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BACKGROUND: Suicide prevention requires diverse, integrated, and evidence-based measures. Comprehensive evaluation of interventions and reliable suicide data are crucial for guiding policy-making and advancing suicide prevention efforts. This study aimed to analyze current issues and gaps in the evaluation of suicide prevention measures and the quality of suicide data in Germany, Austria, and Switzerland to derive specific recommendations for improvement. METHODS: Online, semi-structured interviews were conducted with 36 experts in suicide prevention from Germany, Austria, and Switzerland, covering insights from policy, science, and practice. The interviews took place between September 2022 and February 2023, were audio-recorded, transcribed verbatim, and analyzed using the Framework method. RESULTS: While solid evidence supports the effectiveness of some suicide prevention interventions, experts indicated that the evaluation of many other measures is weak. Conducting effectiveness studies in suicide prevention presents a range of methodological and practical challenges, including recruitment difficulties, choosing adequate outcome criteria, ethical considerations, and trade-offs in allocating resources to evaluation efforts. Many interviewees rated the quality of national suicide statistics in Germany, Austria, and Switzerland as comparatively high. However, they noted limitations in the scope, timeliness, and reliability of these data, prompting some regions to implement their own suicide monitoring systems. None of the three countries has national routine data on suicide attempts. CONCLUSION: While some challenges in evaluating suicide prevention measures are inevitable, others can potentially be mitigated. Evaluations could be enhanced by combining traditional and innovative research designs, including intermediate outcomes and factors concerning the implementation process, and employing participatory and transdisciplinary research to engage different stakeholders. Reliable suicide data are essential for identifying trends, supporting research, and designing targeted prevention measures. To improve the quality of suicide data, a standardized monitoring approach, including uniform definitions, trained professionals, and cross-sector agreement on leadership and financing, should be pursued. This study provides actionable recommendations and highlights existing good practice approaches, thereby supporting decision-makers and providing guidance for advancing suicide prevention on a broader scale.
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Entrevistas como Assunto , Pesquisa Qualitativa , Prevenção do Suicídio , Humanos , Suíça , Áustria , Alemanha , Confiabilidade dos Dados , Suicídio/psicologia , Suicídio/estatística & dados numéricos , Feminino , MasculinoRESUMO
Background: Accurate and timely infectious disease surveillance is pivotal for effective public health responses. An important component of this is the disease surveillance tools used. Understanding views and experiences of users is crucial for informing policy decisions and ensuring the seamless functioning of surveillance systems. Objective: In this study, we aimed to assess the user perceptions of 3 disease surveillance tools used in Côte d'Ivoire, namely, MAGPI, District Health Information Software 2 (DHIS2), and Surveillance Outbreak Response Management and Analysis System (SORMAS), the latter was implemented in 2021 within a pilot scheme. Methods: We conducted interviews and a web-based survey distributed to users of the 3 surveillance tools. The survey assessed users' views of the surveillance tools' usefulness, ease of use, feelings toward the tool, conditions that may influence the use, and other characteristics. The descriptive analysis compared responses from SORMAS, MAGPI, and DHIS2 users, providing a comprehensive evaluation of their experiences. Results: Among the 159 respondents who actively use one of the systems, MAGPI was the most widely used surveillance tool among respondents (n=127, 79.9%), followed by DHIS2 (n=108, 67.9%), and SORMAS (n=25, 15.7%). In terms of users' perceptions, SORMAS, despite its limited implementation, emerged as a tool that allows for data analysis and had the most comprehensive set of functionalities. DHIS2 was appreciated for its frequency of report provision, although users reported occasional IT system failures. MAGPI was recognized for its ease of use but was reported to lack certain functionalities offered by the other surveillance systems. Conclusions: This study offers valuable insights into the perceptions of disease surveillance tools users in Côte d'Ivoire. While all systems were positively regarded, each exhibited strengths and weaknesses addressing different needs and functionalities. Policy makers and health officials can use these findings to enhance existing tools or consider a unified approach for infectious disease surveillance systems. Understanding users' perspectives allows them to optimize the choice of surveillance tools, ultimately strengthening public health responses in Côte d'Ivoire and potentially serving as a model for other countries facing similar decisions in their health care systems.
