91 research outputs found
Economic evaluation and decision making for quality improvement in complex community health systems
No full textCommunity health is a fundamental part of many healthcare systems and is widely advocated as a means to increase access to and coverage of health services, yet the quality of care in large-scale community health programmes is mixed. Quality improvement (QI) approaches are now being tested in community settings and there is limited evidence that integrating QI approaches can underpin success of community programmes. However, how best to measure that success and the cost and value thereof to the different decision makers in complex community health systems is not yet known.
This thesis provides the first economic evaluation of QI in community health systems, linking this to an exploration of decision making that includes an assessment of how economic evidence like this is used. Using an interdisciplinary mixed methods approach, I worked across several countries (Ethiopia, Kenya, Indonesia, Malawi, and Mozambique) to provide evidence to inform policy decisions. I first examined the costs of a QI intervention in all five countries and then used those data as the foundation of a cost-effectiveness decision tree model for the intervention in Kenya. Through interviews with national and global decision makers, I qualitatively examined the use and value of evidence in community health programmes. I present the results in a series of three related publications, linking them together with a literature review and discussion that show how these studies build upon each other and what they add to the existing evidence base.
This thesis shows that QI for community health is a good investment contingent on an existing cadre of community health workers. The budget impact of the QI intervention is low (less than 0.53% of general government health expenditure) and the modelled cost-effectiveness yields an incremental cost-effectiveness ratio of US$249.43 per disability-adjusted life year. The absolute costs are highly dependent on context and the intensity of the intervention. Qualitative findings indicate that decision makers are not satisfied with existing evidence and have limited capacity to assess its relevance for their settings and perspectives. As a result, power and politics fill this evidence gap.
Evidence must be at the heart of decisions in funding universal health coverage for them to be sustainable. To achieve this, the global community must strengthen the relevance of evidence and build the capacity of decision makers to understand and apply it. For a complex system, useful evaluation should describe context and mechanism of an intervention, estimate the effect size on both programmatic and health impacts and accurately reflect the opportunity costs
Global financing facility investments for vulnerable populations: content analysis regarding maternal and newborn health and stillbirths in 11 African countries, 2015 to 2019
No full textThe Global Financing Facility (GFF) was launched in 2015 to catalyse increased domestic and external financing for reproductive, maternal, newborn, child, adolescent health, and nutrition. Half of the deaths along this continuum are neonatal deaths, stillbirths or maternal deaths; yet these topics receive the least aid financing across the continuum. To conduct a policy content analysis of maternal and newborn health (MNH), including stillbirths, in GFF country planning documents, and assess the mortality burden related to the investment. Content analysis was conducted on 24 GFF policy documents, investment cases and project appraisal documents (PADs), from 11 African countries. We used a systematic data extraction approach and applied a framework for analysis considering mindset, measures, and money for MNH interventions and mentions of mortality outcomes. We compared PAD investments to MNH-related deaths by country. For these 11 countries, USD303 million (16%) from GFF. All documents had strong content on MNH, with particular focus on pregnancy and childbirth interventions. The investment cases commonly included comprehensive results frameworks, and PADs generally had less technical content and fewer indicators. Mortality outcomes were mentioned, especially for maternal. Stillbirths were rarely included as targets. Countries had differing approaches to funding descriptions. PAD allocations are commensurate with the burden. The GFF country plans present a promising start in addressing MNH. Emphasising links between investments and burden, explicitly including stillbirth, and highlighting high-impact packages, as appropriate, could potentially increase impact
Collaborative creative inquiry: an arts-informed approach to transdisciplinary research
No full textThis paper presents Collaborative Creative Inquiry (CCI) as innovative arts-informed approach to transdisciplinary research. Moving away from conventional qualitative research paradigms, we adopt a reflexive stance to introduce CCI as a process that challenges static narratives and fosters inclusivity within the research process. Through critical introspection, we describe an iterative five-step CCI approach, elucidating its unique process and methodological underpinnings. Drawing upon vivid personal illustrations, we offer vignettes to illustrate the application of CCI in practice and showcase opportunities for collaborative knowledge generation with co-creation. We conclude by reflecting on insights we gained through our CCI process and inviting others to join us in exploring the ways this approach can be applied across disciplines
Collaborative Creative Inquiry: An Arts-Informed Approach to Transdisciplinary Research
