1,721,062 research outputs found
Attraction and Retention of Rural Primary Health Care Workers in Asia Pacific Region
No full textBackground Human resources for health are crucial for health system strengthening and achieving sustainable development goals and universal health coverage, but the shortage and maldistribution of health workers have been critical concerns in the Asia Pacific region. This study aimed to identify the key interventions on attracting and retaining rural health workers, understand their management structure, examine the effectiveness and analyze the contexts in the Asia Pacific region.Methods This mixed-method study used systematic review and country case studies to synthesize and analyze the available data. A systematic review on attraction and retention of rural health workers in the Asia Pacific region was conducted. Thirty-five, fourteen and nineteen studies were included for the interventions and their management structure, effectiveness and contexts, respectively. In-depth interviews of twenty-two key informants and gray literature recommended from the key informants in China, Vietnam and Cambodia were used to gather information for the country case studies. Narrative synthesis was applied to review and synthesize the extracted data from the systematic review and qualitative analysis using Nvivo 11 was conducted for the interviews.Results Five categories of interventions, involving education, regulation, financial incentives, personal and professional support and bundled interventions were implemented to attract and retain rural health workers in the Asia Pacific region. Regulatory interventions, such as MRBS, task shifting and compulsory rural services, were the key interventions reported in the systematic review. Although financial incentives were scarce in the systematic review, they were the key strategies in the country case studies of China, Vietnam and Cambodia. Asian Pacific countries also had their distinctive interventions, such as a system of compulsory rural services in Thailand, training on community health workers in Afghanistan, and a government midwifery incentive scheme in Cambodia. Geographically, the Pacific island countries were neglected. Six categories of management structure of implementation were summarized. Decentralization from the central to the regional government was the dominant management structure. The regional government was responsible for program implementation in the decentralized programs, program development and implementation in the regional initiatives, which were more likely to be discovered in the countries and regions with strong economies. International donors were significant stakeholders for the low-income and post-conflict countries through providing financial and technical assistance. Several challenges emerged during implementation, including lack of rural eligible candidates, low and unsustainable financial incentives, complicated recruitment, poor management and deployment of HRH. Although the majority of interventions lacked rigorous effectiveness evaluation or were without evaluation, most evaluated interventions demonstrated effectiveness in attracting and retaining rural health professionals. Some of the interventions also reported effectiveness in expanding health service coverage and improving health status. The regulatory interventions seemed to be more effective in attracting and retaining rural health workers through administrative and legislative enforcement. Bundled interventions were expected to be more effective and be more often recommended by the researchers and interviewees. Various contexts, including political, economic and social factors and health system related issues, directly and indirectly impacted the attraction and retention of rural health workers. The political issues, economic development and social culture influenced rural HRH strengthening at the macro level while the health system reform pulled or pushed rural health workers. The promotion of rural health workers to be civil servants in Vietnam and Cambodia was a good motivation for rural health workers. The post mechanism in China, abolition of the referral system and increasing financial autonomy in the hospitals in Vietnam, the popular private sector, limited physical and human resources all served to push the health workers out of rural positions.Conclusion Due to great variation in economic development, Asian Pacific countries implemented three different patterns of interventions: 1) comprehensive packages in the high-income countries; 2) one or two categories of interventions in the low- and middle-income countries; and 3) training of community health workers in the post-conflict countries. Economic variation was also reflected in the differences of the management structure of implementation. The upper-middle- and high-income countries were likely to initiate regional interventions while the low-income countries partly relied on donations for HRH development and implementation, especially for the post-conflict countries. Although decentralization was widely applied to implementation, its implications were neglected and unclear. Based on the exclusive mechanism, effectiveness of each category of interventions varied. However, the regulatory interventions seemed be better. The socio-economic development significantly influenced interventions on attracting and retaining rural health workers. Rural HRH strengthening required strong economic support. Health financing reform for universal health coverage did impact the capacity building of rural health workforce. Further research was needed.</p
