Simulation training on respectful emergency obstetric and neonatal care in north-western Madagascar: a mixed-methods evaluation of an innovative training program.

BACKGROUND: The rates of maternal and neonatal deaths in Madagascar are among the highest in the world. In response to a request for additional training from obstetrical care providers at the Ambanja district hospital in north-eastern Madagascar, a partnership of institutions in Switzerland and Madagascar conducted innovative training on respectful emergency obstetric and newborn care using e-learning and simulation methodologies. The training focused on six topics: pre-eclampsia, physiological childbirth, obstetric maneuvers, postpartum hemorrhage, maternal sepsis, and newborn resuscitation. Cross-cutting themes were interprofessional communication and respectful patient care. Ten experienced trainers participated in an e-training-of-trainers course conducted by the Swiss partners. The newly-trained trainers and Swiss partners then jointly conducted the hybrid remote/in-person training for 11 obstetrical care providers in Ambanja. METHODS: A mixed methods evaluation was conducted of the impact of the training on participants' knowledge and practices. Trainees' knowledge was tested before, immediately after, and 6 months after the training. Focus group discussions were conducted to elicit participants' opinions about the training, including the content and pedagogical methods. RESULTS: Trainees' knowledge of the six topics was higher at 6 months (with an average of 71% correct answers) compared to before the training (62%), although it was even higher (83%) immediately after the training. During the focus group discussions, participants highlighted their positive impressions of the training, including its impact on their sense of professional effectiveness. They reported that their interprofessional relationships and focus on respectful care had improved. Simulation, which was a new methodology for the participants native to Madagascar, was appreciated for its engaging and active format, and they enjoyed the hybrid delivery of the training. Participants (including the trainers) expressed a desire for follow-up engagement, including additional training, and improved access to more equipment. CONCLUSION: The evaluation showed improvements in trainees' knowledge and capacity to provide respectful emergency care to pregnant women and newborns across all training topics. The hybrid simulation-based training method elicited strong enthusiasm. Significant opportunity exists to expand the use of hybrid onsite/remote simulation-based training to improve obstetrical care and health outcomes for women and newborns in Madagascar and elsewhere.

Politics and Policies of Health Systems: Reflections on 50 Years of Observing Protests, Leaders, and Political Analysis.

This commentary presents reflections on my work over the past five decades related to the politics and policies of health systems from various perspectives. The essay is based on a plenary lecture at the Seventh Global Symposium on Health Systems Research in Bogotá, Colombia, in November 2022. The commentary examines a central concern in many of my writings-and a persistent challenge for people working to improve public health: How can the powerless influence policy? Using examples drawn from my past writings, I discuss three broad themes related to this question: the role of social protest movements, the impact of political leadership, and the relevance of political analysis. These reflections are offered in the hope of expanding the use of applied political analysis in public health, and thus contributing to improved health and health equity in the world.

Comprehensive Assessment of Health System Performance in Odisha, India.

India has recently implemented several major health care reforms at national and state levels, yet the nation continues to face significant challenges in achieving better health system performance. These challenges are particularly daunting in India's poorer states, like Odisha. The first step toward overcoming these challenges is to understand their root causes. Toward this end, the Harvard T.H. Chan School of Public Health conducted a comprehensive study in Odisha based on ten new field surveys of the system's performance to provide a multi-perspective analysis. This article reports on the assessment of the performance of Odisha's health system and the preliminary diagnosis of underlying causes of the strengths and challenges. This comprehensive health system assessment is aimed toward the overarching goals of informing and supporting efforts to improve the performance of health systems in Odisha and other similar contexts.

Challenges of Guaranteeing Access to Medicines in Mexico: Lessons from Recent Changes in Pharmaceuticals Procurement.

During the last two decades, Mexico adopted policies intended to increase the efficiency and effectiveness of medicines procurement in its nationally fragmented health system. In this policy report, we review Mexico's efforts to guarantee access to medicines during three national administrations (from 2000 to 2018), and then examine major health system changes introduced by the current government (2018-2024), which have created significant setbacks in guaranteeing access to medicines in Mexico. These recent changes are having important consequences in the levels of satisfaction of health care users and citizens, household expenditure on health, and health conditions. We suggest key lessons for Mexico and other countries seeking to improve pharmaceutical procurement as part of guaranteeing access to medicines.

