintaining the counterfactual, recruitment; and relevance of findings for and translation into policy and practice. Objectives: The current NPRI funded trial of SFP 10-14 UK is presented as a case study to discuss these issues, solutions and remaining barriers. The SFP 10-14 UK programme aims to strengthen areas of family life that protect against substance misuse, for example, parenting, communication, and young people's resilience skills. The SFP 10-14 UK is being delivered by statutory and voluntary agencies in six local authority areas across Wales, and is offered to mixed groups comprised of families from the general population, and families who may experience/present challenges within a group setting. Methods: The trial aims to recruit 748 families, 374 of whom will be randomised to receive the usual services available to families within their local area. 374 families will receive the SFP 10-14 UK in addition to usual care. Families are identified by staff employed within the statutory services and voluntary sectors and referred to embedded research staff for recruitment. Results: Challenges encountered related to a lack of awareness of the randomised trial as a research paradigm among staff and key referring agencies, related concerns about the ethics of randomisation and the maintenance of the counterfactual among the usual care group, and challenges regarding the maintenance of recruitment and intervention fidelity. Whilst a challenge in itself, partnership working with delivery agencies, programme trainers, and the Welsh Assembly Government at all stages of the development, funding and conduct of the trial has proved an important strategy to overcome these issues. Conclusions: This trial seeks to generate evidence on the effectiveness and cost effectiveness of the SFP10-14 UK which is of direct relevance to policy makers, commissioners and practitioners. The trial highlights that strategic partnership working, the winning of 'hearts and minds' regarding the ethics and operationalisation of randomisation, and maintaining the balance between internal and external validity are key areas of focus for the successful conduct of pragmatic trials in non-NHS settings. The lessons learnt from its implementation will be important for future multi-sector/agency policy trials and for role out of the intervention if found to be efficacious.