Toward health system strengthening in low- and middle-income countries: insights from mathematical modeling of drug supply chains.

BACKGROUND: Global health priority setting increasingly focuses on understanding the functioning of health systems and on how they can be strengthened. Beyond vertical programs, health systems research should examine system-wide delivery platforms (e.g. health facilities) and operational elements (e.g. supply chains) as primary units of study and evaluation. METHODS: We use dynamical system methods to develop a simple analytical model for the supply chain of a low-income country's health system. In doing so, we emphasize the dynamic links that integrate the supply chain within other elements of the health system; and we examine how the evolution over time of such connections would affect drug delivery, following the implementation of selected interventions (e.g. enhancing road networks, expanding workforce). We also test feedback loops and forecasts to study the potential impact of setting up a digital system for tracking drug delivery to prevent drug stockout and expiration. RESULTS: Numerical simulations that capture a range of supply chain scenarios demonstrate the impact of different health system strengthening interventions on drug stock levels within health facilities. Our mathematical modeling also points to how implementing a digital drug tracking system could help anticipate and prevent drug stockout and expiration. CONCLUSION: Our mathematical model of drug supply chain delivery represents an important component toward the development of comprehensive quantitative frameworks that aim at describing health systems as complex dynamical systems. Such models can help predict how investments in system-wide interventions, like strengthening drug supply chains in low-income settings, may improve population health outcomes.

Identifying Information Gaps in a Surgical Capacity Assessment Tool for Developing Countries: A Methodological Triangulation Approach.

BACKGROUND: Surgical capacity assessment in low- and middle-income countries (LMICs) is challenging. The Surgeon OverSeas' Personnel Infrastructure Procedure Equipment and Supplies (PIPES) survey tool has been proposed to address this challenge. There is a need to examine the gaps in veracity and context appropriateness of the information obtained using the PIPES tool. METHODS: We performed a methodological triangulation by comparing and contrasting information obtained using the PIPES tool with information obtained simultaneously via three other methods: time and motion study (T&M); provider focus group discussions (FGDs); and a retrospective review of hospital records. RESULTS: In its native state, the PIPES survey does not capture the role of non-physician clinicians who contribute immensely to surgical care delivery in LMICs. The surgical workforce was more accurately captured by the FGDs and T&M. It may also not reflect the improvisations (e.g., patients sharing beds, partitioning the operating theater, and using preoperative rooms for surgery, etc.) that occur to expand surgical capacity to overcome the limited infrastructure and equipment. CONCLUSIONS: The PIPES tool captures vital surgical capacity information but has gaps that can be filled by modifying the tool and/or using ancillary methodologies. The interests of the researcher and the local stakeholders' perspectives should inform such modifications.

Trauma registry implementation in low- and middle-income countries: challenges and opportunities.

BACKGROUND: Trauma registries are an essential part of trauma quality improvement programs aimed at decreasing morbidity and mortality in high-income countries. In low- and middle-income countries (LMICs), where the burden of injury is disproportionately high, hospitals have faced challenges in adapting trauma registry models implemented in high-income countries. We analyze the barriers to trauma registry implementation in LMICs to inform development of sustainable models in resource-constrained settings. MATERIALS AND METHODS: A structured review of published literature was performed. Relevant abstracts were identified using the PubMed, Embase, and CINAHL databases. The search terms included were: "implement registry," "trauma registry," "wounds and injuries," and "injury registry" combined with "Africa," "Asia," "low and middle income countries," "LMIC," and "developing countries." Articles describing challenges of trauma registry implementation were reviewed in full and details were abstracted. RESULTS: Twenty-eight articles addressed challenges of implementing trauma registries. Data quality (18), lack of resources (6), insufficient prehospital care (3), and difficulty with administrative duties and hospital organization (2) were reported as the most significant barriers to successful implementation. Solutions to the identified barriers were proposed by 15 articles. All 28 studies acknowledged that the presence of at least one local trauma registry improved injury surveillance and promoted better patient outcomes. CONCLUSIONS: Many LMICs face unique challenges to implementation that must be overcome to create sustainable trauma databases. Understanding these barriers and taking steps to evaluate the effectiveness of proposed solutions may further improve trauma care to address the high burden in these settings.

Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature.

BACKGROUND: Strategic purchasing of health care services has become a key policy measure on the path to achieving universal health coverage. National provider payment systems for health services are typically characterized by mixes of provider payment methods with each method associated with distinct incentives for provider behaviours. Reaching incentive alignment across methods is critical to enhancing the effectiveness of strategic purchasing. METHODS: A structured literature review was conducted to synthesize the evidence on how purposively aligned mixed provider payment systems affect health expenditure growth management, efficiency, and equity in access to services with a particular focus on coordinated and/or integrated care management. RESULTS: The majority of the 37 reviewed articles focused on high-income countries with 74% from the US. Four categories of payment mixes were examined in this review: blended payment, bundled payment, cost-containment reward models, and aligned cost sharing mechanisms. Blended payment models generally reported moderate to no substantive reductions in expenditure growth, but increases in health system efficiency. Bundled payment schemes consistently report increases in efficiency and corresponding cost savings. Cost-containment rewards generated cost savings that can contribute to effective management of health expenditure growth. Evidence on aligned cost-sharing is scarce. CONCLUSION: There is lacking evidence on when and how mixed provider payment systems and cost sharing practices align towards achieving goals. A guiding framework for how to study and evaluate mixed provider payment systems across contexts is warranted. Future research should consider a conceptual framework explicitly acknowledging the complex nature of mixed provider payment systems.

Barriers and facilitators of surgical care in rural Uganda: a mixed methods study.

BACKGROUND: Surgical care delivery is poorly understood in resource-limited settings. To effectively move toward universal health coverage, there is a critical need to understand surgical care delivery in developing countries. This study aims to identify the barriers and facilitators of surgical care delivery at Soroti Regional Referral Hospital in Uganda. METHODS: In this mixed methods study, we (1) applied the Surgeons OverSeas' Personnel, Infrastructure, Procedures, Equipment, and Supplies tool to assess surgical capacity; (2) retrospectively reviewed inpatient records; (3) conducted four semistructured focus group discussions with 18 purposively sampled providers involved in perioperative care; and (4) observed the perioperative process of care using a time and motion approach. Descriptive statistics were generated from quantitative data. Qualitative data were thematically analyzed. RESULTS: The Personnel, Infrastructure, Procedures, Equipment, and Supplies survey revealed severe deficiencies in workforce (P-score = 14) and infrastructure (I-score = 5). Equipment, supplies, and procedures were generally available. Male and female wards were overbooked 83% and 60% of the time, respectively. Providers identified lack of space, patient overload, and superfluous patients' attendants as barriers to surgical care. Workforce challenges were tackled using teamwork and task sharing. Inadequate equipment and processes were addressed using improvisations. All observed subjects (n = 31) received interventions. The median decision-to-intervention time was 2.5 h (Interquartile Range [IQR], 0.4, 21.4). However, 48% of subjects experienced delays. Median decision-to-intervention delay was 14.8 h (IQR, 0.9, 26.6). CONCLUSIONS: Despite severe workforce and physical infrastructural deficiencies at Soroti Regional Referral Hospital, providers are adjusting and innovating to deliver surgical care.

A pilot orthopedic trauma registry in Ugandan district hospitals.