No full textThis paper presents Collaborative Creative Inquiry (CCI) as innovative arts-informed approach to transdisciplinary research. Moving away from conventional qualitative research paradigms, we adopt a reflexive stance to introduce CCI as a process that challenges static narratives and fosters inclusivity within the research process. Through critical introspection, we describe an iterative five-step CCI approach, elucidating its unique process and methodological underpinnings. Drawing upon vivid personal illustrations, we offer vignettes to illustrate the application of CCI in practice and showcase opportunities for collaborative knowledge generation with co-creation. We conclude by reflecting on insights we gained through our CCI process and inviting others to join us in exploring the ways this approach can be applied across disciplines
Collaborative creative inquiry: an arts-informed approach to transdisciplinary research
No full textThis paper presents Collaborative Creative Inquiry (CCI) as innovative arts-informed approach to transdisciplinary research. Moving away from conventional qualitative research paradigms, we adopt a reflexive stance to introduce CCI as a process that challenges static narratives and fosters inclusivity within the research process. Through critical introspection, we describe an iterative five-step CCI approach, elucidating its unique process and methodological underpinnings. Drawing upon vivid personal illustrations, we offer vignettes to illustrate the application of CCI in practice and showcase opportunities for collaborative knowledge generation with co-creation. We conclude by reflecting on insights we gained through our CCI process and inviting others to join us in exploring the ways this approach can be applied across disciplines
The old and young Amazon: Dung beetle biomass, abundance, and species diversity
No full textThe Amazon Basin can be divided into two geomorphological regions based on the age of its soils: young ( 300 mya). We tested the effects of soil age on dung beetle communities by comparing biomass, abundance, and species between reserves in Ecuador on young soils and reserves in Brazil on old soils. Beetle biomass in the old Amazon was one-third that in the young Amazon, and beetle abundance in the old Amazon was one-fourth that in the young Amazon. Species richness, rarefied to equal sample sizes, was not significantly different between old and young soils. These data suggest young soils of the Amazon support a significantly greater biomass and abundance of dung beetles than old soils, but that species richness across the Basin is similar. As dung beetles are bio-indicators of mammals, our data support previous studies indicating a greater biomass of mammals on young versus old Amazon soils. © 2007 The Author(s)
SEEP-CI: A Structured Economic Evaluation Process for Complex Health System Interventions.
No full textThe economic evaluation of health system interventions is challenging, and methods guidance on how to respond to these challenges is lacking. The REACHOUT consortium developed and evaluated complex interventions for community health program quality improvement in six countries in Africa and Asia. Reflecting on the challenges we faced in conducting an economic evaluation alongside REACHOUT, we developed a Structured Economic Evaluation Process for Complex Health System Interventions (SEEP-CI). The SEEP-CI aims to establish the threshold effect size that would justify investment in a complex intervention, and provide an assessment to a decision-maker of how likely it is that the intervention can achieve this impact. We illustrate how the SEEP-CI could have been applied to REACHOUT to identify outcomes where the intervention might have impact and causal mechanisms, through which that impact might occur, guide data collection by focusing on proximal outcomes most likely to illustrate the effectiveness of the intervention, identify the size of health gain required to justify investment in the intervention, and indicate the assumptions required to accept that such health gains are credible. Further research is required to determine the feasibility and acceptability of the SEEP-CI, and the contexts in which it could be used
A Dominant Allele of Arabidopsis Pectin-Binding Wall-Associated Kinase Induces a Stress Response Suppressed by MPK6 but Not MPK3 Mutations
No full textThe plant cell wall is composed of a matrix of cellulose fibers, flexible pectin polymers, and an array of assorted carbohydrates and proteins. The receptor-like Wall-Associated Kinases (WAKs) of Arabidopsis bind pectin in the wall, and are necessary both for cell expansion during development and for a response to pathogens and wounding. Mitogen Activated Protein Kinases (MPKs) form a major signaling link between cell surface receptors and both transcriptional and enzyme regulation in eukaryotes, and Arabidopsis MPK6 and MPK3 indeed have important roles in development and the response to stress and pathogens. A dominant allele of WAK2 requires kinase activity and activates a stress response that includes an increased ROS accumulation and the up-regulation of numerous genes involved in pathogen resistance, wounding, and cell wall biogenesis. This dominant allele requires a functional pectin binding and kinase domain, indicating that it is engaged in a WAK signaling pathway. A null mutant of the major plasma membrane ROS-producing enzyme complex, rbohd/f does not suppress the WAK2cTAP-induced phenotype. A mpk6, but not a mpk3, null allele is able to suppress the effects of this dominant WAK2 mutation, thus distinguishing MPK3 and MPK6, whose activity previously was thought to be redundant. Pectin activation of gene expression is abated in a wak2-null, but is tempered by the WAK-dominant allele that induces elevated basal stress-related transcript levels. The results suggest a mechanism in which changes to the cell wall can lead to a large change in cellular responses and help to explain how pathogens and wounding can have general effects on growth. The Author 2011. Published by the Molecular Plant Shanghai Editorial Office in association with Oxford University Press on behalf of CSPB and IPPE, SIBS, CAS.2011 © The Author 2011. Published by the Molecular Plant Shanghai Editorial Office in association with Oxford University Press on behalf of CSPB and IPPE, SIBS, CAS
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