Reduction in the Treatment Gap for Breast Cancer in Mexico under Seguro Popular, 2007 to 2016.

As Mexico's government restructures the health system, a comprehensive assessment of Seguro Popular's Fund for Protection against Catastrophic Expenses (FPGC) can help inform decision makers to improve breast cancer outcomes and health system performance. This study aimed to estimate the treatment gap for breast cancer patients treated under FPGC and assess changes in this gap between 2007 (when coverage started for breast cancer treatment) and 2016. We used a nationwide administrative claims database for patients whose breast cancer treatment was financed by FPGC in this period (56,847 women), Global Burden of Disease breast cancer incidence estimates, and other databases to estimate the population not covered by social security. We compared the observed number of patients who received treatment under FPGC to the expected number of breast cancer cases among women not covered by social security to estimate the treatment gap. Nationwide, the treatment gap was reduced by more than half: from 0.71, 95% CI (0.69, 0.73) in 2007 to 0.15, 95%CI (0.09, 0.22) in 2016. Reductions were observed across all states . This is the first study to assess the treatment gap for breast cancer patients covered under Seguro Popular. Expanded financing through FPGC sharply increased access to treatment for breast cancer. This was an important step toward improving breast cancer care, but high mortality remains a problem in Mexico. Increased access to treatment needs to be coupled with effective interventions to assure earlier cancer diagnosis and earlier initiation of high-quality treatment.

Pharmaceutical services in public hospitals in Mexico: a cross-sectional study.

OBJECTIVE: To describe the provision of pharmaceutical services within Ministry of Health hospitals in Mexico and identify the main factors that affect their implementation. METHODS: Between November 2018 and April 2019, we conducted telephone interviews with the heads of pharmacy departments of 413 state and federal Ministry of Health hospitals in Mexico. Responses were analyzed with descriptive and inferential statistics to determine the main factors influencing the implementation of pharmaceutical services within these public hospitals. KEY FINDINGS: Of the 413 hospitals, a total of 96 hospitals in 27 states reported the provision of at least one pharmaceutical service. The most frequently reported services were: patient education on the correct use of medications (23%), provision of information to other health professionals on the rational use of medications (21%), and participation in the hospital´s pharmacovigilance system (19%). The main factors associated with the implementation of HPS were the number of pharmacists (46%, n = 215, p=0.001) and the pharmaceutical- or health sciences-oriented education of the head of the pharmacy department of the hospital (46%, n = 215, P = 0.001). CONCLUSIONS: Hiring more pharmacists and ensuring the appropriate professional education of the head of the pharmacy department are key factors to expanding the implementation of pharmaceutical services in Mexico's public hospitals.

[Telemedicine in maternal health in times of COVID-19: Five national and international projects]. / Télémédecine en santé maternelle en temps de Covid-19 : cinq projets internationaux et nationaux.

Telemedicine in maternal health consists on the use of remote communication to reach, diagnose, treat and follow up patients in the context of pre and post-natal care. Covid-19 has accelerated the use of telemedicine. In the Obstetrics Division of HUG we have developed five projects in Geneva and in low-resource zones of the world with the objective of improving access and quality of care. Based on our experience, the application of telemedicine to maternal health problems has shown three major advantages: improved access to care, standardized procedures and accelerated speed of intervention. However, to be effective, telemedicine requires a health staff with a good level of medical and computer skills as well as fluid communication among all participants and constant follow-up of the information flow.

La télémédecine en santé maternelle consiste à l'utilisation des moyens de communication à distance pour rejoindre, diagnostiquer, traiter et suivre les patientes dans le contexte des soins pré-, per- et postnatals. Le Covid-19 a accéléré l'utilisation de la télémédecine. Dans le Service d'obstétrique des HUG, nous avons développé cinq projets à Genève et dans des régions défavorisées du monde, avec l'objectif d'améliorer l'accès et la qualité des soins. Basée sur notre expérience, l'application de la télémédecine aux problèmes de santé maternelle présente trois avantages essentiels: la facilitation de l'accès aux soins, la standardisation des procédures et la vitesse d'intervention. Mais pour être efficace, elle présuppose un bon niveau de compétence médicale et informatique du staff sanitaire, une communication fluide entre les différents intervenants et un contrôle constant du flux d'informations.

