Addressing Care Continuity and Quality Challenges in the Management of Hypertension: Case Study of the Private Health Care Sector in Kenya.

BACKGROUND: Hypertension is a major risk factor of cardiovascular disease and a leading cause of morbidity and mortality globally. In Kenya, the rise of hypertension strains an already stretched health care system that has traditionally focused on the management of infectious diseases. Health care provision in this country remains fragmented, and little is known about the role of health information technology in care coordination. Furthermore, there is a dearth of literature on the experiences, challenges, and solutions for improving the management of hypertension and other noncommunicable diseases in the Kenyan private health care sector. OBJECTIVE: The aim of this study is to assess stakeholders' perspectives on the challenges associated with the management of hypertension in the Kenyan private health care sector and to derive recommendations for the design and functionality of a digital health solution for addressing the care continuity and quality challenges in the management of hypertension. METHODS: We conducted a qualitative case study. We collected data using in-depth interviews with 18 care providers and 8 business leads, and direct observations at 18 private health care institutions in Nairobi, Kenya. We analyzed the data thematically to identify the key challenges and recommendations for technology-enabled solutions to support the management of hypertension in the Kenyan private health sector. We subsequently used the generated insights to derive and describe the design and range of functions of a digital health wallet platform for enabling care quality and continuity. RESULTS: The management of hypertension in the Kenyan private health care sector is characterized by challenges such as high cost of care, limited health care literacy, lack of self-management support, ineffective referral systems, inadequate care provider training, and inadequate regulation. Care providers lack the tools needed to understand their patients' care histories and effectively coordinate efforts to deliver high-quality hypertension care. The proposed digital health platform was designed to support hypertension care coordination and continuity through clinical workflow orchestration, decision support, and patient-mediated data sharing with privacy preservation, auditability, and trust enabled by blockchain technology. CONCLUSIONS: The Kenyan private health care sector faces key challenges that require significant policy, organizational, and infrastructural changes to ensure care quality and continuity in the management of hypertension. Digital health data interoperability solutions are needed to improve hypertension care coordination in the sector. Additional studies should investigate how patients can control the sharing of their data while ensuring that care providers have a holistic view of the patient during any encounter.

[Certification of medical care facilities in Mexico: analysis of the incentives for its continuity.] / Certificación de establecimientos de atención médica en México: análisis de los incentivos para su continuidad.

OBJECTIVE: To analyze the possible effect of certification models and healthcare organizations' (HOs) participation incentives in the General Health Council certification process in the 1999-2017 period. MATERIALS AND METHODS: Official printed and online documents about HOs' certification were collected. Information from instances related to the process was requested through transparency mechanisms. Health organizations' participation in political-administrative periods between 1997-2017 was analyzed. RESULTS: The annual average participation in the certification process during the 1999-2000 period was 259.5 HOs; during the 2013-2016 period, the average was 72.5. Public units' participation in this process has been decreasing. In 2017, certified HO were <1%. CONCLUSIONS: No positive effects of adjustments to the certification model or the incentives applied were identified. Conversely, there is decreasing participation in the different political-administrative periods. The National HO Certification System and its possible effect on clinical quality must be thoroughly evaluated.

OBJECTIVE: Analizar el posible efecto de los modelos de certificación y de los incentivos implementados en la participación de establecimientos de atención médica (EAM) en la certificación del Consejo de Salubridad General entre 1999-2017. MATERIALS AND METHODS: Se colectaron documentos oficiales, impresos y en línea, sobre la certificación de EAM y se solicitó información a diversas instancias relacionadas mediante mecanismos de transparencia. Se analizó la participación de EAM en los períodos político-administrativos entre 1999-2017. RESULTS: El promedio anual de participación entre 1999-2000 fue de 259.5 EAM; entre 2013-2016, de 72.5. La participación de EAM públicos es decreciente. En 2017, los EAM certificados eran <1%. CONCLUSIONS: No se identificaron efectos positivos ni sostenidos de ajustes al modelo, ni de los incentivos implementados. Se observa disminución de la participación en los distintos periodos político-administrativos. Debe evaluarse profundamente el Sistema Nacional de Certificación de EAM y su posible efecto en la calidad clínica.

