401 research outputs found
Performance of verbal autopsy methods in estimating HIV-associated mortality among adults in South Africa.
No full textINTRODUCTION: Verbal autopsy (VA) can be integrated into civil registration and vital statistics systems, but its accuracy in determining HIV-associated causes of death (CoD) is uncertain. We assessed the sensitivity and specificity of VA questions in determining HIV status and antiretroviral therapy (ART) initiation and compared HIV-associated mortality fractions assigned by different VA interpretation methods. METHODS: Using the WHO 2012 instrument with added ART questions, VA was conducted for deaths among adults with known HIV status (356 HIV positive and 103 HIV negative) in South Africa. CoD were assigned using physician-certified VA (PCVA) and computer-coded VA (CCVA) methods and compared with documented HIV status. RESULTS: The sensitivity of VA questions in detecting HIV status and ART initiation was 84.3% (95% CI 80 to 88) and 91.0% (95% CI 86 to 95); 283/356 (79.5%) HIV-positive individuals were assigned HIV-associated CoD by PCVA, 166 (46.6%) by InterVA-4.03, 201 (56.5%) by InterVA-5, and 80 (22.5%) and 289 (81.2%) by SmartVA-Analyze V.1.1.1 and V.1.2.1. Agreement between PCVA and older CCVA methods was poor (chance-corrected concordance [CCC] <0; cause-specific mortality fraction [CSMF] accuracy ≤56%) but better between PCVA and updated methods (CCC 0.21-0.75; CSMF accuracy 65%-98%). All methods were specific (specificity 87% to 96%) in assigning HIV-associated CoD. CONCLUSION: All CCVA interpretation methods underestimated the HIV-associated mortality fraction compared with PCVA; InterVA-5 and SmartVA-Analyze V.1.2.1 performed better than earlier versions. Changes to VA methods and classification systems are needed to track progress towards targets for reducing HIV-associated mortality
Mechanisms of effect: a health systems analysis of the impact of introducing treatment services for human immunodeficiency virus (HIV) into four public primary health centres in Zambia
No full text© 2013 Dr. Stephanie M. ToppBetween 1996 and 2008 global funding for the treatment of human immuno-deficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) increased from US15.6 billion. Much of this money was directed to a small number of countries such as Zambia in sub-Saharan Africa, where HIV/AIDS constitutes a major health, social and economic threat. Although the necessity and urgency of responding to the HIV epidemics in these countries was not in question, the exceptional levels of HIV funding and the rapidity of the scale-up of HIV- services did reignite a debate regarding the impact of disease-specific programs on recipient countries’ health systems. Notwithstanding the high profile nature of this debate, little empirical research exists to inform policy makers or programmers in their efforts to meet the dual aims of improving disease-specific health outcomes and simultaneously strengthening health systems.
Meeting a gap in the literature, this study examines the impact of introducing donor-funded HIV services into the Zambian health system, focusing specifically on the impact on primary health ‘micro-systems’. The conceptual framework for this study draws from theory developed in the application of complexity science and systems thinking to health systems analysis, which suggests that health systems are characterised by the interconnectedness of their component parts. The multi-disciplinary framework theorises that interactions between system ‘hardware’ and system ‘software’ influence mechanisms of accountability and trust, and through these, the quality and responsiveness of service delivery within health micro-systems. This approach challenges the implicit assumptions of more reductionist frameworks, which suggest that health systems – and particularly micro-level systems – are a simple composite of individual ‘building blocks’.
This study adopted a multi-case study design, with four Zambian health centres purposefully selected based on the presence of an established HIV department (more than 3 years old), and urban, peri-urban and rural characteristics. Case data collected in each facility included facility audits, direct observation of facility operations and interviews with patients, staff, and District and non-government officials. Data were triangulated and analysed for each case first, and cross-case analysis subsequently carried out to improve the analytical generalisability of the findings.