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Surtos de Doenças , Humanos , Côte d'Ivoire/epidemiologia , Surtos de Doenças/prevenção & controle , Estudos Transversais , Masculino , Feminino , Adulto , Inquéritos e Questionários , Pessoa de Meia-Idade , Vigilância da População/métodos , PercepçãoRESUMO
Introduction: Suicide is a significant public health problem, impacting individuals, families and communities worldwide. Effective suicide prevention requires a comprehensive approach with diverse integrated interventions and collaboration across sectors, stakeholders and professions. This study aims to identify challenges, gaps and success factors in current suicide prevention efforts in Germany, Austria and Switzerland, providing specific recommendations for advancement. Methods: We conducted online, semi-structured interviews with 36 suicide prevention experts from Germany, Austria and Switzerland, incorporating perspectives from policy, science and practice. Interviews were conducted between September 2022 and February 2023, audio-recorded, transcribed verbatim and analyzed using the Framework method. Results: Despite progress in national strategies and coordinated efforts for suicide prevention, challenges such as resource scarcity, stigma and structural issues in psychiatric and psychotherapeutic care persist. The interviewees identified several areas for advancement, including developing targeted prevention measures for men and older people, strengthening collaboration across sectors, stakeholders and professions, and increasing the involvement of individuals with lived experience. While the COVID-19 pandemic has exacerbated challenges in psychiatric and psychotherapeutic care, it has concurrently strengthened interest in suicide prevention among policymakers and the media. Discussion: National suicide prevention strategies play a crucial role in setting priorities, raising public awareness, and guiding action. However, since most suicide prevention efforts are still predominantly health sector-driven, a more comprehensive approach is needed to promote the involvement of all relevant actors and address suicidality as a collective societal responsibility. Tailoring prevention programs for risk groups like older people and men is important, as these populations show high suicide rates and face a lack of targeted interventions. Our study underscores the importance to continuously monitor, refine and strengthen collaborative and evidence-based suicide prevention efforts.
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COVID-19 , Pesquisa Qualitativa , Prevenção do Suicídio , Humanos , Áustria , Suíça , Alemanha , Masculino , Feminino , COVID-19/prevenção & controle , COVID-19/epidemiologia , Adulto , Entrevistas como Assunto , Pessoa de Meia-Idade , Suicídio/estatística & dados numéricos , Suicídio/psicologiaRESUMO
BACKGROUND: The implementation of digital disease surveillance systems at national levels in Africa have been challenged by many factors. These include user applicability, utility of IT features but also stable financial support. Funding closely intertwines with implementations in terms of geographical reach, disease focus, and sustainability. However, the practice of evidence sharing on geographical and disease coverage, costs, and funding sources for improving the implementation of these systems on the continent is unclear. OBJECTIVES: To analyse the key characteristics and availability of evidence for implementing digital infectious disease surveillance systems in Africa namely their disease focus, geographical reach, cost reporting, and external funding support. METHODS: We conducted a systematic review of peer-reviewed and grey literature for the period 2003 to 2022 (PROSPERO registration number: CRD42022300849). We searched five databases (PubMed, MEDLINE over Ovid, EMBASE, Web of Science, and Google Scholar) and websites of WHO, Africa CDC, and public health institutes of African countries. We mapped the distribution of projects by country; identified reported implementation cost components; categorised the availability of data on cost components; and identified supporting funding institutions outside Africa. RESULTS: A total of 29 reports from 2,033 search results were eligible for analysis. We identified 27 projects implemented in 13 countries, across 32 sites. Of these, 24 (75%) were pilot projects with a median duration of 16 months, (IQR: 5-40). Of the 27 projects, 5 (19%) were implemented for HIV/AIDs and tuberculosis, 4 (15%) for malaria, 4 (15%) for all notifiable diseases, and 4 (15%) for One Health. We identified 17 cost components across the 29 reports. Of these, 11 (38%) reported quantified costs for start-up capital, 10 (34%) for health personnel compensation, 9 (31%) for training and capacity building, 8 (28%) for software maintenance, and 7(24%) for surveillance data transmission. Of 65 counts of external funding sources, 35 (54%) were governmental agencies, 15 (23%) foundations, and 7 (11%) UN agencies. CONCLUSIONS: The evidence on costing data for the digitalisation of surveillance and outbreak response in the published literature is sparse in quantity, limited in detail, and without a standardised reporting format. Most initial direct project costs are substantially donor dependent, short lived, and thus unsustainable.
