1,721,183 research outputs found
Winners and losers: the expansion of health insurance coverage in Russia in the 1990s
No full textObjectives. This study sought to describe the evolution of the Russian compulsory health insurance system and to identify factors associated with noncoverage.Methods. Data from successive waves of the Russian Longitudinal Monitoring Survey (1992–2000) were analyzed.Results. Insurance coverage grew rapidly throughout the 1990s, although 11.8% of the country’s citizens were still uninsured by 2000. Coverage initiation rates were greater at first among citizens who were better off, but this gap closed over the study period. Among individuals of working age, coverage rates diminished with age and were lower for the unemployed, for the self-employed, and for those residing outside Moscow or St. Petersburg.Conclusions. The growth of insurance coverage in Russia slowed toward the end of the 1990s, and gaps remain. Achievement of universal coverage will require new, targeted policies
Learning from implementation of Integrated Child Health Events: lessons from global practice and the experience of Zambia
Get PDFBackground: Integrated child health events (ICHEs) are an established and popular mechanism for delivering essential health interventions in low- and middle-income countries (LMICs) suffering resource constraints and health system deficiencies. There is scarce empirical research on whether their expansion and addition of multiple components affect coverage, on the institutional capacities and processes required to support these, and on their implications for routine delivery of immunization.
Aim: To examine whether delivering multiple interventions through campaign-style events is an effective strategy in LMICs, given the drive towards expansion of this delivery strategy, and the need to sustain and strengthen routine immunization systems in the long-term.
Methods: Guided by an implementation research framework, the study involved a quantitative analysis of a global ICHE dataset, and a qualitative case study of CHWk in Zambia (1999-2014) including semi-structured interviews and document reviews. Zambia represented a unique case as it has consistently relied on campaigns with larger numbers of interventions per event than elsewhere.
Findings: ICHEs represented an effective platform with a potential to incorporate multiple key interventions globally without necessarily compromising their coverage. Political stability, government stewardship, high levels of collaborative action and coordination, and the institutionalization of CHWk in Zambia provided a solid base for expansion. Lack of financial and human resources to strengthen district health management fostered a reliance on CHWk to deliver routine immunization. An abrupt top-down policy shift to de-emphasize CHWk, and insufficient local buy-in, in effect obstructed the move towards re-building routine systems.
Conclusions: ICHEs continue to play a major role in delivering multiple essential child health interventions in many LMICs. Given their potential to undermine routine immunization systems, a synchronised approach of continued delivery of key services through campaigns in targeted areas, in parallel with strengthening routine delivery, is a viable strategy in pursuing child mortality reductions in the long term
Aid (In)dependence? Promoting long-term sustainability in the response to HIV/AIDS: the case of the Global Fund in Peru
Get PDFIn the current scenario of decreasing aid, it is critical to develop mechanisms to guarantee the
sustainability of programmes once donors exit a country. This study seeks to provide an indepth
understanding of this process in Peru, an upper-middle income country and recipient of
multiple HIV/AIDS Global Fund grants that, given recent economic growth, has allocated
strategic funding for HIV/AIDS activities within the national budget. The aim of this study is
to evaluate the transition of Peru from receiving Global Fund financing for HIV/AIDS to the
increasing role of national institutions and capacity for policy development. For this, an
original framework was employed, which allowed for the analysis of inputs (resources
invested), actor motivations and incentives, HIV policies and plans, and their effects on
programmatic sustainability; finally providing recommendations to inform decision-makers
on priority areas that must be strengthened to ensure sustainable HIV/AIDS programming.
To achieve these objectives, a case study (2004–2012) was conducted, employing a review of
the literature and in-depth interviews among the main actors working in HIV in Peru, carried
out between October–December of 2011.
Findings demonstrate that Peru has made important progress towards ensuring a sustainable
response for HIV/AIDS, primarily in the allocation of government funding and creation of
spaces for actor discussion. Yet, this is not without challenges. The weak leadership and lack
of coordination between the central and regional levels has exacerbated the already existing
capacity issues in the regions, in this case related to HIV activity planning and
implementation. Moreover, in order for HIV to remain a policy priority, mechanisms of
accountability must be strengthened, as well as information systems to demonstrate need and
key areas for action. Although findings are specific to the Peruvian context, this experience
leaves important lessons learned in programmatic sustainability for other countries
Democracy and growth in divided societies: A health-inequality trap?