The findings from this study demonstrate that the rapid scale-up of HIV services in Zambia, which focused predominantly on investing in health system hardware, acted unevenly on mechanisms of accountability and trust and had mixed outcomes on the four health centres’ overall functionality. It was revealed, for example, that the short-term gains in health worker performance achieved through investment in system hardware for HIV services were difficult to sustain, as the lack of investment in underlying mechanisms of accountability such as improved answerability and enforceability or stronger patient-provider trust, enabled perverse work norms to flourish in ways that undermined quality and responsiveness of care. The study points to the critical importance of accounting for the ideas, values and norms of actors in the health system (system software) in order to plan and deliver disease-specific interventions that achieve both their programmatic aims as well as producing long-term, system-strengthening effects. The study constitutes an important contribution to the field of health policy and systems research providing empirical evidence of the complex, social and adaptive nature of health micro-systems and demonstrating the critical value of the hardware-software construct for analysing mechanisms of effect in this domain
Health inequality in the tropics and its costs: a Sustainable Development Goals alert
No full textBackground: It is known that health impacts economic performance. This article aims to assess the current state of health inequality in the tropics, defined as the countries located between the Tropic of Cancer and the Tropic of Capricorn, and estimate the impact of this inequality on gross domestic product (GDP).
Methods: We constructed a series of concentration indices showing between-country inequalities in disability-adjusted life years (DALYs), taken from the Global Burden of Disease Study. We then utilized a non-linear least squares model to estimate the influence of health on GDP and counterfactual analysis to assess the GDP for each country had there been no between-country inequality.
Results: The poorest 25% of the tropical population had 68% of the all-cause DALYs burden in 2015; 82% of the communicable, maternal, neonatal and nutritional DALYs burden; 55% of the non-communicable disease DALYs burden and 61% of the injury DALYs burden. An increase in the all-cause DALYs rate of 1/1000 resulted in a 0.05% decrease in GDP. If there were no inequality between countries in all-cause DALY rates, most high-income countries would see a modest increase in GDP, with low- and middle-income countries estimated to see larger increases.
Conclusions: There are large and growing inequalities in health in the tropics and this has significant economic cost for lower-income countries
Is there unwarranted variation in obstetric practice in Australia? Obstetric intervention trends in Queensland hospitals
No full textObjective: The aim of this study was to report on the rates of obstetric interventions within each hospital jurisdiction in the state of Queensland, Australia.
Methods: This project used a whole-of-population linked dataset that included the health and cost data of all mothers who gave birth in Queensland, Australia, between 2012 and 2015 (n = 186 789), plus their babies (n = 189 909). Adjusted and unadjusted rates of obstetric interventions and non-instrumental vaginal delivery were reported within each hospital jurisdiction in Queensland.
Results: High rates of obstetric intervention exist in both the private and public sectors, with higher rates demonstrated in the private than public sector. Within the public sector, there is substantial variation in rates of intervention between hospital and health service jurisdictions after adjusting for confounding variables that influence the need for obstetric intervention.
Conclusions: Due to the high rates of obstetric interventions statewide, a deeper understanding is needed of what factors may be driving these high rates at the health service level, with a focus on the clinical necessity of the provision of Caesarean sections
A cascade of interventions: a classification tree analysis of the determinants of primary cesareans in Australian public hospitals
No full textBackground: Both globally and in Australia, there has been a sharp rise in cesarean births (CB). Commonly, this rise has been attributed to the changing epidemiology of women giving birth. A significant body of knowledge exists on the risk factors associated with a greater need for cesarean. Yet, we have little information on the reasons recorded by clinicians as to why cesareans are provided. This study aimed to explore the drivers of primary cesareans in Australian public hospitals.
Methods: Using a linked administrative data set, the frequency and percent of mothers’ characteristics were compared between those who had a cesarean birth and those who had a vaginal birth (n = 98 967) with no history of previous cesareans in Queensland public hospitals between July 1, 2012, and June 30, 2015. The top 10 reasons recorded by clinicians for a primary cesarean were reported. Using a machine‐learning algorithm, two decision trees were built to determine factors driving primary cesarean birth.
Results: “Labour and delivery complicated by fetal heart rate anomaly” (23%) and “primary inadequate contractions” (22.8%) were the top two reasons for a primary cesarean birth. The most common characteristics among mothers who had fetal heart rate anomalies were as follows: artificial rupture of membranes (39%), oxytocin (32%), no obstruction of labor (42%), and epidural (52%). For women who had primary inadequate contractions, the most common characteristics were as follows: epidural (33%), oxytocin (49%), artificial rupture of membranes (45%), and fetal stress (56%).