Evaluation of China's health system from the perspective of TB underreporting
No full textAbstractBackground: As the country with the third largest TB epidemic, China has a major responsibility to control the prevalence of TB. A standardized health information system is required to monitor the TB epidemic and the performance of the national TB control program. However, the capacity of the health information systems to detect infectious diseases in China need further enhancement. It is widely perceived that the problems of underreporting exist in China’s infectious diseases reporting systems, but little is known about the extent of underreporting as no rigorous empirical research has been conducted. Therefore, the aim of this study is to empirically analyze the issues of TB underreporting, identify weaknesses in the health information systems, and make suggestions for improvement.Methods: This study utilized a mixed method approach to evaluate China’s health information system by identifying the problems of TB underreporting in Zhenjiang, China. Using the data of 2,136 TB cases from the hospital information and TB information management systems, we analyzed the extent to which TB cases are underreported through chi-square test and multivariable logit regression. We subsequently conducted policy document review and evaluated the transcripts from 19 interviews to investigate the key factors causing TB underreporting.Results: Our study indicates that approximately 29.3% of TB cases in Zhenjiang city are unreported. The unreported rates of outpatients are higher than the unreported rates of inpatients except the cases in Jurong Hospital. Generally, inpatients who did not reside in their jurisdiction had higher unreported rates than those inpatients living in their jurisdiction for a long period. Moreover, patients without a personal ID card had higher unreported rates than those with ID cards. Additionally, underreporting among inpatient was significantly higher than non-in-hospital referrals. Through in-depth interviews, we discovered the potential factors causing TB underreporting are poor system design and some human resource related issues. More specifically, for the former one, hospitals use different electronic systems to record patient information, which often causes confusion when TB reporters search the records for a TB diagnosis. The lack of a self-check function reduces the accuracy of data reported. Moreover, the health information systems lack interoperability among different health facilities, which slows the transfer of information and creates room for mistakes. For the latter one, clinicians and hospital statisticians reflected that the heavy workload and low financial incentives made them reluctant to report TB cases timely and accurately. What’s more, the absence of specific and unified standards for health workers from different cities, counties, and facilities with which to comply is also evident. The limited requirements of government intensified the chaos generated during the establishment of information systems at the local level. The political context of inadequate incentive policies and low degree of supervision aggravated the quality of implementation.Conclusion: We found that the lack of self-check function, lack of data standardization, lack of system interoperability and accessibility, heavy workload for healthcare workers, lack of awareness of reporting, lack of financial incentives, absence of surveillance, and lack of guidance and role clarity are associated with TB underreporting. Our study reveals the important role of system design, government leadership, and qualified, dedicated, and well- paid health personnel play in ensuring the accuracy of data.</p
Understanding the Current Situation and Challenges in the Public Private Mix (PPM) of Human Resources for Health (HRH) in Selected Areas in Egypt
No full textBackground: Human Resource for Health (HRH) is one of the most important building blocks of the health system. The performance of the health systems is substantially impacted by the performance of health workers. Egypt has a highly fragmented health care system. Health services in Egypt are currently managed, financed, and provided by agencies in both public and private sectors. Egypt's health system has limited government oversight of the private sector and more open-ended healthcare market, which has contributed to a complexity of Public Private Mix (PPM). Since 1996, Egypt has been undergoing the Health Sector Reform Program (HSRP) with the aim of achieving universal healthcare coverage of the country. This study was conducted to contribute to the evidence in understanding the PPM of HRH in Egypt, towards contributing to the national dialogue to address related issue with its governance and development. Methods: This study uses qualitative method and literature review to approach the research topic. We visited 4 public hospitals and 3 private hospitals in Cairo, Benha and Fayoum in May to July, 2014. We conducted 45 in-depth interviews with health workers and 5 key-informant interviews with health policy experts. Document reviews were conducted from December 2013 to February 2015. Documents relevant to the country context and health profile were retrieved through PubMed and Google Scholar. Government activity and statistics were retrieved through openly published government report and reports from international organizations. An interview guide was developed and