[General characteristics of medical education in Mexico. A look from medical schools]. / Características generales de la educación médica en México. Una mirada desde las escuelas de medicina.

OBJECTIVE: To know the characteristics of medical education and identify its strengths and weaknesses. MATERIALS AND METHODS: A transversal and quantitative study of the characteristics of medical education in 29 medical schools in Mexico was carried out, between April and September 2017. Questionnaire with Likert scale was applied to explore context, regulation, structure, process, results and impact of medical education. Bivariate analysis was performed with a Chi square test and the significance level was equal to or less than 0.05. RESULTS: The political context obtained 64%, economical context 10% and mechanisms of regulation 31%. The educational structure was 61% and the social impact was 93%. CONCLUSIONS: Public policies, regulatory mechanisms and public investment must be strengthened to improve the quality of medical education.

OBJETIVO: Conocer las características de la educación médica e identificar sus fortalezas y debilidades. MATERIAL Y MÉTODOS: Se realizó un estudio transversal y cuantitativo para conocer las características de la educación médica en 29 escuelas de medicina en México, entre abril y septiembre de 2017. Se utilizó un cuestionario con escala tipo Likert para explorar el contexto, la regulación, la estructura, el proceso, los resultados y el impacto de la educación médica. Se realizó un análisis bivariado con ji cuadrada y una significancia estadística de p igual o menor a 0.05. RESULTADOS: El contexto político obtuvo 64%, el contexto económico 10%, los mecanismos de regulación 31%, la estructura educativa 61% y el impacto social 93%. CONCLUSIONES: Se requiere fortalecer las políticas públicas, la regulación y la inversión pública, para mejorar la calidad de la educación médica.

Patients' satisfaction and public and private sectors' health care service quality in Pakistan: Application of grey decision analysis approaches.

PURPOSE: The study aims to evaluate the comprehensive relationship between patient satisfaction and five dimensions of health care service quality in Pakistani public/private health care sectors, using a novel grey relational analysis (GRA) models and the Hurwicz criteria of decision making under uncertainty. DESIGN/METHODOLOGY/APPROACH: Data were collected from private and public health care facilities of Pakistan through an improved SERVQUAL instrument. Deng's GRA, absolute GRA, and the second synthetic GRA models were applied to address the problem under study. FINDINGS: Grey relational analysis models revealed that reliability and responsiveness are most strongly predicting patient satisfaction in public and private health care sectors, respectively. The Hurwicz criteria showed that patients are more likely to be satisfied from private health care facilities. LIMITATIONS/IMPLICATIONS: Limitations of SERVQUAL model are also the limitations of the study; eg, the study suggests that because of the absence of "cost," which is a key quality indicator of Pakistani public sector health care facilities, the model was unable to comprehensively evaluate the health care situation in light of the observations of price-focused Pakistani patients. The study recommends tailoring of SERVQUAL model for the resource-scant and underdeveloped countries where people's evaluation of the quality of the hospitals is likely to be influenced by the price of services. ORIGINALITY/VALUE: The study is a pioneer in health care evaluation of public and private sectors of Lahore and Rawalpindi while using GRA models, in general, and the second synthetic GRA model, in particular. It presents an alternative method to the statistical way of analyzing data by successfully demonstrating the use of grey methods, which can make reasonable decisions even through small samples.

[Public, private or third sector management? Differences in the results in Primary Care in Catalonia]. / ¿Gestión pública, privada o por el tercer sector? Diferencias en los resultados en atención primaria de Cataluña.

GOAL: Compare the performance of primary health centers managed by the public sector (ICS), the third sector (Hospitals) or by small private organizations known as EBAs. DESIGN: Multidimensional comparative analysis. We follow a quasi-experimental logic comparing primary health centers managed by EBAs with other centers managed by the public sector (ICS) o by the third sector (hospitals). LOCALIZATION: Barcelona, Catalonia, Spain. PARTICIPANTS: We have 368 observations (primary health centers) and 18 indicators measured in 2015. INTERVENTION: Different management models (public, third sector, private). MAIN MEASURES: We compare activity measures, measures of effectiveness in the process of medical assistance, and efficiency. We compare before and after controlling for the socio-economic level corresponding to the basic health area and the characteristics of the population and health region. We conduct a test of significant differences between the indicators corresponding to centers managed differently, after a process of matching using key variables and Propensity Score Matching. RESULTS: Significant differences in the measure of work load for family doctors, in five measures of effectiveness in the process of assistance and in the cost per user. CONCLUSIONS: The diversity in the management model through EBAs shows results that can be interpreted in favor of the maintenance or the expansion of this model of management. The majority of EBAs have been implanted in areas of a medium or high level, but their results are still significantly positive once the socio economic level of the area is controlled.