BACKGROUND: Musculoskeletal injuries are a major public health problem in low-income countries like Uganda. Patterns of musculoskeletal injuries presenting to district hospitals are unknown. Our pilot orthopedic trauma registry establishes a framework for broader district hospital injury surveillance. MATERIALS AND METHODS: We interviewed and examined patients presenting to Mityana, Entebbe, and Nakaseke hospitals with musculoskeletal injuries from October 2013 to January 2014. We compared patient and Demographic and Health Survey population demographics and determined predictors of delayed presentation for care. RESULTS: Men, adults, and individuals with postsecondary education were more common among patients than in the Demographic and Health Survey population. Common causes included road traffic injuries (48.5%) and falls (25.1%). Closed, simple fractures comprised 70% of injuries. Compared to the self-employed, subsistence farmers (odds ratio [OR] = 2.99, 95% confidence interval [CI] = 1.15-7.91), motorcycle taxi drivers (OR = 10.50, 95% CI = 1.92-64.57), and preschool children (OR = 4.24, 95% CI = 1.05-17.39) were significantly more likely to be delayed to care after adjustment for covariates. Subsistence farmers were more likely than other occupations to seek care from traditional bonesetters (23% versus 7%, P = 0.001). All patients who visited bonesetters were delayed to hospital care. CONCLUSIONS: Policies for trauma systems strengthening must address the needs of underserved groups and involve all stakeholders, including bonesetters. Research should address reasons for delayed care among subsistence farmers, motorcycle taxi drivers, and preschool children. Injury surveillance at district hospitals facilitates evidence-based resource allocation and should continue in the form of an Ugandan national trauma registry.

Optimizing treatment for the prevention of pre-eclampsia/eclampsia in Nepal: is calcium supplementation during pregnancy cost-effective?

BACKGROUND: In Nepal, pre-eclampsia/eclampsia (PE/E) causes an estimated 21% of maternal deaths annually and contributes to adverse neonatal birth outcomes. Calcium supplementation has been shown to reduce the risk of PE/E for pregnant women and preterm birth. This study presents findings from a cost-effectiveness analysis of a pilot project, which provided calcium supplementation through the public sector to pregnant women during antenatal care for PE/E prevention as compared to existing PE/E management in Nepal. METHODS: Economic costs were assessed from program and societal perspectives for the May 2012 to August 2013 analytic time horizon, drawing from implementing partner financial records and the literature. Effects were calculated as disability-adjusted life years (DALYs) averted for mothers and newborns. A decision tree was used to model the cost-effectiveness of three strategies delivered through the public sector: (i) calcium supplementation in addition to the existing standard of care (MgSO4); (ii) standard of care, and (iii) no treatment. Uncertainty was assessed using one-way and probabilistic sensitivity analyses in TreeAge Pro. RESULTS: The costs to start-up calcium introduction in addition to MgSO4 were $44,804, while the costs to support ongoing program implementation were $72,852. Collectively, these values correspond to a program cost per person per year of $0.44. The calcium program corresponded to a societal cost per DALY averted of $25.33 ($25.22-29.50) when compared against MgSO4 treatment. Primary cost drivers included rate for facility delivery, costs associated with hospitalization, and the probability of developing PE/E. The addition of calcium to the standard of care corresponds to slight increases in effect and cost, and has a 84% probability of cost-effectiveness above a WTP threshold of $40 USD when compared to the standard of care alone. CONCLUSIONS: Calcium supplementation for pregnant mothers for prevention of PE/E provided with MgSO4 for treatment holds promise for the cost-effective reduction of maternal and neonatal morbidity and mortality associated with PE/E. The findings of this study compare favorably with other low-cost, high priority interventions recommended for South Asia. Additional research is recommended to improve the rigor of evidence available on the treatment strategies and health outcomes.

Equally able, but unequally accepted: Gender differentials and experiences of community health volunteers promoting maternal, newborn, and child health in Morogoro Region, Tanzania.

