Antibiotic prescribing practices of medical doctors in a resource-limited setting and the influence of individual perceptions and stewardship support: a survey in three tertiary hospitals in Vietnam.

Objectives: To understand antibiotic prescribing and influencing factors to inform antimicrobial stewardship (AMS) interventions to reduce unwanted consequences of antibiotic use in hospitals in Vietnam, a lower-middle-income country in Asia. Methods: We conducted a cross-sectional study of doctors at three tertiary hospitals using non-probability convenience sampling, through a paper-based (Hospitals 1 and 2) or electronic (Hospital 3) survey. Questions included items on perceptions regarding antibiotic resistance and AMS, prescribing practices, knowledge, demographics and training. We used principal components analysis and mixed-effects models to examine practices and identify influencing factors. Results: Among 314 surveyed participants, 61%, 57% and 59% in Hospitals 1, 2 and 3, respectively, felt certain about the appropriateness of their antibiotic prescriptions. In total, 9% reported sometimes prescribing antibiotics when not needed to meet patients' expectations, and 13% reported doing so to avoid perceived complications. Higher prescribing confidence was found among those with positive perceptions about AMS (P < 0.0001), whereas negative perceptions about colleagues' practices reduced this confidence (P < 0.0001). Individual preference for branded antibiotics was associated with more unnecessary prescribing whereas having higher prescribing confidence decreased the habits of prescribing when not needed. Conclusions: This study provides important implications for design of hospital interventions to address influencing factors on antibiotic prescribing in Vietnam and similar resource-limited settings. Specific interventions should target improving knowledge through education and training for doctors, enhancing the support from the AMS team, and promoting guidelines and policies for appropriate antibiotic use in hospital.

Enhanced podophyllotoxin production of endophyte Fusarium proliferatum TQN5T by host extract and phenylalanine.

Fermentation technology using endophytes is considered a potential alternative approach for producing pharmaceutical compounds like podophyllotoxin (PTOX). In this study, fungus TQN5T (VCCM 44284) was selected from endophytic fungi isolated from Dysosma versipellis in Vietnam for PTOX production through TLC. The presence of PTOX in TQN5T was further confirmed by HPLC. Molecular identification indicated TQN5T as Fusarium proliferatum with 99.43% identity. This result was asserted by morphological characteristics such as white cottony, filamentous colony, layer and branched mycelium, and clear hyphae septa. Cytotoxic assay indicated both biomass extract and culture filtrate of TQN5T presented strong cytotoxicity on LU-1 and HepG2 with IC50 of 0.11, 0.20, 0.041, and 0071, respectively, implying anti-cancer compounds were accumulated in the mycelium and secreted into the medium. Further, the production of PTOX in TQN5T was investigated in the fermentation condition supplemented with 10 µg/ml of host plant extract or phenylalanine as elicitors. The results revealed a significantly higher amount of PTOX in the PDB + PE and PDB + PA at all studied time points in comparison with PDB (control). Especially, after 168 h of culture, PTOX content in the PDB with plant extract reached the peak with 314 µg/g DW which is 10% higher than the best yield of PTOX in previous studies, denoting F. proliferatum TQN5T as a promising PTOX producer. This is the first study on enhancing the PTOX production in endophytic fungi by supplementing phenylalanine-a precursor for PTOX biosynthesis in plants into fermented media, suggesting a common PTOX biosynthetic pathway between host plant and endophytes. KEY POINTS: • Fusarium proliferatum TQN5T was proven for PTOX production. • Both mycelia extract and spent broth extract of Fusarium proliferatum TQN5T presented strong cytotoxicity on cancer cell lines LU-1 and HepG2. • The supplementation of 10 µg/ml host plant extract and phenylalanine into fermentation media of F. proliferatum TQN5T improved the yield of PTOX.

Management of Non-Communicable Diseases in Kosovo: A Scoping Review.