No full textDespite a tremendous increase in financial resources, many countries are not on track to achieve the child and maternal mortality targets set out in the Millennium Development Goals 4 and 5. It is commonly argued that two main social factors - improved democratic governance and aggregate income - will ultimately lead to progress in reducing child and maternal mortality. However, these two factors alone may be insufficient to achieve progress in settings where there is a high level of social division. To test the effects of growth and democratisation, and their interaction with social inequalities, we regressed data on child and maternal mortality rates for 192 countries against internationally used indexes of income, democracy, and population inequality (including income, ethnic, linguistic, and religious divisions) covering the period 1970-2007. We found that a higher degree of social division, especially ethnic and linguistic fractionalisation, was significantly associated with greater child and maternal mortality rates. We further found that, even in democratic states, greater social division was associated with lower overall population access to healthcare and lesser expansion of health system infrastructure. Perversely, while greater democratisation and aggregate income were associated with reduced maternal and child mortality overall, in regions with high levels of ethnic fragmentation the health benefits of democratisation and rising income were undermined and, at high levels of inequality reversed, so that democracy and growth were adversely related to child and maternal mortality. These findings are consistent with literature suggesting that high degrees of social division in the context of democratisation can strengthen the power of dominant elite and ethnic groups in political decision-making, resulting in health and welfare policies that deprive minority groups (a health-inequality trap). Thus, we show that improving economic growth and democratic governance are insufficient to achieve child and maternal health targets in communities with high levels of persistent social inequality. To reduce child and maternal mortality in highly divided societies, it will be necessary not only to increase growth and promote democratic elections, but also empower disenfranchised communities
Can the Midwives Service Scheme (MSS) present an effective and health systems strengthening response to the shortages in human resources for maternal health services in Nigeria?
Get PDFThe flagship Midwives Service Scheme (MSS) was introduced in 2009 as the first large-scale intervention to address rural retention of midwives in Nigeria. This was a multi-component intervention including financial incentives to midwives, provision of accommodation and systems level support, aiming to improve human resource capacity to provide quality services. This study explores how effectively the scheme’s design and implementation drew on the health system’s context, resources, needs and population preferences, and how it contributed to strengthening health systems at all levels. To meet the objectives, 87 in-depth interviews and eight focus group discussions with policymakers, implementers, midwives and community members were conducted in two Nigerian states and at the federal level. Drawing on a systems-thinking approach, the study developed a new framework examining the fit of the intervention with the local health system’s context considering: i) leadership and commitment ii) policy and financing context iii) human resource management capacity, and iv) stakeholder participation. The framework informed the framing of the study and guided data collection; however, themes were identified and synthesised inductively. The broad principles and features of the scheme were widely supported by program managers and policy-makers across the three health systems levels (local, state, federal). However, its design was based on federal level program managers’ knowledge of maternal health and health worker issues, and limited recognition of the decentralised nature of the health system. Implementation was hampered by inadequate management and logistical capacity to deal with the complex design, poor absorptive capacity of states for the posted midwives, failure to provide continued supervision, and welfare issues that affected the midwives. The MSS was successful in attracting midwives including those employed in the private sector due to the promised pay package and capacity building opportunities offered under it. Several factors affected motivation of midwives and impacted on midwife retention. These include low and unpaid salaries and incentives, housing difficulties and distance of housing from the facility, and travel costs and hardships incurred from commuting to the facility. Unmet career development priorities were an additional source of demotivation. The findings point to poor retention of midwives in both states. Retention was better among retired midwives compared to other categories. Younger midwives were more mobile and exited the scheme mainly to the private sector. The MSS had the potential to bring about system-wide changes; however, weak implementation severely hampered its achievement of the intended outcomes and dampened the expectations of significant improvements in the health systems. The findings underscore the importance of reflecting overall health systems structures and processes and local contextual factors, including local health workers’ preferences in designing effective human resource retention schemes. The scheme is potentially replicable as a bundled package of interventions to improve access to skilled workers in rural communities in LMICs. Since decentralisation critically modifies the decision-making space, an inclusive process where sub-national actors participate in choosing policy options should be a prerequisite
Going Beyond Counting First Authors in Author Co-citation Analysis
Get PDFThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Get PDF“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
Evaluation of a Complex Health Intervention in Zambia: The case of the Better Health Outcome through Mentorship and Assessment (BHOMA) Applying system wide approaches to measuring health system strengthening: Essential Markers and Impact Pathway
Get PDFIntroduction:
In many low income countries the delivery of quality health services is hampered by health system-wide barriers which are often interlinked, however empirical evidence on how to assess the level and scope of these barriers is scarce. It has been recognised that taking a more comprehensive approach to assessing these barriers is more likely to provide lessons on what works and why. WHO has been advocating the use of systems wide approaches such as systems thinking to guide intervention design and evaluation. This thesis reports system-wide assessment of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality at the health facility and influence service demand from the community.