Access to HPV vaccination in Japan: Increasing social trust to regain vaccine confidence.

Vaccine hesitancy is a growing concern in global public health, and illustrates serious problems arising from loss of social trust. Japan is experiencing a human papillomavirus (HPV) vaccine crisis that started with a rapid decline in the vaccination rate in 2013 from approximately 70% to less than 1% and lasting for 7 years. We analyze Japan's case of vaccine hesitancy for HPV vaccine, using a framework for examining barriers to access and use of health technologies according to four categories: architecture, availability, affordability, and adoption. Significant problems were identified in the architecture of the decision-making body, public information availability, adoption of evidence in policy-making process, knowledge and confidence among providers, education to the public, and communication with end-users. We propose a series of actions to address these barriers. The national government should diversify the advisory committee to include broader scientific evidence and various viewpoints. Municipalities should actively distribute information cooperating with local providers. Professional associations should create an alliance to influence policy makers and deliver education to health care providers and end-users. Politicians should integrate opinions from citizens and scientists to implement an up-to-date policy. Civil society should share individual stories from cervical cancer patients and positive experiences of vaccinated girls. Mass media should use more diverse sources of information to report more comprehensive and science-based views. These actions would help build mutual trust among stakeholders, which is required to increase social trust in the HPV vaccine in Japan and thereby regain vaccine confidence and reduce preventable deaths and complications.

Acute Lymphoblastic Leukaemia Survival in Children Covered by Seguro Popular in Mexico: A National Comprehensive Analysis 2005-2017.

The aim of the study was to measure survival of children with acute lymphoblastic leukemia (ALL) under Mexico's public health insurance for the population treated under Seguro Popular. A retrospective cohort study using claims data from Mexico's Seguro Popular program, covering cancer treatment from 2005 to 2015 was conducted. Overall 5-year national and state-specific survival for children with ALL across Mexico who initiated cancer treatment under this program was estimated. From 2005 to 2015, 8,977 children with ALL initiated treatment under Seguro Popular. Under this financing scheme, the annual number of treated children doubled from 535 in 2005 to 1,070 in 2015. The estimates for 5-year overall survival of 61.8% (95%CI 60.8, 62.9) remained constant over time. We observed wide gaps in risk-standardized 5-year overall survival among states ranging from 74.7% to 43.7%. We found a higher risk of mortality for children who received treatment in a non-pediatric specialty hospital (Hazards Ratio, HR = 1.18; 95%CI 1.09, 1.26), facilities without a pediatric oncology/hematology specialist (HR = 2.17; 95%CI 1.62, 2.90), and hospitals with low patient volume (HR = 1.22; 95%CI 1.13, 1.32). In a decade Mexico's Seguro Popular doubled access to ALL treatment for covered children and by 2015 financed the vast majority of estimated ALL cases for that population. While some progress in ALL survival may have been achieved, nationwide 5-year overall survival did not improve over time and did not achieve levels found in comparable countries. Our results provide lessons for Mexico's evolving health system and for countries moving toward universal health coverage.

The implementation of pharmaceutical services in public hospitals in Mexico: an analysis of the legal framework and organizational practice.

BACKGROUND: The implementation of pharmaceutical services in hospitals contributes to the appropriate use of medicines and patient safety. However, the relationship of implementation with the legal framework and organizational practice has not been studied in depth. The objective of this research is to determine the role of these two factors (the legal framework and organizational practice) in the implementation of pharmaceutical services in public hospitals of the Ministry of Health of Mexico. METHODS: Semi-structured interviews were conducted with four groups of actors involved. The analysis focused on the legal framework, defined as the rules, laws and regulations, and on organizational practice, defined as the implementation of the legal framework by related individuals, that is, how they put it into practice. RESULTS: The main problems identified were the lack of alignment between the rules and the incentives for compliance. Decision-makers identified the lack of managerial capacity in hospitals as the main implementation barrier, while hospital pharmacists pointed to poor regulation and the lack of clarity of the legal framework as the problems to consider. CONCLUSIONS: Although the legal framework related to hospital pharmaceutical services in Mexico is inadequate, organizational factors (such as adequate skills of professional pharmacists and the support of the hospital director) have facilitated gradual implementation. To improve implementation, priority should be given to evaluation and modification of the current legislation along with the development of an official minimum standard for activities and services in hospital pharmacies.