Conclusions: Efforts should be made by health practitioners during the antenatal period to maximize the use of preventative measures that minimize the need for medical interventions
COVID-19 and global health systems
No full textThis chapter situates the COVID-19 pandemic and responses to it within global public health systems. As a mixture of public health and social measures were implemented globally to slow the spread of the virus, economies and social interactions were curtailed to huge social and economic cost. Reinforcing existing and deeply entrenched social inequalities, the crisis highlighted the incapacity of health systems around the world to address inequality and highlighted the need for a radical rethink of the neoliberal institutions – including health systems – that underpin modern life. Building systems through a lens of social justice requires better focus on local, national, and global coordination and an explicit focus on addressing social and health inequalities
The Lancet Global Health Commission on High Quality Health Systems—where's the complexity?
No full text[Extract] The Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals (SDG) Era (HQSS Commission).1 The launch draws attention to the fact that high quality health care, rather than just access to health care, will be necessary to meet the health-related SDGs. The Commission aims to address the lack of an “agreed upon single definition” of high quality health systems and produce “science-led, multidisciplinary, actionable work with […] measurable indicators”. But phrases like single definition and measurable indicators in the context of an exercise seeking to strengthen quality in highly variable health systems in low-income and middle-income countries (LMICs) should raise red flags
Ethnic, socio-economic and geographic inequities in maternal health service coverage in Australia
No full textBackground:
Disparities in health service use exist in many sectors of Australia's health system, particularly affecting the most vulnerable people in the population, who are typically those with the greatest healthcare needs. Understanding patterns of health service coverage is critical for acknowledging the underlying, systemic drivers including racialised practices that inhibit the uptake of health services for certain population groups. This study aims to determine whether there are disparities in health service utilisation between socioeconomic, geographic and ethnic groups of mothers who experience hypertension, diabetes and mental health conditions.
Methods:
This study utilised a linked administrative healthcare dataset containing data of all mothers who gave birth in Queensland, Australia, between 2012 and 2015 (n = 186,789), plus their resultant babies (n = 189,909). The study compared health service utilisation for mothers with maternal health conditions between population groups.
Results:
The results of this study showed a broad trend of inequitable health service utilisation, with mothers who experienced the greatest healthcare needs—First Nations, rural and remote and socio-economically disadvantaged mothers—being less likely to access health services and in some cases when care was accessed, fewer services being utilised during the perinatal period.
Conclusion:
Access to health care during the perinatal period is a reflection of Australia's general health system strengths and weaknesses, in particular a failure of the government to translate national and state policy intent into acceptable and accessible care in rural and remote areas, for First Nations women and for mothers experiencing socio-economic disadvantage
Adaptation with robustness: the case for clarity on the use of 'resilience' in health systems and global health
No full text[Extract] In the last 3 years, the concept of resilience has received much attention in the health systems and global health literature, triggered by the Ebola outbreak in West Africa (which, in 2014, exposed a lack of health system and global health resilience) and followed in 2016 by the Global Symposium on Health Systems Research (with the theme ‘Resilient and responsive health systems in a changing world’). Resilience has been widely embraced in the literature,1–5 and also by the immediate past6 and current7 WHO Director General. BMJ Global Health has also published several reports applying the concept of resilience to how health systems respond to acute shocks and chronic stress
Call for papers-the Alma Ata Declaration at 40: reflections on primary healthcare in a new era
No full text[Extract] The Declaration of AlmaAta was a watershed moment in global health. Indeed, in the four decades since its launch, there is a sense in which all declarations or communiques issued at global health conferences have been aiming for comparable historical impact. Launched in 1978 at the International Conference on Primary HealthCare, the declaration called for 'Health for All by the Year 2000 and promoted comprehen-sive primary healthcare as the preferred back-bone of national health systems alongside a number of other key elements including an emphasis on global cooperation and peace; a new economic order to underpin it; acknowledgement of the social determinants of health; involvement of all sectors in the promotion of health; community participation in planning, implementation and regulation of primary healthcare; and a focus on achieving equity in health status. In totality, these elements—which became known as the 'primary healthcare approach' —flagged a paradigm shift away from the medical model of health planning and service delivery and towards a 'social model' with an emphasis on addressing social determinants of health via intersectoral public health and preventive strategies based on local ownership and community participation
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