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Doenças Transmissíveis , Humanos , África/epidemiologia , Doenças Transmissíveis/epidemiologia , Doenças Transmissíveis/economia , Vigilância da População/métodosRESUMO
BACKGROUND: Health administrations require evidence, meaning robust information, data, and research, on health services and systems. Little is known about the resources and processes available within administrations to support evidence-informed policymaking. This study assessed Swiss health administrations' capacity for evidence use and investigated civil servants' needs and perspectives regarding the role and use of evidence in health services management and planning. METHODS: In this mixed-method study, we interviewed civil servants from Swiss German-speaking cantonal health administrations. We quantitatively assessed administrations' organization-level capacity by applying six structured interviews using an existing measurement tool (ORACLe). Individual-level needs and perspectives regarding evidence use and capacity were qualitatively explored with twelve in-depth interviews that were analyzed using the framework method. FINDINGS: Respondents indicated moderate evidence-use capacity in all administrations. Administrations displayed a similar pattern of high and low capacity in specific capacity areas, generally with considerable variation within administrations. Most administrations indicated high capacity for producing or commissioning evidence and close relationships with research. They showed limited capacity in the documentation of processes and availability of tools, programs, or training opportunities. Administrations place the responsibility for engagement with evidence at the level of individual civil servants rather than at the organizational level. Although administrations highly value evidence-informed policymaking and consider it vital to effective health services management and planning, they face significant constraints in accessing evidence-specific resources and receive little organizational support. Administrations rely on external capacity to compensate for these limitations and engage with evidence pragmatically. CONCLUSION: Our findings indicate moderate and improvable capacity for evidence use in Swiss health administrations that place limited value on organizational support. Besides strengthening organizational support, leadership buy-in, particular staff needs, and balancing the implementation of specific measures with the provision of more general resources should be considered to unlock the potential of strengthened engagement with evidence.
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Administração de Serviços de Saúde , Suíça , Humanos , Feminino , Entrevistas como Assunto , Masculino , Prática Clínica Baseada em Evidências , Adulto , Pessoa de Meia-Idade , Formulação de PolíticasRESUMO
Effective and sustainable strategies are needed to address the burden of preventable deaths among children under-five in resource-constrained settings. The Tools for Integrated Management of Childhood Illness (TIMCI) project aims to support healthcare providers to identify and manage severe illness, whilst promoting resource stewardship, by introducing pulse oximetry and clinical decision support algorithms (CDSAs) to primary care facilities in India, Kenya, Senegal and Tanzania. Health impact is assessed through: a pragmatic parallel group, superiority cluster randomised controlled trial (RCT), with primary care facilities randomly allocated (1:1) in India to pulse oximetry or control, and (1:1:1) in Tanzania to pulse oximetry plus CDSA, pulse oximetry, or control; and through a quasi-experimental pre-post study in Kenya and Senegal. Devices are implemented with guidance and training, mentorship, and community engagement. Sociodemographic and clinical data are collected from caregivers and records of enrolled sick children aged 0-59 months at study facilities, with phone follow-up on Day 7 (and Day 28 in the RCT). The primary outcomes assessed for the RCT are severe complications (mortality and secondary hospitalisations) by Day 7 and primary hospitalisations (within 24 hours and with referral); and, for the pre-post study, referrals and antibiotic. Secondary outcomes on other aspects of health status, hypoxaemia, referral, follow-up and antimicrobial prescription are also evaluated. In all countries, embedded mixed-method studies further evaluate the effects of the intervention on care and care processes, implementation, cost and cost-effectiveness. Pilot and baseline studies started mid-2021, RCT and post-intervention mid-2022, with anticipated completion mid-2023 and first results late-2023. Study approval has been granted by all relevant institutional review boards, national and WHO ethical review committees. Findings will be shared with communities, healthcare providers, Ministries of Health and other local, national and international stakeholders to facilitate evidence-based decision-making on scale-up.Study registration: NCT04910750 and NCT05065320.