Methodology:
This study is nested within a cluster randomised trial of the BHOMA intervention that aims to strengthen the health system in three rural districts covering 42 health facilities in Zambia. The main trial has a stepped wedge design where the intervention is being rolled-out to all the 42 health facilities over a period of 4 years. A baseline health facility survey was done in 2011. This was followed by a 12 months post-intervention evaluation survey. At the time of the follow up survey 24 health facilities had received the intervention while 18 had not. Data collection used both quantitative and qualitative methods. The study was guided by a systems thinking theoretical framework which was inspired by the WHO building blocks for health system strengthening.
Results:
The baseline survey validated tools and indicators for assessing health system building blocks. Research paper 2 applied an innovative measure of health worker motivation which was initially applied in Kenya. The results showed that this simple tool was reliable with cronbach’s alpha of 0.73 for the 21 item measures of health workers’ motivation. Baseline assessment of health worker motivation showed variation in motivation score based on gender and access to training. Research paper 3 tested and applied a new tool for measuring health systems governance at health facility level. The new tool for measuring governance was reliable with the 16 item one side cronbach’s alpha ranging between 0.69-0.74.The tool was simple to use and found to be applicable in the Zambian health care setting.
A balanced scorecard approach was applied to measure the baseline health system characteristics for the target districts. Differences in performance were noted by district and residence in most domains with finance and service delivery domains performing poorly in all study districts. Regression modelling showed that children’s clinical observation scores were negatively correlated with drug availability (coeff 20.40, p = 0.02) while Adult clinical observation scores were positively association with adult service satisfaction score (coeff 0.82, p = 0.04)
Baseline qualitative results are presented in paper 5. The results showed close linkages between health system building blocks. Challenges noted in service delivery were linked to human resources, medical supplies, information flow, governance and finance building blocks either directly or indirectly.
The 12 months post intervention survey applied both quantitative and qualitative methods. Research paper 6 presents 12 months post intervention quantitative results applying the balanced scorecard approach as at baseline. Comparison was made between the control and intervention health facilities. The results showed significant mean differences between intervention (I) and control (C) sites in the following domains: Training domain (Mean I:C;87.5.vs 61.1, mean difference 23.3,p=0.031),adult clinical observation domain (mean I:C;73.3 vs.58.0, mean difference 10.9,p=0.02 ).
The 12 months post intervention qualitative evaluation applied systems thinking approach and the conceptual framework developed before the intervention. The findings are presented in research paper 7. The overall results showed that the community had accepted the intervention with increasing demand for services reported in all sites where the BHOMA intervention was implemented. The indications were that in the short term there was increased demand for services but the health workers’ capacity was not severely affected. However, from a systems thinking perspective, it was clear that several unintended consequences also occurred during the implementation of the BHOMA.
Conclusion:
In evaluation of complex interventions such as the BHOMA attention should be paid to context. Using system wide approaches and triangulating data collection methods seems to be important to successful evaluation of such complex intervention
Appropriate Similarity Measures for Author Cocitation Analysis
Get PDFWe provide a number of new insights into the methodological discussion about author cocitation analysis. We first argue that the use of the Pearson correlation for measuring the similarity between authors’ cocitation profiles is not very satisfactory. We then discuss what kind of similarity measures may be used as an alternative to the Pearson correlation. We consider three similarity measures in particular. One is the well-known cosine. The other two similarity measures have not been used before in the bibliometric literature. Finally, we show by means of an example that our findings have a high practical relevance.information science;Pearson correlation;cosine;similarity measure;author cocitation analysis
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