pretested. Interviews were recorded and transcribed. Data analysis began while data collection was still ongoing. Using a grounded theory approach, we reviewed the transcripts of interviews and coded with a table of key words. Codes and transcripts were double-checked for accuracy, based on which relevant themes were decided. We also compared the codes and transcripts among different stakeholders. Results: Egypt has a highly fragmented health care system. Health services in Egypt are currently financed and provided by a mix of agencies in both public and private sectors. The uncontrolled growth of private sector has impacted the performance of health workers. Dual practice, the practice of a health worker simultaneously engaging in both the public and private sector, is a prevailing phenomenon in the health workforce in Egypt. Dissatisfaction with the public salary is considered as the main reason which drives health workers to private sector. While pursuing private practice, most people still hold their position in public sector for a variety of reasons. Perceived as a mechanism to compensate the low salary in public sector, dual practice is accepted in the current Egyptian health system despite well-recognized negative impacts on the quality of care. Conclusions: A vast majority of doctors in Egypt has been involved in dual practice, while the prevalence of dual practice is much lower in nurses than in doctors. Financial concerns drive Egyptian doctors to conduct private practice. Meanwhile, most of them still hold their public posts, with various reasons including to gain clinical experience, academic titles, professional reputation, etc. Comparing with doctors, smaller proportion of nurses engage in dual practice as nurses tend to have longer shift time, less significant difference between public and private salaries, and more family responsibility. Dual practice helps to compensate the low salary in public sector although it is considered to negatively impact the quality of care in public sector. However, there is lack of rigorous regulations being implemented to govern the dual practice in Egypt. The weakness in health workforce management in public sector, especially in retention and performance evaluation, is interacting with the regulation and impact of dual practice in the country. The international experience indicates that definitive answer to cope with dual practice is not available and there is no uniform recipe to deal with the issue of dual practice. Further research is needed for the design of the approach to break the vicious circle of weak public capacity and unregulated dual practice, and to make use of HRH as a potential component to bridge public and private sector. It is also necessary to quantify and evaluate the impact of dual practice on social welfare from the perspectives of different stakeholders. Additionally, structural interventions are sorely needed in strengthening public sector and integrating private sector into the overall health system reform.</p
Knowledge, Socioeconomic Determinants, and Cervical Cancer Screening Participation in Longhua District, China: A Mixed Method Study
No full textBackground: Cervical cancer screening is one of the most effective approaches to control the leading cancer among women as recommended by World Health Organization (WHO). To this end, Shenzhen has piloted a free cervical cancer screening service for its at-risk female residents. This study aims to the relationship between screening participation and knowledge and socioeconomic determinants in Longhua District, Shenzhen, China, and to provide insights for governments’ screening policies. Methods: This cross-sectional mixed-method study was conducted in Longhua District, Shenzhen, China. In 2022, a web survey was conducted among 3,230 women aged 30-65 years, and in-depth interviews (IDIs) were conducted with 10 unscreened women and 3 screening providers. Participants provided sociodemographic information and answered questions about their knowledge and cervical cancer screening experiences. The socioeconomic status (SES) and knowledge were considered exposures, and the cervical cancer screening participation in lifetime and in the recent 5 years were considered outcomes of interest. The interviews were conducted by phone calls. Quantitative data were analyzed using multivariate and multinomial logistic regression models, and qualitative data were analyzed using the thematic approach.
Results: The overall rate of lifetime and recent 5-year cervical cancer screening were 82.3% and 72.9% respectively. After adjusting for SES, this study found a higher participation rate of cervical cancer screening associated with a higher knowledge score (Lifetime OR: 1.91, 95% CI: 1.63-2.23; Recent 5-year OR: 2.29, 95% CI: 1.77-2.98), going to college (Lifetime OR: 1.47, 95% CI: 1.08-1.99; Recent 5-year OR: 1.48, 95% CI: 1.22-1.80), and working for public sectors (Recent 5-year OR: 1.73, 95% CI: 1.19-2.51). However, participants with higher annual household income were less likely to take up free cervical cancer screening service (Lifetime OR: 0.72, 95% CI: 0.56-0.93; Recent 5-year OR: 0.71, 95% CI: 0.56, 0.89).
Conclusions: This study indicated that cervical cancer screening participation in Longhua District, Shenzhen, China was overall associated with higher knowledge score and SES. It suggested that efforts should be made to reinforce health education and policy dissemination for women with low education level and to extend the free screening service to low-income group.