Pulse oximetry and clinical decision support algorithms show potential for supporting healthcare providers to identify and manage severe illness among children under-five attending primary care in resource-constrained settings, whilst promoting resource stewardship but scale-up has been hampered by evidence gaps.This study design article describes the largest scale evaluation of these interventions to date, the results of which will inform country- and global-level policy and planning .
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Algoritmos , Sistemas de Apoio a Decisões Clínicas , Oximetria , Humanos , Lactente , Pré-Escolar , Recém-Nascido , Quênia , Atenção Primária à Saúde/organização & administração , Senegal , Índia , TanzâniaRESUMO
INTRODUCTION: The quality of care for the chronically ill is to be improved through interprofessional cooperation (IPC). To date, evaluation projects on IPC have mostly focused on the inpatient sector. The aim was to use a multiple case study design to investigate forms of IPC in primary care and to identify facilitating and inhibiting factors. Factors that facilitated the implementation of IPC included having a responsible person employed to provide the service, supportive training, and the introduction of evidence-based interventions. There appeared to be insufficient incentives to implement IPC and the needs of the chronically ill were poorly integrated. More systematic evaluation of IPC initiatives is needed to demonstrate their added value. Greater integration of patient needs is key.
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Assistência Ambulatorial , Pacientes Ambulatoriais , Humanos , Suíça , Doença Crônica , Atenção à SaúdeRESUMO
BACKGROUND: The Surveillance Outbreak Response Management and Analysis System (SORMAS) has been implemented for various infectious diseases since 2015. 2020, at the beginning of the COVID-19 pandemic, SORMAS was adapted to SARS-CoV2. METHODS: We assessed the acceptability and usability of SORMAS and accompanied its implementation in two pilot regions of Côte d'Ivoire (Abidjan 2 and Gbêkê) from July/August 2021 to March 2022. We conducted 136 semi-structured interviews to cover knowledge on COVID-19, information on conventional surveillance systems for disease monitoring including COVID-19, acceptability of SORMAS, and impact of SORMAS on epidemic preparedness and surveillance. Scores before and 6-8 months after implementation were compared. RESULTS: SORMAS was implemented in two pilot regions in Côte d'Ivoire. The conventional software for the surveillance of the COVID-19 pandemic by the company MAGPI was maintained in parallel; the additional time needs to enter and manage the data in SORMAS were the main concern. SORMAS acceptance and satisfaction scores were high after the user training, which was prior to implementation, and after 6-8 months of use. The ability of SORMAS to improve COVID-19 preparedness and early detection of cases and contacts was widely acknowledged. To keep the understanding and skills of users up-to-date, regular refresher trainings were requested. The expectation to be able to make decisions based on data produced by SORMAS was high at baseline and the perceived experience after several months of use of the software was very positive. Unfortunately, the link with the laboratories could not be established in the pilot regions, but it is an existing feature of SORMAS that many users were asking for. Following the positive experience using SORMAS for COVID-19, the pilot regions expanded its use for monitoring and management of measles, yellow fever, meningitis, and cholera. CONCLUSION: SORMAS was very well accepted by users and decision makers in the two pilot regions of Côte d'Ivoire and its ability to improve epidemic preparedness and surveillance was acknowledged. If the hurdles of maintenance (tablets, server, and maintaining user skills) are handled sustainably, it can serve as a valid tool to identify, surveil and manage future outbreaks of various infectious diseases in Côte d'Ivoire.