Introduction of safety and quality standards for private health care providers: a case-study from the Republic of Srpska, Bosnia and Herzegovina.

BACKGROUND: Regulation of private health care providers (PHPs) in middle-income countries can be challenging. Mandatory safety and quality standards for PHPs have been in place in the Republic of Srpska since 2012, but not all PHPs have adopted them yet. Adoption rates have differed among different types of providers. We studied three predominant types of PHPs to determine why the rate of adoption of the standards varies among them. METHODS: This study used a mixed methods approach, which allowed the integration of both quantitative and qualitative data, to develop an explanatory case study. The case study covered three types of private PHPs: pharmacies, dental practices and specialist practices. Primary data were collected through face-to-face semi-structured in-depth interviews and a self-administered postal survey of private health care providers. Our study's theoretical framework was based on the diffusion of innovation theory. RESULTS: The rate of adoption of mandatory standards varied among different types of PHP mainly due to four factors: (1) level of concern about negative financial consequences, such as the risk of fines or of losing contracts with the Health Insurance Fund of the Republic of Srpska; (2) availability of information on the standards and implementation process; (3) level of the relevant professional association's support for the introduction of standards; and (4) provider's perceptions of the relevant health chamber's attitude toward the standards. Opinions conveyed to PHPs by peers slightly negatively influenced adoption of the standards at the attitude-forming stage. Perceived gains in professional status did not have a major influence on the decision to adopt standards. All three types of PHPs perceived the same disadvantages of the introduction of safety and quality standards: associated expense, increased administrative burden and disruption of service provision. CONCLUSIONS: When introducing mandatory quality and safety standards for PHPs, national health authorities need to: ensure adequate availability of information on the relative advantages of adhering to standards; support the introduction of standards with relevant incentives and penalties; and work in partnership with relevant professional associations and health chambers to get their buy-in for regulation of quality and safety of health services.

Making free public healthcare attractive: optimizing health equity funds in Cambodia.

BACKGROUND: Following the introduction of user fees in Cambodia, Health Equity Funds (HEF) were developed to enable poor people access to public health services by paying public health providers on their behalf, including non-medical costs for hospitalised beneficiaries (HEFB). The national scheme covers 3.1 million pre-identified HEFB. Uptake of benefits, however, has been mixed and a substantial proportion of poor people still initiate care at private facilities where they incur considerable out-of-pocket costs. We examine the benefits of additional interventions compared to existing stand-alone HEF scenarios in stimulating care seeking at public health facilities among eligible poor people. METHODS: We report on three configurations of HEF and their ability to attract HEFB to initiate care at public health facilities and their degree of financial risk protection: HEF covering only hospital services (HoHEF), HEF covering health centre and hospital services (CHEF), and Integrated Social Health Protection Scheme (iSHPS) that allowed non-HEFB community members to enrol in HEF. The iSHPS also used vouchers for selected health services, pay-for-performance for quantity and quality of care, and interventions aimed at increasing health providers' degree of accountability. A cross sectional survey collected information from 1636 matched HEFB households in two health districts with iSHPS and two other health districts without iSHPS. Respondents were stratified according to the three HEF configurations for the descriptive analysis. RESULTS: The findings indicated that the proportion of HEFB who sought care first from public health providers in iSHPS areas was 55.7%, significantly higher than the 39.5% in the areas having HEF with health centres (CHEF) and 13.4% in the areas having HEF with hospital services only (HoHEF). The overall costs (out-of-pocket and transport) associated with the illness episode were lowest for cases residing within iSHPS sites, US$10.4, and highest in areas where health centres were not included in the package (HoHEF), US$20.7. Such costs were US$19.5 at HEF with health centres (CHEF). CONCLUSIONS: The findings suggest that HEF encompassing health centre and hospital services and complemented by additional interventions are better than stand-alone HEF in attracting sick HEFB to public health facilities and lowering out-of-pocket expenses associated with healthcare seeking.