Guidelines for Pregnancy Management During the COVID-19 Pandemic: A Public Health Conundrum.

Pregnant women seem to be at risk for developing complications from COVID-19. Given the limited knowledge about the impact of COVID-19 on pregnancy, management guidelines are fundamental. Our aim was to examine the obstetrics guidelines released from December 2019 to April 2020 to compare their recommendations and to assess how useful they could be to maternal health workers. We reviewed 11 guidelines on obstetrics management, assessing four domains: (1) timeliness: the time between the declaration of pandemics by WHO and a guideline release and update; (2) accessibility: the readiness to access a guideline by searching it on a common browser; (3) completeness: the amount of foundational topics covered; and (4) consistency: the agreement among different guidelines. In terms of timeliness, the Royal College of Obstetricians and Gynaecologists (RCOG) was the first organization to release their recommendation. Only four guidelines were accessible with one click, while only 6/11 guidelines covered more than 80% of the 30 foundational topics we identified. For consistency, the study highlights the existence of 10 points of conflict among the recommendations. The present research revealed a lack of uniformity and consistency, resulting in potentially challenging decisions for healthcare providers.

Pandemic Governance in Japan and the United States: The Control-Tower Metaphor.

A comparative assessment of pandemic governance in Japan and the United States helps explain the strikingly different shapes of the Covid-19 pandemic in these two countries. Japan has more successfully managed the pandemic compared to the striking failure of the US response. This paper uses the metaphor of the control tower of an airport to examine four aspects of pandemic governance: (1) the culture of the control tower, showing strikingly different cultures of mask-wearing; (2) the social value context of the control tower, reflecting a greater tendency in Japan for people to follow government advice, compared to the US libertarian values of emphasizing personal liberty and disregarding official advice; (3) the role of national leadership, especially who is sitting in the control tower making decisions, with Prime Minister Abe largely taking responsibility while President Trump effectively left decisions up to markets and individual states; and (4) the use and clarity of information provided by control-tower authorities, showing greater clarity and consistency in Japan compared to the confused and contradictory messages in the US. These differences in control-tower governance have had marked effects on the pandemic responses of the two countries and have important implications for sustaining democratic traditions.

Improving the Quality of Antenatal Care Using Mobile Health in Madagascar: Five-Year Cross-Sectional Study.

BACKGROUND: Despite many efforts, maternal mortality remains a major burden in most developing countries. Mobile health (mHealth) has the potential to improve access to obstetric care through apps that help patients and providers. OBJECTIVE: This study aimed to use mHealth to provide antenatal care (ANC) to 1446 pregnant women in a rural area in Madagascar and evaluate the quality of ANC provided by an mHealth system designed to change the behaviors of providers and patients. METHODS: We included 1446 women who attended ANC visits in rural Madagascar from 2015 to 2019 using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). This cross-sectional study used data from different participants, with information collected over several years, to analyze the outputs related to the quality of ANC over time. Specifically, we examined the timing of the first ANC visit, the relationship between the visit duration and the risk factors among pregnant women, and the number of ANC visits per woman. RESULTS: Following the implementation of the mHealth system in 2015, we observed that women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years (P<.001). In 2019, fewer women attended their first ANC visit in the third trimester (57/277, 20.6%) than in 2015 (147/343, 42.9%). There were statistically significant associations between the ANC visit durations and the risk factors, including age (>35 years; 25.0 min, 95% CI 24.0-25.9), educational level (longer visit for women with lower than primary education and for women who attended university and shorter for women with primary school-level education; 40.7 min, 95% CI 30.2-51.3 and 25.3 min, 95% CI 24.4-26.3 vs 23.3 min, 95% CI 22.9-23.8; P=.001), experience of domestic violence during pregnancy, gravidity, parity, infectious diseases (HIV, malaria, and syphilis), and level of anemia. Statistically significant associations were observed for all quality indicator variables. We observed a statistically significant increase in the number of ANC visits per woman over time from 2015 to 2017; the number of ANC visits per woman then became stable after the third year of implementing the PANDA mHealth system. CONCLUSIONS: This study shows the potential of an mHealth system to improve the quality of ANC, change provider behavior by standardizing ANC visits, and change patient behavior by increasing the willingness to return for subsequent visits and encouraging ANC attendance early in pregnancy. As this is an exploratory study, further studies are necessary to better understand how mHealth can change behavior and identify the conditions required for behavioral changes to persist over time.