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COVID-19 , Doenças Transmissíveis , Humanos , Côte d'Ivoire/epidemiologia , Pandemias/prevenção & controle , RNA Viral , COVID-19/epidemiologia , SARS-CoV-2 , Doenças Transmissíveis/epidemiologia , Surtos de Doenças/prevenção & controleRESUMO
INTRODUCTION: Approximately 30% of somatic hospital inpatients experience psychosocial distress, contributing to increased (re-)hospitalisation rates, treatment resistance, morbidity, and direct and indirect costs. However, such distress often remains unrecognised and unaddressed. We established 'SomPsyNet', a 'stepped and collaborative care model' (SCCM) for somatic hospital inpatients, aiming at alleviating this issue through early identification of distress and provision of appropriate care, providing problem-focused pathways and strengthening collaborative care. We report the protocol of the 'SomPsyNet' study, aiming to evaluate implementation and impact of the SCCM on distressed patients' health-related quality of life. Secondary objectives include assessing efficacy of the screening procedures, influence of SCCM on other health outcomes and associated costs. METHODS AND ANALYSIS: Our stepped wedge cluster randomised trial conducted at three tertiary hospitals comprises three conditions: treatment as usual (TAU) without screening for distress (phase 0), TAU with screening but without consequences (phase I, main comparator) and TAU with screening and psychosomatic-psychiatric consultations for those distressed (phase II). The time-of-transition between phases I and II was randomised. Sample size target is N=2200-2500 participants, with 6 month follow-up for distressed (anticipated n=640-700) and a subsample of non-distressed (anticipated n=200) patients. Primary outcome is mental health-related quality of life (SF-36 'Mental Health Component Summary score'); secondary outcomes include psychosocial distress, anxiety, depressive and somatic symptoms, symptom burden and distress, resilience, social support and qualitative of life, assessed by internationally accepted instruments, with good psychometric properties. Further, health claims data will be used to assess SCCM's impact on direct and indirect costs. ETHICS AND DISSEMINATION: SomPsyNet adheres to the Helsinki Declaration and is approved by the 'Ethikkommission Nordwest- und Zentralschweiz' (2019-01724). Findings will be published in peer-reviewed journals and communicated to participants, healthcare professionals and the public. TRIAL REGISTRATION NUMBER: Swiss National Clinical Trials Portal; ClinicalTrials.gov (NCT04269005, updated 19.09.2023).
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Pacientes Internados , Qualidade de Vida , Humanos , Saúde Mental , Medição de Risco , Hospitais , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: In the past 2 decades, many countries have recognized the use of electronic systems for disease surveillance and outbreak response as an important strategy for disease control and prevention. In low- and middle-income countries, the adoption of these electronic systems remains a priority and has attracted the support of global health players. However, the successful implementation and institutionalization of electronic systems in low- and middle-income countries have been challenged by the local capacity to absorb technologies, decisiveness and strength of leadership, implementation costs, workforce attitudes toward innovation, and organizational factors. In November 2019, Ghana piloted the Surveillance Outbreak Response Management and Analysis System (SORMAS) for routine surveillance and subsequently used it for the national COVID-19 response. OBJECTIVE: This study aims to identify the facilitators of and barriers to the sustainable implementation and operation of SORMAS in Ghana. METHODS: Between November 2021 and March 2022, we conducted a qualitative study among 22 resource persons representing different stakeholders involved in the implementation of SORMAS in Ghana. We interviewed study participants via telephone using in-depth interview guides developed consistent with the model of diffusion of innovations in health service organizations. We transcribed the interviews verbatim and performed independent validation of transcripts and pseudonymization. We performed deductive coding using 7 a priori categories: innovation, adopting health system, adoption and assimilation, diffusion and dissemination, outer context, institutionalization, and linkages among the aspects of implementation. We used MAXQDA Analytics Pro for transcription, coding, and analysis. RESULTS: The facilitators of SORMAS implementation included its coherent design consistent with the Integrated Disease Surveillance and Response system, adaptability to evolving local needs, relative advantages for task performance (eg, real-time reporting, generation of case-base data, improved data quality, mobile offline capability, and integration of laboratory procedures), intrinsic motivation of users, and a smartphone-savvy workforce. Other facilitators were its alignment with health system goals, dedicated national leadership, political endorsement, availability of in-country IT capacities, and financial and technical support from inventors and international development partners. The main barriers were unstable technical interoperability between SORMAS and existing health information systems, reliance on a private IT company for data hosting, unreliable internet connectivity, unstable national power supply, inadequate numbers and poor quality of data collection devices, and substantial dependence on external funding. CONCLUSIONS: The facilitators of and barriers to SORMAS implementation are multiple and interdependent. Important success conditions for implementation include enhanced scope and efficiency of task performance, strong technical and political stewardship, and a self-motivated workforce. Inadequate funding, limited IT infrastructure, and lack of software development expertise are mutually reinforcing barriers to implementation and progress to country ownership. Some barriers are external, relate to the overall national infrastructural development, and are not amenable even to unlimited project funding.