Do students from public schools fare better in medical school than their colleagues from private schools? If so, what can we learn from this?

BACKGROUND: Internal grade inflation is a documented practice in secondary schools (mostly in private schools) that jeopardises fairness with regard to access to medical school. However, it is frequently assumed that the higher internal grades are in fact justifiable, as they correspond to better preparation of students in private schools in areas that national exams do not cover but nevertheless are important. Consequently, it is expected that students from private schools will succeed better in medical school than their colleagues, or at least not perform worse. We aimed to study whether students from private schools do fare better in medical school than their colleagues from public schools, even after adjusting for internal grade inflation. METHODS: We analysed all students that entered into a medical course from 2007 to 2014. A linear regression was performed using mean grades for the 1st-year curse units (CU) of the medical school curriculum as a dependent variable and student gender, the nature of students' secondary school (public/private), and whether their secondary school highly inflated grades as independent variables. A logistic regression was also performed, modelling whether or not students failed at least one CU exam during the 1st year of medical school as a function of the aforementioned independent variables. RESULTS: Of the 1709 students analysed, 55% came from public secondary schools. Private (vs. public) secondary school (ß = - 0.459, p < 0.001) and whether secondary schools highly inflated grades (ß = - 0.246, p = 0.003) were independent factors that significantly influenced grades during the first year of medical school. Having attended a private secondary school also significantly increased the odds of a student having failed at least one CU exam during the 1st year of medical school (OR = 1.33), even after adjusting for whether or not the secondary school used highly inflated grades. CONCLUSIONS: It is important to further discuss what we can learn from the fact that students from public secondary schools seem to be better prepared for medical school teaching methodologies than their colleagues from private ones and the implications for the selection process.

Patients' satisfaction as a dimension of quality: a survey on outpatients' care in Dubai.

PURPOSE: The last few years have seen a stronger emphasis on patient-centred care within the international healthcare setting. Patient-centred care is clearly perceived to be important to optimise the satisfaction and well-being of patients. The purpose of this paper is to review current patient-centred practices for outpatients in both private clinics and public hospitals in Dubai. Such a comparison contributes to the identification of best management practices as a means of enhancing healthcare delivery. DESIGN/METHODOLOGY/APPROACH: This study is based on an independent survey consisting of self-administered questionnaires, in which patients were asked to rate several aspects of private clinics or government hospitals in Dubai. The questionnaire used has been drawn from the Consumer Assessment of Healthcare Providers and Systems Clinician and Group Survey, Version 3.0. Responses from 420 patients form a data set that is analysed quantitatively. FINDINGS: In total, 420 respondents took part in this survey. The results of the survey show that there is a considerable difference between the expectation levels of patients from government hospitals and patients from private clinics. Patients from government hospitals consistently show that time is a critical aspect of the service received, with 68 per cent of the respondents reporting this issue. Additionally, poor customer care, as reported by 14 per cent of the respondents, is also a critical issue. Timely service and appointments are among the main factors that contribute to patient satisfaction. Patients in private clinics, instead, particularly value clear explanations from doctors and nurses - this is corroborated by the fact that 11 per cent of the respondents reported appreciation of this type of service. PRACTICAL IMPLICATIONS: This paper draws attention to a patient-centric perspective of healthcare, and highlights the importance of educating patients through clear explanations. ORIGINALITY/VALUE: Little evidence exists on the standards of healthcare in Dubai. The authors explore this area and present direct evidence on quality standard implementation, identify implementation shortcomings and make recommendations for future research and practice.

[Private medical education in Germany]. / Medizinische Studienangebote privater Träger in Deutschland.

Through the years, a range of privately funded medical training opportunities has been established in Germany. Only a few of them operate along the German Medical Licensure Act and thus underlie quality assurance regulations in Germany. Most of the courses are a result of German hospitals cooperating with universities from other EU countries. The content of the courses and the examinations underlie the regulations of the university's home country. This article aims to give an overview of the private medical training opportunities offered in Germany and to show differences compared to state funded German medical schools. The authors discuss the opportunities of private medical training as well as its challenges and risks. Basic principles concerning finances and quality assurance of national and international private medical training are provided. Regardless of their mode of financing, the superior goal of the training, according to the German Medical Licensure Act, should always be to enable young doctors to pursue further professional training, so that they can maintain the best possible quality in patient care, research, and medical education.