BACKGROUND: Despite emerging qualitative evidence of gendered community health worker (CHW) experience, few quantitative studies examine CHW gender differentials. The launch of a maternal, newborn, and child health (MNCH) CHW cadre in Morogoro Region, Tanzania enlisting both males and females as CHWs, provides an opportunity to examine potential gender differences in CHW knowledge, health promotion activities and client acceptability. METHODS: All CHWs who received training from the Integrated MNCH Program between December 2012 and July 2013 in five districts were surveyed and information on health promotion activities undertaken drawn from their registers. CHW socio-demographic characteristics, knowledge, and health promotion activities were analyzed through bi- and multivariate analyses. Composite scores generated across ten knowledge domains were used in ordered logistic regression models to estimate relationships between knowledge scores and predictor variables. Thematic analysis was also undertaken on 60 purposively sampled semi-structured interviews with CHWs, their supervisors, community leaders, and health committee members in 12 villages from three districts. RESULTS: Of all CHWs trained, 97% were interviewed (n = 228): 55% male and 45% female. No significant differences were observed in knowledge by gender after controlling for age, education, date of training, marital status, and assets. Differences in number of home visits and community health education meetings were also not significant by gender. With regards to acceptability, women were more likely to disclose pregnancies earlier to female CHWs, than male CHWs. Men were more comfortable discussing sexual and reproductive concerns with male, than female CHWs. In some cases, CHW home visits were viewed as potentially being for ulterior or adulterous motives, so trust by families had to be built. Respondents reported that working as female-male pairs helped to address some of these dynamics. CONCLUSIONS: Male and female CHWs in this study have largely similar knowledge and health promotion outputs, but challenges in acceptance of CHW counseling for reproductive health and home visits by unaccompanied CHWs varied by gender. Programs that pair male and female CHWs may potentially overcome gender issues in CHW acceptance, especially if they change gender norms rather than solely accommodate gender preferences.

Initial experiences and innovations in supervising community health workers for maternal, newborn, and child health in Morogoro region, Tanzania.

BACKGROUND: Supervision is meant to improve the performance and motivation of community health workers (CHWs). However, most evidence on supervision relates to facility health workers. The Integrated Maternal, Newborn, and Child Health (MNCH) Program in Morogoro region, Tanzania, implemented a CHW pilot with a cascade supervision model where facility health workers were trained in supportive supervision for volunteer CHWs, supported by regional and district staff, and with village leaders to further support CHWs. We examine the initial experiences of CHWs, their supervisors, and village leaders to understand the strengths and challenges of such a supervision model for CHWs. METHODS: Quantitative and qualitative data were collected concurrently from CHWs, supervisors, and village leaders. A survey was administered to 228 (96%) of the CHWs in the Integrated MNCH Program and semi-structured interviews were conducted with 15 CHWs, 8 supervisors, and 15 village leaders purposefully sampled to represent different actor perspectives from health centre catchment villages in Morogoro region. Descriptive statistics analysed the frequency and content of CHW supervision, while thematic content analysis explored CHW, supervisor, and village leader experiences with CHW supervision. RESULTS: CHWs meet with their facility-based supervisors an average of 1.2 times per month. CHWs value supervision and appreciate the sense of legitimacy that arises when supervisors visit them in their village. Village leaders and district staff are engaged and committed to supporting CHWs. Despite these successes, facility-based supervisors visit CHWs in their village an average of only once every 2.8 months, CHWs and supervisors still see supervision primarily as an opportunity to check reports, and meetings with district staff are infrequent and not well scheduled. CONCLUSIONS: Supervision of CHWs could be strengthened by streamlining supervision protocols to focus less on report checking and more on problem solving and skills development. Facility health workers, while important for technical oversight, may not be the best mentors for certain tasks such as community relationship-building. We suggest further exploring CHW supervision innovations, such as an enhanced role for community actors, who may be more suitable to support CHWs engaged primarily in health promotion than scarce and over-worked facility health workers.

Profile, knowledge, and work patterns of a cadre of maternal, newborn, and child health CHWs focusing on preventive and promotive services in Morogoro Region, Tanzania.