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With the COVID-19 pandemic, the notion of health system (HS) performance has been discussed, and the notion of resilience has become increasingly important. Lacking a recognised framework that measures the performance of HSs throughout a crisis, i.e., one that explicitly includes time as a key aspect, we examined the literature about conceptual frameworks for measuring the performance and the resilience of HSs. This review highlighted a significant diversity among 18 distinct HS performance frameworks and 13 distinct HS resilience frameworks. On this basis, we developed a model that integrates the WHO's widely recognised six building block framework in a novel approach derived from the European Observatory on HSs and Policies. The resulting framework adapts the building blocks to the different stages of a crisis, thereby allowing for a comprehensive assessment of an entire health system's performance throughout the crisis's duration, while also considering the key aspect of resilience. For a more pragmatic use of this framework in the future, indicators will be developed as a next step.
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COVID-19 , Humanos , COVID-19/epidemiologia , Pandemias , Programas Governamentais , Assistência Médica , PolíticasRESUMO
BACKGROUND: Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland. METHODS: We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding. RESULTS: Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment. CONCLUSIONS: Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time.
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Etnicidade , Hospitais Gerais , Humanos , Suíça , Testes de Coagulação Sanguínea , Pessoal de SaúdeRESUMO
INTRODUCTION: Although well-performing workforce is essential to equitable and efficient health service delivery, few countries have systematically addressed performance improvements. How health workers use their work time and what tasks they accomplish is here an important starting point. Therefore, a time motion study was conducted to assess the work time allocation patterns of primary health care doctors and nurses in two regions of Albania. METHODS: We used observation tool to record the time allocation along eight predefined main categories of activities. Conditional to presence at work, 48 health workers were continuously observed in early 2020 before start of the Covid-19 pandemic over five consecutive working days. RESULTS: The observed health workers spent 40.7% of their overall working time unproductively (36.8% on waiting for patients and 3.9% on breaks), 25.3% on service provision to users, 18.7% on administrative activities, 12.7% on outreach activities, 1.6% on continuous medical education and 1% on meetings. The study found variations in work time allocation patterns across cadres, with nurses spending more time unproductively, on administrative activities and on outreach and less on all other activities than doctors. Further, the work time allocation patterns were similar between urban and rural settings, except for nurses in rural settings spending less time than those in urban settings on administrative work. CONCLUSION: This study found that primary health care workers in Albania devote a substantial amount of work time to unproductive, service provision to users and administrative activities. Consequently, there is possibility for productivity, respectively efficiency gains in how health workers use their time.