[Physical exercise health promotion in the workplace: participative experimentation in a private company]. / Promotion de la santé par l'activité physique sur les lieux de travail : expérimentation participative dans une entreprise privée.

CONTEXT: The objective of this study was to identify collaborative processes involved in a physical activity health promotion project in companies, conducted through a participatory approach in a cross-sectoral partnership, and to estimate the preliminary effects in terms of employee health. METHODS: Action research was conducted in an industrial company comprising 240 employees over a 2-year period. This research was based on 4 criteria: description of the actors' network, the opportunities and constraints of the project, the implementation of physical activities, the participation of employees in the various activities, the impacts observed (after 3 months of activities) on physical parameters and quality of life. RESULTS: Six work groups selected two activities : muscle-development exercise and Taïchi. We evaluated muscle strengthening activity. The participation rate in the activity was 16%. A higher age, female gender and being a manager or employee rather than a worker were significantly associated with participation. A tendency towards increased physical and mental scores of SF12 was observed. We identified two major barriers: logistic and communicational. CONCLUSION: The participatory approach, based on a cross-sectoral partnership, is the determining element of the project's success in a context of local opportunities. Two factors were identified to perpetuate this dynamic and improve the system: rationalization of the structuring of the service and greater resources, particularly financial resources.

Patients pathways to tuberculosis diagnosis and treatment in a fragmented health system: a qualitative study from a south Indian district.

BACKGROUND: India's Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB diagnosis and treatment. But more than 50% of TB patients seek care from private practitioners (PPs), where TB is managed sub-optimally. In India, there is dearth of studies capturing experiences of TB patients when they navigate through health facilities to seek care. Also, there is less information available on how PPs make decisions to refer TB cases to RNTCP. We conducted this study to understand the factors influencing TB patient's therapeutic itineraries to RNTCP and PP's cross referral practices linked to RNTCP. METHODS: We conducted in-depth interviews on a purposive sample of 33 TB patients and 38 PPs. Patients were categorised into three groups: those who reached RNTCP directly, those who were referred by PPs to RNTCP and patients who took DOT from PPs. We assessed patient's experiences in each category and documented their journey from initial symptoms until they reached RNTCP, where they were diagnosed and started on treatment. PPs were categorised into three groups based on their TB case referrals to RNTCP: actively-referring, minimally-referring and non-referring. RESULTS: Patients had limited awareness about TB. Patients switched from one provider to the other, since their symptoms were not relieved. A first group of patients, self-medicated by purchasing get rid drugs from private chemists over the counter, before seeking care. A second group sought care from government facilities and had simple itineraries. A third group who sought care from PPs, switched concurrently and/or iteratively from public and private providers in search for relief of symptoms causing important diagnostic delays. Eventually all patients reached RNTCP, diagnosed and started on treatment. PP's cross-referral practices were influenced by patient's paying capacity, familiarity with RNTCP, kickbacks from private labs and chemists, and even to get rid of TB patients. These trade-offs by PPs complicated patient's itineraries to RNTCP. CONCLUSIONS: India aims to achieve universal health care for TB. Our study findings help RNTCP to develop initiatives to promote early detection of TB, by involving PPs and private chemists and establish effective referral systems from private sectors to RNTCP.

From habits of attrition to modes of inclusion: enhancing the role of private practitioners in routine disease surveillance.