BACKGROUND: Despite impressive decreases in under-five mortality, progress in reducing maternal and neonatal mortality in Tanzania has been slow. We present an evaluation of a cadre of maternal, newborn, and child health community health worker (MNCH CHW) focused on preventive and promotive services during the antenatal and postpartum periods in Morogoro Region, Tanzania. Study findings review the effect of several critical design elements on knowledge, time allocation, service delivery, satisfaction, and motivation. METHODS: A quantitative survey on service delivery and knowledge was administered to 228 (of 238 trained) MNCH CHWs. Results are compared against surveys administered to (1) providers in nine health centers (n = 88) and (2) CHWs (n = 53) identified in the same districts prior to the program's start. Service delivery outputs were measured by register data and through a time motion study conducted among a sub-sample of 33 randomly selected MNCH CHWs. RESULTS: Ninety-seven percent of MNCH CHWs (n = 228) were interviewed: 55% male, 58% married, and 52% with secondary school education or higher. MNCH CHWs when compared to earlier CHWs were more likely to be unmarried, younger, and more educated. Mean MNCH CHW knowledge scores were <50% for 8 of 10 MNCH domains assessed and comparable to those observed for health center providers but lower than those for earlier CHWs. MNCH CHWs reported covering a mean of 186 households and were observed to provide MNCH services for 5 h weekly. Attendance of monthly facility-based supervision meetings was nearly universal and focused largely on registers, yet data quality assessments highlighted inconsistencies. Despite program plans to provide financial incentives and bicycles for transport, only 56% of CHWs had received financial incentives and none received bicycles. CONCLUSIONS: Initial rollout of MNCH CHWs yields important insights into addressing program challenges. The social profile of CHWs was not significantly associated with knowledge or service delivery, suggesting a broader range of community members could be recruited as CHWs. MNCH CHW time spent on service delivery was limited but comparable to the financial incentives received. Service delivery registers need to be simplified to reduce inconsistencies and yet expanded to include indicators on the timing of antenatal and postpartum visits.

A cross-sectional survey of emergency and essential surgical care capacity among hospitals with high trauma burden in a Central African country.

BACKGROUND: As the overwhelming surgical burden of injury and disease steadily increases, disproportionately affecting low- and middle-income countries, adequate surgical and trauma care systems are essential. Yet, little is known about the emergency and essential surgical care (EESC) capacity of facilities in many African countries. The objective of this study was to assess the EESC capacity in different types of hospitals across Cameroon. METHODS: This cross-sectional survey used the WHO Tool for Situational Analysis to Assess EESC, investigating four key areas: infrastructure, human resources, interventions, and equipment and supplies. Twelve hospitals were surveyed between August and September 2009. Facilities were conveniently sampled based on proximity to road traffic and sociodemographic composition of population served in four regions of Cameroon. To complete the survey, investigators interviewed heads of facilities, medical advisors, and nursing officers and consulted hospital records and statistics at each facility. RESULTS: Seven district hospitals, two regional hospitals, two general hospitals, and one missionary hospital completed the survey. Infrastructure for EESC was generally inadequate with the largest gaps in availability of oxygen concentrator supply, an on-site blood bank, and pain relief management guidelines. Human resources were scarce with a combined total of six qualified surgeons, seven qualified obstetrician/gynecologists, and no anesthesiologists at district, regional, and missionary hospitals. Of 35 surgical interventions, 16 were provided by all hospitals. District hospitals reported referring patients for 22 interventions. Only nine of the 67 pieces of equipment were available at all hospitals for all patients all of the time. CONCLUSIONS: Severe shortages highlighted by this survey demonstrate the significant gaps in capacity of hospitals to deliver EESC and effectively address the increasing surgical burden of disease and injury in Cameroon. This data provides a foundation for evidence-based decision-making surrounding appropriate allocation and provision of resources for adequate EESC in the country.

Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa.

The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.

Examining decentralization and managerial decision making for child immunization program performance in India.

Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mechanisms of the Intensified Mission Indradhanush (IMI) in India relate to measurable performance of the immunization program. Data on decision space and its related dimensions of institutional capacity and accountability were collected by conducting structured interviews with managers based in 24 districts, 61 blocks, and 279 subcenters. Two measures by which to assess performance were selected: (1) proportion reduction in the DTP3 coverage gap (i.e., effectiveness), and (2) total IMI doses delivered per incremental USD spent on program implementation (i.e., efficiency). Descriptive statistics on decision space, institutional capacity, and accountability for IMI managers were generated. Structural equation models (SEM) were specified to detect any potential associations between decision space dimensions and performance measures. The majority of districts and blocks indicated low levels of decision space. Institutional capacity and accountability were similar across areas. Increases in decision space were associated with less progress towards closing the immunization coverage gap in the IMI context. Initiatives to support health workers and managers based on their specific contextual challenges could further improve outcomes of the program. Similar to previous studies, results revealed strong associations between each of the three decentralization dimensions. Health systems should consider the impact that management structures have on the efficiency and effectiveness of health services delivery. Future research could provide greater evidence for directionality of direct and indirect effects, interaction effects, and/or mediators of relationships.

Role of User Benefit Awareness in Health Coverage Utilization among the Poor in Cambodia.

The objective of this study was to understand the steps to health coverage benefit utilization in Cambodia toward improving access to health care and financial risk protection for the poor. We particularly examine the role of user awareness in the pathway to care seeking and benefit utilization with respect to the Health Equity Funds (HEF). Using 2016 survey data that were nationally representative of households with children under two years of age, we used a series of logistic regression models to evaluate associations between respondents' awareness of benefits, public health care seeking behaviors, coverage benefit claims, and out-of-pocket expenditures. Beneficiaries were generally aware of their entitlements, although their awareness of specific benefits, such as transport reimbursement, was relatively lower. Awareness of free services at public health centers was associated with twice the odds of having ever visited a public provider for outpatient care, while awareness of free services at public hospitals was associated with higher odds of always seeking inpatient care in the public sector. Study findings point to the decision of where to seek care as the critical point in the pathway to HEF utilization. If the decision had already been made to go to a public provider, it was likely that HEF benefits were claimed. Interventions that prompt appropriate care seeking in the public sector may do the most to improve HEF utilization and subsequently improve access to care through sufficient financial risk protection.

A comparative assessment of action plans on antimicrobial resistance from OECD and G20 countries using natural language processing.

Following the launch of the Global Action Plan on antimicrobial resistance (AMR-GAP) in 2015, most OECD and G20 countries developed their own national action plans (AMR-NAPs). This is the first paper that deploys natural language processing (NLP) techniques to systematically measure and compare the extent to which AMR-NAPs from 21 OECD and G20 countries align with the AMR-GAP in terms of the strategic objectives and interventions. We quantify the extent of alignment based on two NLP metrics: term-frequency (TF) and term-frequency-inverse document frequency (TF-IDF). Quantifying TF allows us to compare the relative prominence of strategic objectives and interventions, whereas quantifying TF-IDF enables us to identify interventions that occur more frequently in each AMR-NAP. Similar to the AMR-GAP, in our sample, terms associated with optimizing antimicrobial use in human and animal health have the highest frequency (TF = 0. 287), whereas terms linked to raising AMR awareness and education have the lowest frequency (TF = 0.066). Substantial cross-country variation exists in the distribution of interventions that are distinctly frequent in each AMR-NAP. We also report new evidence on the selected policy design and monitoring and evaluation features of these documents. Our results suggest a high degree of congruence between the AMR-GAP and AMR-NAPs, with notable diversity in the spate of interventions that OECD and G20 countries discuss in their action plans.

Health equity funds as the pathway to universal coverage in Cambodia: care seeking and financial risk protection.

Cambodia has developed the health equity fund (HEF) system to improve access to health services for the poor, and this strengthens the health system towards the universal health coverage goal. Given rising healthcare costs, Cambodia has introduced several innovations and accomplished considerable progress in improving access to health services and catastrophic health expenditures for the targeted population groups. Though this is improving in recent years, HEF households remain at the higher risk of catastrophic spending as measured by the higher share of HEF households with catastrophic health expenses being at 6.9% compared to the non-HEF households of 5.5% in 2017. Poverty targeting poses another challenge for the health system. Nevertheless, HEF appeared to be more significantly associated with decreased out-of-pocket expenditure per illness among those who sought care from public providers. Increasing population and cost coverages of the HEF and effectively attracting beneficiaries to the public sector will further enhance the financial protection and pave the pathway towards universal coverage. Our recommendations focus on leveraging the HEF experience for expanding coverage and increasing equitable access, as well as strengthening the quality of healthcare services.

Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia.

In Cambodia, diabetes caused nearly 3% of the country's mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.

Financial strategies targeting healthcare providers to promote the prudent use of antibiotics: a systematic review of the evidence.

Improving prudent use of antibiotics is one way to limit the spread of antimicrobial resistance (AMR). The objective of this systematic review was to assess the effects of financial strategies targeting healthcare providers on the prudent use of antibiotics. A systematic review of the literature was conducted searching PubMed, Embase and Cochrane databases, and the grey literature. Search terms related to antibacterial agents, drug resistance, financial strategies, and healthcare providers and/or prescribers. Twenty-two articles were included in the review, reporting on capitation and salary reimbursement, cost containment interventions, pay-for-performance initiatives, penalties, and a one-off bonus payment. There was substantial variation in the reported outcomes describing prescribing behaviours, including proportion of patients prescribed antibiotics, antibiotic prescriptions per patient, and number of cases treated with recommended antibiotic therapy. All financial strategies were associated with improvements in the appropriate prescription of antibiotics in the short-term, although the magnitude of observed effects varied across financial strategies. Financial penalties were associated with the greatest decreases in inappropriate antibiotic prescriptions, followed by capitation models and pay-for-performance schemes that paid bonuses upon achievement of performance targets. However, the risk of bias across studies must be noted. Findings point to the viability of financial strategies to promote the prudent use of antibiotics. Measuring the downstream impact of prescriber behaviour changes is key to estimating the true value of such interventions to tackle AMR. Research efforts should continue to build the evidence on causal mechanisms driving provider prescribing patterns for antibiotics and the long-term impact on antibiotic prescriptions.

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review.

BACKGROUND: About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings. MATERIALS AND METHODS: This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score's capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized. RESULTS: Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility. CONCLUSIONS: The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective. PROSPERO REGISTRATION NUMBER: CRD42017064600.

Epidemiology and cost of pediatric injury in Yaoundé, Cameroon: a prospective study.

PURPOSE: Unintentional injury is the leading cause of death among children aged 10-19 years and over 95% of injury deaths occur in low- and middle-income countries (LMICs). As patterns of injury in the pediatric population may differ from those in adults, risks specific to children in LMICs need to be identified for effective injury prevention and treatment. This study explores patterns of pediatric injury epidemiology and cost in Yaoundé, Cameroon to inform injury prevention and resource allocation. METHODS: Pediatric (age < 20 years) trauma patient data were collected at the emergency department (ED) of Central Hospital of Yaoundé (CHY) from April through October 2009. Univariate, bivariate, and multivariate analyses were used to explore injury patterns and relationships between variables. Regression analyses were conducted to identify predictors of receiving surgical care. RESULTS: Children comprised 19% (544) of trauma cases. About 54% suffered road traffic injuries (RTIs), which mostly affected the limbs and pelvis (37.3%). Half the RTI victims were pedestrians. Transportation to CHY was primarily by taxi or bus (69.4%) and a preponderance (71.1%) of the severely and profoundly injured patients used this method of transport. Major or minor surgical intervention was necessary for 17.9% and 20.8% of patients, respectively. Patients with an estimated injury severity score ≥ 9 (33.2%) were more likely to need surgery (p < 0.01). The median ED cost of pediatric trauma care was USD12.71 [IQR 12.71, 23.30]. CONCLUSIONS: Injury is an important child health problem that requires adequate attention and funding. Policies, surgical capacity building, and health systems strengthening efforts are necessary to address the high burden of pediatric injuries in Cameroon. Pediatric injury prevention efforts in Cameroon should target pedestrian RTIs, falls, and burns and consider school-based interventions.