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Equity in access to healthcare in Brunei Darussalam: Results from the Brunei Darussalam Health System Survey (HSS)
Full text linkBackground: Universal healthcare has been promoted by organizations including the World Health Organization and United Nations as a means of ensuring healthcare access for vulnerable populations. Despite momentum towards universal healthcare, especially among Southeast Asian nations, little research has been conducted to understand healthcare equity in nations that have already implemented universal healthcare. This paper assesses equity in healthcare access in Brunei Darussalam using results from the Brunei Darussalam Health System Survey (HSS). Methods: Data were gathered using a nationally-representative survey of 1,197 households across four districts in Brunei Darussalam. The Health System Survey aimed to measure individual's expectations and utilization of the Brunei national healthcare system. Data were analyzed using descriptive statistics and multinomial logistic regression to identify respondent- and household-level characteristics that affect healthcare utilization and expenditures. Results: HSS data suggest that healthcare utilization in Brunei varies by ethnicity, district of residence, health status, and income. When compared to other ethnic groups, Chinese households were significantly less likely to utilize public healthcare and significantly more likely to utilize private healthcare services. Indigenous groups also demonstrated significantly lower rates of private healthcare utilization compared to other ethnicities. Temburong district had the lowest rates of both private and public healthcare utilization and was associated with a 2.67 decreased likelihood of using public healthcare in the past six months. When stratifying for health status, data indicate that healthcare utilization in Brunei is proportional to healthcare need, with 93 percent of respondents in poor health reporting using government hospitals 12 or more times in the past six months compared to 76 percent of respondents in excellent health reporting using healthcare only once in the past six months. Income was also found to be positively associated with increased healthcare expenditures and private healthcare use. Conclusion: This study highlights an example of a universal healthcare system in Southeast Asia and indicates that a well-funded universal healthcare system can reduce significant utilization disparities. Substantial financial resources do not, however, guarantee equity among rural and minority populations and universal healthcare efforts should incorporate measures to understand and address barriers to healthcare among these groups.</p
Regional Disparities of Under-Five Mortality in China: Issues and Challenges for Improving Child Survival
No full textBackground: Over the past decade in the Millennium Development Goal Era, China has made great progress at the national level in decreasing the under-five mortality rate, but the progress has varied across China’s regions with different socioeconomic development levels. These regional disparities in the under-five mortality rate (U5MR) raises concerns for improving child survival in the Sustainable Development Goal Era, especially when in depth studies on this particular indicator is absent. This study aimed to examine disparities in child survival and identify factors explaining the regional disparities in the U5MR in China, key lessons, and future priority areas for improving child survival. Methods: This is a mixed methods study using quantitative data from secondary sources, mainly the National Chinese Statistical Yearbooks with some additional quantitative data from the Institute of Health Metrics and grey and peer-reviewed literature. The qualitative data collection involved key informant interviews of maternal and child health (MCH) administrators and practitioners in urban and rural MCH institutions in Yunnan province in China’s western region and Hubei province in the central region. In Yunnan and Hubei we conducted interviews at institutions both at the city level in the capital cities, Kunming and Wuhan respectively, and at the county/district level in Shaungbai and Caidian respectively.Results: Socioeconomic, health-system related, and cultural factors were found to explain the regional disparities of U5MR in China. First was the regional income inequality, with Yunnan’s rural population earning about 50% less than Hubei’s rural population and its U5MR was more than one-third higher than Hubei’s U5MR. The greatest gap of the U5MR existed between the urban and rural areas within regions and also across rural areas in different regions, where the human resources for MCH were unevenly distributed. From 2004 to 2017 Yunnan had 32% increase in human resources for MCH whereas Hubei saw an almost 50% increase. The third factor was caregiver-related in which key informants reported parental awareness and taking preventative measures when taking care of children as reason for regional disparities. Secondary data revealed a disparity amongst children left behind in rural areas compared to their urban counterparts in terms of parental presence which can affect the parental awareness. Key lessons in improving child survival in the MDG era came from health financing with the three main social public health insurance schemes and health service delivery with strict management for mothers with increasing rate of systematic maternal management