Background-Non-communicable diseases (NCDs) affect a growing share of the population in Kosovo. The country faces challenges with NCDs management, specifically detecting, screening, and treating people with NCDs. Objective-To assess the management of NCDs, including the inputs that influence the provision of NCDs and outcomes of NCD management. Eligibility criteria-Studies had to report NCD management in Kosovo. Sources of evidence-We systematically searched Google Scholar, PubMed, Scopus, and Web of Science. Charting methods-The data were charted by two researchers. We extracted data on general study details and design and information on the management and outcomes of NCDs in Kosovo. Synthesis of results-For the mix of studies that were included in the review, thematic narrative synthesis was used. We developed a conceptual framework based on health production core components to analyze the data. Results-Kosovo's health care system is available to provide basic care for patients with NCDs. However, there are serious limitations in the availability of key inputs providing care, i.e., funding, medicines, supplies, and medical staff. Additionally, in terms of the management of NCDs, there are areas for improvement, such as limited application of clinical pathways and guidelines and issues with referrals of patients among levels and sectors of care. Finally, it is worth noting that there is overall limited information on NCD management and outcomes. Conclusions-Kosovo provides only basic services and treatment of NCDs. The data reporting the existing situation on NCD management are limited. The inputs from this review are helpful for existing policy efforts by the government aimed to enhance NCD care in Kosovo. Funding-This study is part of the research done for a World Bank review of the state of NCDs in Kosovo and was funded through the Access Accelerated Trust Fund (P170638).

Cost-effectiveness of health systems strengthening interventions in improving maternal and child health in low- and middle-income countries: a systematic review.

Health systems strengthening (HSS) interventions are increasingly being implemented to improve maternal and child health (MCH) services in low- and middle-income countries (LMICs). This study reviews global literature on cost-effectiveness of HSS interventions in improving MCH. A systematic review was conducted. Keywords, based on World Health Organization framework on health systems and prior studies, were applied to search in bibliographic databases and on the web. Articles that estimated cost-effectiveness of HSS interventions in LMICs were included in the analysis. Each of the 24 selected studies from 15 countries was assessed in terms of quality and biases using Cochrane's criteria. Review Manager and an Excel template were used to extract data and synthesize findings. HSS interventions concentrated on the components of service delivery, health financing, human resources and quality improvement. Within each component, there existed diverse strategies to strengthen health systems. Among the 24 studies, 15 were rated as high quality, 5 as medium and 4 as low quality. A majority of studies reported cost per disability-adjusted life year (DALY) averted or cost per quality-adjusted life year (QALY) gained; other studies reported cost per life saved or life year gained. However, studies used mixed perspectives of analyses. Compared with gross domestic product per capita, interventions in studies reporting cost per DALY averted or QALY gained were all cost-effective, including performance-based financing, health insurance and quality improvement. This review shows the diversity of HSS interventions in improving MCH, and their potential cost-effectiveness. However, the different perspectives employed in the studies, costing components included in the analyses, and heterogeneous measures of effectiveness and outputs, made it challenging to compare cost-effectiveness across all studies, calling for more and standardized cost-effectiveness studies. For policy making, it is critical to examine long-term cost-effectiveness of programs and cost-effectiveness of synergistic demand- and supply-side interventions.

Incentives to change: effects of performance-based financing on health workers in Zambia.

BACKGROUND: Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers' job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before-after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. METHODS: Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. RESULTS: Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity. CONCLUSIONS: In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.

Getting Incentives Right? The Impact of Hospital Capitation Payment in Vietnam.

This paper evaluates the impact on cost and utilization of a shift from fee-for-service to capitation payment of district hospitals by Vietnam's social health insurance agency. Hospital fixed effects analysis suggests that capitation leads to reduced costs. Hospitals also increased service provision to the uninsured who continue to pay out-of-pocket on a fee-for-service basis. The study points to the need to anticipate unintended effects of payment reforms, especially in the context of a multiple purchaser system. Copyright © The World Bank Health Economics © 2015 John Wiley & Sons, Ltd.

Encouraging Health Insurance for the Informal Sector: A Cluster Randomized Experiment in Vietnam.

Subsidized voluntary enrollment in government-run health insurance schemes is often proposed as a way of increasing coverage among informal sector workers and their families. We report the results of a cluster randomized experiment, in which 3000 households in 20 communes in Vietnam were randomly assigned at baseline to a control group or one of three treatments: an information leaflet about Vietnam's government-run scheme and the benefits of health insurance, a voucher entitling eligible household members to 25% off their annual premium, and both. At baseline, the four groups had similar enrollment rates (4%) and were balanced on plausible enrollment determinants. The interventions all had small and insignificant effects (around 1 percentage point or ppt). Among those reporting sickness in the 12 months prior to the baseline survey the subsidy-only intervention raised enrollment by 3.5 ppts (p = 0.08) while the combined intervention raised enrollment by 4.5 ppts (p = 0.02); however, the differences in the effect sizes between the sick and non-sick were just shy of being significant. Our results suggest that information campaigns and subsidies may have limited effects on voluntary health insurance enrollment in Vietnam and that such interventions might exacerbate adverse selection. Copyright © The World Bank Health Economics © 2015 John Wiley & Sons, Ltd.