BACKGROUND: Private practitioners are the preferred first point of care in a majority of low and middle-income countries and in this position, best placed for the surveillance of diseases. However their contribution to routine surveillance data is marginal. This systematic review aims to explore evidence with regards to the role, contribution, and involvement of private practitioners in routine disease data notification. We examined the factors that determine the inclusion of, and the participation thereof of private practitioners in disease surveillance activities. METHODS: Literature search was conducted using the PubMed, Web of Knowledge, WHOLIS, and WHO-IRIS databases to identify peer-reviewed and gray full-text documents in English with no limits for year of publication or study design. Forty manuscripts were reviewed. RESULTS: The current participation of private practitioners in disease surveillance efforts is appalling. The main barriers to their participation are inadequate knowledge leading to unsatisfactory attitudes and misperceptions that influence their practices. Complicated reporting mechanisms with unclear guidelines, along with unsatisfactory attitudes on behalf of the government and surveillance program managers also contribute to the underreporting of cases. Infrastructural barriers especially the availability of computers and skilled human resources are critical to improving private sector participation in routine disease surveillance. CONCLUSION: The issues identified are similar to those for underreporting within the Integrated infectious Disease Surveillance and Response systems (IDSR) which collects data mainly from public healthcare facilities. We recommend that surveillance program officers should provide periodic training, supportive supervision and offer regular feedback to the practitioners from both public as well as private sectors in order to improve case notification. Governments need to take leadership and foster collaborative partnerships between the public and private sectors and most importantly exercise regulatory authority where needed.

Leveraging the private sector for child health: a qualitative examination of caregiver and provider perspectives on private sector care for childhood pneumonia in Uttar Pradesh, India.

BACKGROUND: The private health sector is a primary source of curative care for childhood illnesses in many low- and middle-income countries. Therefore ensuring appropriate private sector care is an important step towards improving outcomes from illnesses like pneumonia, which is the leading infectious cause of childhood mortality worldwide. This study aimed to provide evidence on private sector care for childhood pneumonia in Uttar Pradesh, India, by simultaneously exploring providers' knowledge and practices and caregivers' experiences. METHODS: We conducted in-depth interviews with a purposive sample of 36 practitioners and 34 caregivers in two districts. Practitioners included allopathic doctors, AYUSH providers, and drug sellers. Caregivers were mothers of children under the age of five with symptoms consistent with pneumonia who had seen one of those practitioners. Interview transcripts were analyzed thematically. RESULTS: Caregivers were generally prompt in seeking care outside the home, but many initially favored local informal providers based on access and cost. Drug sellers were not commonly consulted for treatment. Formal providers had imperfect, but reasonable, knowledge of pneumonia and followed appropriate steps for diagnosis, though some gaps were noticed that were primarily related to lack of (or failure to use) diagnostic tools. Most practitioners prescribed antibiotics and supportive symptomatic treatment. Relational and structural factors encouraged overuse of antibiotics and treatment interruption. Caregivers often had a limited understanding of treatment but wanted rapid symptomatic improvements, frequently leading to sequentially consulting multiple providers and interrupting treatment when symptoms improved. Providers were confronted with these expectations and care-seeking patterns. CONCLUSIONS: This study contributes in-depth evidence on private sector care for childhood pneumonia in UP. Achieving appropriate care requires an enriched perspective that simultaneously considers the critical role of provider-caregiver interactions and of the context in which they occur in shaping treatment outcomes.

Continuum of care in maternal, newborn and child health in Pakistan: analysis of trends and determinants from 2006 to 2012.

BACKGROUND: Pakistan, being a developing country, presents the dismal picture of maternal and neonatal mortality and morbidity. The majority of maternal and neonatal deaths could be avoided if Continuum of Care (CoC) is provided in a structured pathway from pregnancy to birth and to the first week of life of the newborn child. This study aimed to analyse the trends of CoC at all three levels (antenatal care, skilled delivery and postpartum care) and to identify various factors affecting the continuation in receiving CoC in Pakistan during 2006 to 2012. METHODS: Secondary data analysis was performed on nationally representative data from the last two iterations of Pakistan Demographic and Health Survey (PDHS), conducted during 2006/07 to 2012/13. The analysis is limited to women of the reproductive age group (15-49 years) who gave birth during the last five years preceding both surveys. This leads to a sample size of 5,724 and 7,461 respondents from PDHS 2006/07 and 2012/13 respectively. The association between CoC and several factors, including individual attributes (reproductive status), family influences, community context, as well as cultural and social values was assessed in bivariate analyses in a first step. Furthermore, odds ratios and adjusted odds ratios with 95% confidence intervals using a binary and multivariable logistic regression were calculated. RESULTS: Our research presents the trends of a composite measure of CoC including antenatal care, delivery assistance and postpartum care. The largest gap in CoC was observed at antenatal care followed by delivery and postnatal care within 48 h after delivery. Results show that CoC completion rate has increased from 15% to 27% amongst women in Pakistan over time from 2006 to 2012. Women with high age at first birth, having less number of children, with higher education, belonging to richest quintile, living in Sindh province and urban areas, having high autonomy and exposure to mass media were most likely to avail complete CoC. CONCLUSIONS: The findings show that women in Pakistan still lack the CoC. This calls for attention to develop and implement tailored interventions, focusing on the needs of women in Pakistan to provide CoC in an integrated manner, involving both public and private sectors by appropriately addressing the factors hindering CoC completion rates.