nationally and regionally. Future priority areas for improving child survival were addressing the health workforce shortage in pediatric and neonatal departments and health promotion and education for all caregivers, including mothers, parents and other family members. Conclusion: Regional disparities in the U5MR revealed rural populations in the western region of China at a great disadvantage in regards to determinants of child survival. Key factors explaining these disparities are clear barriers to improving child survival and highlight the inequities persisting in child health and survival in China. From a human rights perspective, reducing child health disparities and improving child survival in rural areas across and within regions in China will reflect China’s pursuit for health equity in the Sustainable Development Goal era.</p
Putting Adequate Financial and Human Resources in Healthcare for Effective Universal Health Coverage in Kenya: Lessons and Experiences from China
No full textIn recent years, most low and middle-income countries, have adopted different approaches to universal health coverage (UHC), to ensure equity and financial risk protection in accessing essential healthcare services. UHC-related policies and delivery strategies are largely based on existing healthcare systems, a result of gradual development (based on local factors and priorities). Most countries have emphasized on health financing, and human resources for health (HRH) reform policies, based on good practices of several healthcare plans to deliver UHC for their population.Health financing and labor market frameworks were used, to understand health financing, HRH dynamics, and to analyze key health policies implemented over the past decade in Kenya’s effort to achieve UHC. Through the understanding, policy options are proposed to Kenya; analyzing, and generating lessons from health financing, and HRH reforms experiences in China. Data was collected using mixed methods approach, utilizing both quantitative (documents and literature review), and qualitative (in-depth interviews) data collection techniques. The problems in Kenya are substantial: high levels of out-of-pocket health expenditure, slow progress in expanding health insurance among informal sector workers, inefficiencies in pulling of health are revenues, inadequate deployed HRH, maldistribution of HRH, and inadequate quality measures in training health worker. The government has identified the critical role of strengthening primary health care and the National Hospital Insurance Fund (NHIF) in Kenya’s move towards UHC. Strengthening primary health care requires; re-defining the role of hospitals, and health insurance schemes, and training, deploying and retaining primary care professionals according to the health needs of the population; concepts not emphasized in Kenya’s healthcare reforms or programs design. Kenya’s top leadership commitment is urgently needed for tougher reforms implementation, and important lessons from China’s extensive health reforms in the past decade are beneficial. Key lessons from China include health insurance expansion through rigorous research, monitoring, and evaluation, substantially increasing government health expenditure, innovative primary healthcare strengthening, designing, and implementing health policy reforms that are responsive to the population, and regional approaches to strengthening HRH.</p
Changes in financial burden, healthcare utilization for cancer patients in East, Central and West China
No full textObjective: This study aims to investigate the cancer epidemiology and impact of healthcare system reform on patient out-of-pocket expense, presence of catastrophic health expenditures (CHE), healthcare utilization, and inpatient/outpatient medical expenditure in China after 2009 from the perspective of health system reforms.Methods: This study is a mixed-methods study, includes an analysis of quantitative data and key informant interviews with major stakeholders. Quantitative analysis was performed on data collected from the China Health and Retirement Longitudinal Study (CHARLS) in 2011 and 2018 to investigate the correlation between cancer prevalence, CHE incidence (households that spend 40% of their non-food incomes on healthcare), and socioeconomic characteristics. This analysis explored the healthcare utilization and out-of-pocket expenses (OOPE) of cancer patients across different socioeconomic status groups and in urban and rural areas, as well as in the eastern, central, and western regions. Key informant interviews were conducted with major stakeholders including physicians, scholars, and disease control leaders/managers. The transcripts of the interviews were coded and analyzed for themes on the results of the quantitative study, inequalities in healthcare service utilization, and inequalities in healthcare insurance finance.Results: The self-reported prevalence rate of cancer increased from 0.93% in 2011 to 1.02% in 2018. The incidence of CHE of cancer patients increased from 45.40% in 2011 to 58.50% in 2018. Urban-Rural Resident Basic Medical Insurance (URRBMI) beneficiaries are more likely to experience CHE than Urban Employee Basic Medical Insurance (UEBMI) beneficiaries. In 2018, the incidence of CHE was significantly lower in the group with the highest socioeconomic status compared to other groups. Compared to 2008 and 2011, the outpatient visit rate for cancer patients decreased by 7% in 2018, while the hospitalization rate significantly increased by