Access to Chagas disease treatment in the United States after the regulatory approval of benznidazole.

Approximately 300,000 persons in the United States (US) are infected with Trypanosoma cruzi, the protozoan that causes Chagas disease, but less than 1% are estimated to have received antiparasitic treatment. Benznidazole was approved by the US Food and Drug Administration (FDA) for treatment of T. cruzi infection in 2017 and commercialized in May 2018. This paper analyzes factors that affect access to benznidazole following commercialization and suggests directions for future actions to expand access. We applied an access framework to identify barriers, facilitators, and key actors that influence the ability of people with Chagas disease to receive appropriate treatment with benznidazole. Data were collected from the published literature, key informants, and commercial databases. We found that the mean number of persons who obtained benznidazole increased from just under 5 when distributed by the CDC to 13 per month after the commercial launch (from May 2018 to February 2019). Nine key barriers to access were identified: lack of multi-sector coordination, failure of health care providers to use a specific order form, lack of an emergency delivery system, high medical costs for uninsured patients, narrow indications for use of benznidazole, lack of treatment guidelines, limited number of qualified treaters, difficulties for patients to make medical appointments, and inadequate evaluation by providers to determine eligibility for treatment. Our analysis shows that access to benznidazole is still limited after FDA approval. We suggest six areas for strategic action for the pharmaceutical company that markets benznidazole and its allied private foundation to expand access to benznidazole in the US. In addition, we recommend expanding the existing researcher-clinician network by including government agencies, companies and others. This paper's approach could be applied to access programs for benznidazole in other countries or for other health products that target neglected populations throughout the world.

Restructuring Health Reform, Mexican Style.

Mexico's health system is undergoing major restructuring by the administration of President Andrés Manuel López Obrador (known as AMLO) starting in December 2018. The government has eliminated the 2003 health reform (Seguro Popular) from national laws and government agencies and is returning Mexico to a centralized health system with integrated public financing and delivery and reduced private participation. This article looks at the political drivers of Mexico's restructuring reform. Three main ethical principles are identified as the foundation for the government's health system vision: universality, free services, and anti-corruption. The article then compares what existed under Seguro Popular with the new system under the Instituto de Salud para el Bienestar (INSABI), which began on 1 January 2020. The analysis uses the five policy levers that shape health system performance: financing, payment, organization, regulation, and persuasion. The article concludes with five lessons about the reform process in Mexico. First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government's restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization.

The Politics of Taxes for Health: An Analysis of the Passage of the Sugar-Sweetened Beverage Tax in Mexico.

This article explores the politics of passage of the sugar-sweetened beverage (SSB) tax in Mexico, using published documents, media articles, and interviews with key stakeholders. The article examines first the period of agenda setting when the tax was included in the President's fiscal reform package; and second, the period of legislative passage, when the bill was introduced in Congress and was passed. The analysis uses Kingdon's three streams theory of agenda setting, to explain how the tax emerged on the agenda and how agenda setting shaped and enabled legislative passage. The article offers five lessons related to the politics of passing the SSB tax in Mexico. First, passing an SSB tax was difficult and required high-level organization, cooperation, planning, and effort. Second, supporters needed an understanding of how to manage the political and economic context, facilitated by a grant from Bloomberg Philanthropies. Third, framing the tax as generating revenue helped get the proposal onto the policy agenda and enabled buy-in from the powerful Ministry of Finance (Hacienda). Fourth, forming networks within the legislature early on allowed tax proponents to have a network of allies within Congress ready when the SSB tax was introduced as a bill. Finally, early public relations campaigns helped shape public perception that Mexico's obesity epidemic was driven in part by SSB consumption. This is the first paper that uses political science theory and primary data collection and interviews with a broad range of stakeholders, to explain how Mexico passed an SSB tax despite opposition from a strong national SSB industry.