Public stewardship of private for-profit healthcare providers in low- and middle-income countries.

BACKGROUND: Governments use different approaches to ensure that private for-profit healthcare services meet certain quality standards. Such government guidance, referred to as public stewardship, encompasses government policies, regulatory mechanisms, and implementation strategies for ensuring accountability in the delivery of services. However, the effectiveness of these strategies in low- and middle-income countries (LMICs) have not been the subject of a systematic review. OBJECTIVES: To assess the effects of public sector regulation, training, or co-ordination of the private for-profit health sector in low- and middle-income countries. SEARCH METHODS: For related systematic reviews, we searched the Cochrane Database of Systematic Reviews (CDSR) 2015, Issue 4; Database of Abstracts of Reviews of Effectiveness (DARE) 2015, Issue 1; Health Technology Assessment Database (HTA) 2015, Issue 1; all part of The Cochrane Library, and searched 28 April 2015. For primary studies, we searched MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, MEDLINE Daily and MEDLINE 1946 to Present, OvidSP (searched 16 June 2016); Science Citation Index and Social Sciences Citation Index 1987 to present, and Emerging Sources Citation Index 2015 to present, ISI Web of Science (searched 3 May 2016 for papers citing included studies); Cochrane Central Register of Controlled Trials (CENTRAL), 2015, Issue 3, part of The Cochrane Library (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register) (searched 28 April 2015); Embase 1980 to 2015 Week 17, OvidSP (searched 28 April 2015); Global Health 1973 to 2015 Week 16, OvidSP (searched 30 April 2015); WHOLIS, WHO (searched 30 April 2015); Science Citation Index and Social Sciences Citation Index 1975 to present, ISI Web of Science (searched 30 April 2015); Health Management, ProQuest (searched 22 November 2013). In addition, in April 2016, we searched the reference lists of relevant articles, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and various electronic databases of grey literature. SELECTION CRITERIA: Randomised trials, non-randomised trials, interrupted time series studies, or controlled before-after studies. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study eligibility and extracted data, comparing their results and resolving discrepancies by consensus. We expressed study results as risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI), where appropriate, and assessed the certainty of the evidence using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). We did not conduct meta-analysis because of heterogeneity of interventions and study designs. MAIN RESULTS: We identified 20,177 records, 50 of them potentially eligible. We excluded 39 potentially eligible studies because they did not involve a rigorous evaluation of training, regulation, or co-ordination of private for-profit healthcare providers in LMICs; five studies identified after the review was submitted are awaiting assessment; and six studies met our inclusion criteria. Two included studies assessed training alone; one assessed regulation alone; three assessed a multifaceted intervention involving training and regulation; and none assessed co-ordination. All six included studies targeted private for-profit pharmacy workers in Africa and Asia.Three studies found that training probably increases sale of oral rehydration solution (one trial in Kenya, 106 pharmacies: RR 3.04, 95% CI 1.37 to 6.75; and one trial in Indonesia, 87 pharmacies: RR 1.41, 95% CI 1.03 to 1.93) and dispensing of anti-malarial drugs (one trial in Kenya, 293 pharmacies: RR 8.76, 95% CI 0.94 to 81.81); moderate-certainty evidence.One study conducted in the Lao People's Democratic Republic shows that regulation of the distribution and sale of registered pharmaceutical products may improve composite pharmacy indicators (one trial, 115 pharmacies: improvements in four of six pharmacy indicators; low-certainty evidence).The outcome in three multifaceted intervention studies was the quality of pharmacy practice; including the ability to ask questions, give advice, and provide appropriate treatment. The trials applied regulation, training, and peer influence in sequence; and the study design does not permit separation of the effects of the different interventions. Two trials conducted among 136 pharmacies in Vietnam found that the multifaceted intervention may improve the quality of pharmacy practice; but the third study, involving 146 pharmacies in Vietnam and Thailand, found that the intervention may have little or no effects on the quality of pharmacy practice (low-certainty evidence).Only two studies (both conducted in Vietnam) reported cost data, with no rigorous assessment of the economic implications of implementing the interventions in resource-constrained settings. No study reported data on equity, mortality, morbidity, adverse effects, satisfaction, or attitudes. AUTHORS' CONCLUSIONS: Training probably improves quality of care (i.e. adherence to recommended practice), regulation may improve quality of care, and we are uncertain about the effects of co-ordination on quality of private for-profit healthcare services in LMICs. The likelihood that further research will find the effect of training to be substantially different from the results of this review is moderate; implying that monitoring of the impact is likely to be needed if training is implemented. The low certainty of the evidence for regulation implies that the likelihood of further research finding the effect of regulation to be substantially different from the results of this review is high. Therefore, an impact evaluation is warranted if government regulation of private for-profit providers is implemented in LMICs. Rigorous evaluations of these interventions should also assess other outcomes such as impacts on equity, cost implications, mortality, morbidity, and adverse effects.