nearly 30%. Urban residents have a higher hospitalization rate, which may be related to the concentration of hospitals providing cancer treatment services in cities, and urban employees enjoy a more comprehensive health insurance benefit package. In groups with higher socioeconomic status, cancer patients tend to have higher rates of outpatient visits and hospitalizations. This may be due to their greater ability to afford the expenses associated with cancer treatment.Both the average outpatient visits expenditure and the average inpatient care expenditure have increased significantly (outpatient visits expenditure per time increased by ¥500, and inpatient per time increased by ¥7000 from 2011 to 2018). While healthcare expenditure has significantly increased, the percentage of out-of-pocket expenses (OOPE) has decreased. Reasons for the decrease include more cancer drugs being included in the reimbursement list, a reduction in the medical insurance deductible, and an increase in the reimbursement ratio. Conclusions: The health system reforms have improved access to healthcare services, especially inpatient care, and improved drug accessibility. However, inequality in healthcare service utilization and healthcare insurance financing still exists. Inequality is mainly reflected in urban-rural differences and different socioeconomic statuses. To address inequalities within the country, China needs to take a series of coordinated actions. Include improving mechanisms used to mobilize the health insurance funds in China, and making comprehensive changes to health insurance benefit packages and healthcare resource contributions.</p
Strengthening Alignments between National Health Financing System and Primary Health Care: Lessons from Taiwan
No full textBackground: To tackle the demographic and epidemiologic challenges, countries around the world need to build a health system centered on primary health care (PHC) in which a supportive financing system is a premise. In this study, the Taiwanese PHC system is taken as a key example. It represents a system that the study can analyze to identify best practice and, additionally, draw out lessons that other systems can consider, replicate and apply for their own primary healthcare delivery needs. Methods: This study used a qualitative research approach to explore stakeholders’ perspectives on the role that the National Health Insurance (NHI) of Taiwan plays in the delivery of PHC. The qualitative data was two-fold: (1) 21 in-depth interviews with local and national health insurance administrators, hospital and health centers’ administrative managers, and service providers at private and hospital levels; and (2) participatory on-site observations of PHC delivery in health facilities and communities. Results: Nvivo 12 was used to conduct data analysis. The data revealed five main themes: (1) Payment method system reform; (2) integrated care services to improve PHC delivery; (3) E-health and technology’s role in regulation and care delivery; (4) leadership support; and (5) education for both service users and providers. Conclusions: The study’s findings include a need to refine the payment methods while keeping geographic disparities and effective incentives in mind; strengthen leadership support at different levels; improve the feasibility and performance of e-health tools; improve the transparency and accountability of the regulation policies; and continuously work on health education.</p
Managing Diabetes in Urban Ghana: Is it Affordable?
No full textBackground: In recent decades there has been an escalating epidemic of diabetes in Ghana. However, there has been little research on the economic burdens associated with diabetes in Ghana, despite diabetes's costly nature. This study investigated economic burdens and financial protections of households with diabetes patient(s) in urban Ghana.Methods: Questionnaire-based interviews were conducted with 40 diabetes patients and their household heads in two urban communities in the city of Accra, Ghana. Information was obtained regarding participants' demographic and socioeconomic characteristics, patterns of healthcare utilization, direct and indirect costs, and financial protections pertaining to diabetes treatment and management. Cost-of-illness analysis and catastrophic health expenditure computation were conducted to investigate the costs associated with diabetes and households' affordability. Statistical tests were also conducted to analyze the effect of the National Health Insurance Scheme (NHIS) on the costs associated with diabetes.Results: The total cost of diabetes for 40 households was estimated to be 14,989 cedis/month, of which 66.5% was direct cost and 30.2% was indirect cost. 52.9% of the households occurred catastrophic health expenditure. The means of outpatient and inpatient expenditure were 136 and 418 Cedi/month, respectively. NHIS had a positive financial protection effect on the economic burden of diabetes, while this effect was diminished by deficiencies in NHIS. Extended family was the main resource of financial support for diabetes treatment and management.Conclusion: The economic burden of diabetes is high in urban Ghana, with a catastrophic effect on households. Except for NHIS, patients' financial support mainly comes from personal resources rather than public resources. Social supports and improvements in NHIS are needed to protect households with diabetes patient(s) against financial risks.</p
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