Opportunities and challenges in developing a whole-of-government national food and nutrition policy: lessons from Australia's National Food Plan.

OBJECTIVE: The present article tracks the development of the Australian National Food Plan as a 'whole of government' food policy that aimed to integrate elements of nutrition and sustainability alongside economic objectives. DESIGN: The article uses policy analysis to explore the processes of consultation and stakeholder involvement in the development of the National Food Plan, focusing on actors from the sectors of industry, civil society and government. Existing documentation and submissions to the Plan were used as data sources. Models of health policy analysis and policy streams were employed to analyse policy development processes. SETTING: Australia. SUBJECTS: Australian food policy stakeholders. RESULTS: The development of the Plan was influenced by powerful industry groups and stakeholder engagement by the lead ministry favoured the involvement of actors representing the food and agriculture industries. Public health nutrition and civil society relied on traditional methods of policy influence, and the public health nutrition movement failed to develop a unified cross-sector alliance, while the private sector engaged in different ways and presented a united front. The National Food Plan failed to deliver an integrated food policy for Australia. Nutrition and sustainability were effectively sidelined due to the focus on global food production and positioning Australia as a food 'superpower' that could take advantage of the anticipated 'dining boom' as incomes rose in the Asia-Pacific region. CONCLUSIONS: New forms of industry influence are emerging in the food policy arena and public health nutrition will need to adopt new approaches to influencing public policy.

Clinical and perceived quality of care for maternal, neonatal and antenatal care in Kenya and Namibia: the service provision assessment.

BACKGROUND: The majority of women in sub-Saharan Africa now deliver in a facility, however, little is known about the quality of services for maternal and newborn basic and emergency care, nor how this is associated with patient's perception of their experiences. METHODS: Using data from the Service Provision Assessment (SPA) survey from Kenya 2010 and Namibia 2009, we explore whether facilities have the necessary signal functions for providing emergency and basic maternal (EmOC) and newborn care (EmNC), and antenatal care (ANC) using descriptives and multivariate regression. We explore differences by type of facility (hospital, center or other) and by private and public facilities. Finally, we see if patient satisfaction (taken from exit surveys at antenatal care) is associated with the quality of services (specific services provided). RESULTS: We find that most facilities do not have all of the signal functions, with 46 and 27 % in Kenya and 18 and 5 % in Namibia of facilities have high/basic scores in routine and emergency obstetric care, respectively. We found that hospitals preform better than centers in general and few differences emerged between public and private facilities. Patient perceptions were not consistently associated with services provided; however, patients had fewer complaints in private compared to public facilities in Kenya (-0.46 fewer complaints in private) and smaller facilities compared to larger in Namibia (-0.26 fewer complaints in smaller facilities). Service quality itself (measured in scores), however, was only significantly better in Kenya for EmOC and EmNC. CONCLUSIONS: This analysis sheds light on the inadequate levels of care for saving maternal and newborn lives in most facilities in two countries of Africa. It also highlights the disconnect between patients' perceptions and clinical quality of services. More effort is needed to ensure that high quality supply of services is present to meet growing demand as an increasing number of women deliver in facilities.