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COVID-19 , Pandemias , Humanos , Albânia , COVID-19/epidemiologia , Mão de Obra em Saúde , Atenção Primária à SaúdeRESUMO
OBJECTIVE: The financial burden from noncommunicable diseases (NCDs) is a threat worldwide, alleviated only when good social protection schemes are in place. Albeit the Government in Albania has committed to Universal Healthcare Coverage (UHC), Out-of-Pockets (OOPs) persist. Through this study, we aimed to assess the OOPs related to consultations, diagnostic tests, and medicine prescriptions as self-reported by people suffering from NCDs. METHODS: A household survey was conducted in two regions of Albania. The present analysis includes respondents who suffered from chronic health conditions and consulted a health care provider within the last 8 weeks (n = 898). Mixed logistic regression models with random intercepts at the level of communities were employed in order to assess the association of OOPs with age, gender, urban vs. rural residency, health insurance, marital status, barriers experienced, type of chronic condition(s) and region. RESULTS: Of those who consulted a provider, 95% also received a drug prescription. Among them, 94% were able to obtain all the drugs prescribed. Out-of-pocket payments occurred throughout the NCD treatment process; specifically, for consultation (36%), diagnostic tests (33%), and drugs purchased (88%). Drug expenditures accounted for 62% of all household expenditures. Respondents with health insurance were less likely to pay for consultation and drugs. The elderly (patients above 60 years old) were less likely to pay for consultations and tests. Those who lived in urban areas were less likely to pay for drugs and consultations. Patients encountering any form of barrier when seeking care had increased odds of OOPs for consultations (OR; 2.25 95%-CI; 1.57; 3.23) and tests (OR; 1.71 95%-CI; 1.19; 2.45). CONCLUSION: Out-of-pocket payments by NCD patients principally made up through the purchase of prescribed drugs, remain important. Tackling the high costs of drugs will be important to accelerate the UHC agenda. Here, it is important to raise the population's awareness on patients' knowledge of their entitlements to health insurance, and on the current health reforms.
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Gastos em Saúde , Doenças não Transmissíveis , Idoso , Albânia , Doença Crônica , Características da Família , Humanos , Pessoa de Meia-Idade , Cobertura Universal do Seguro de SaúdeRESUMO
BACKGROUND: Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale's theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature. METHODS: The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based. RESULTS: The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies. CONCLUSIONS: PERFORM2Scale's experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.
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Necessidades e Demandas de Serviços de Saúde , Comunicação Interdisciplinar , Europa (Continente) , Gana , Humanos , Malaui , UgandaRESUMO
Background: The coronavirus disease 2019 (COVID-19) pandemic and related countermeasures hinder health care access and affect mental wellbeing of non-COVID-19 patients. There is lack of evidence on distress and mental health of patients hospitalized due to other reasons than COVID-19-a vulnerable population group in two ways: First, given their risk for physical diseases, they are at increased risk for severe courses and death related to COVID-19. Second, they may struggle particularly with COVID-19 restrictions due to their dependence on social support. Therefore, we investigated the association of intensity of COVID-19 restrictions with levels of COVID-19-related distress, mental health (depression, anxiety, somatic symptom disorder, and mental quality of life), and perceived social support among Swiss general hospital non-COVID-19 inpatients. Methods: We analyzed distress of 873 hospital inpatients not admitted for COVID-19, recruited from internal medicine, gynecology, rheumatology, rehabilitation, acute geriatrics, and geriatric rehabilitation wards of three hospitals. We assessed distress due to the COVID-19 pandemic, and four indicators of mental health: depressive and anxiety symptom severity, psychological distress associated with somatic symptoms, and the mental component of health-related quality of life; additionally, we assessed social support. The data collection period was divided into modest (June 9 to October 18, 2020) and strong (October 19, 2020, to April 17, 2021) COVID-19 restrictions, based on the Oxford Stringency Index for Switzerland. Results: An additional 13% (95%-Confidence Interval 4-21%) and 9% (1-16%) of hospital inpatients reported distress related to leisure time and loneliness, respectively, during strong COVID-19 restrictions compared to times of modest restrictions. There was no evidence for changes in mental health or social support. Conclusions: Focusing on the vulnerable population of general hospital inpatients not admitted for COVID-19, our results suggest that tightening of COVID-19 restrictions in October 2020 was associated with increased COVID-19-related distress regarding leisure time and loneliness, with no evidence for a related decrease in mental health. If this association was causal, safe measures to increase social interaction (e.g., virtual encounters and outdoor activities) are highly warranted. Trial registration: www.ClinicalTrials.gov, identifier: NCT04269005.
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BACKGROUND: Resilience has become relevant than ever before with the advent of increasing and intensifying shocks on the health system and its amplified effects due to globalization. Using the example of non-state actors based in Switzerland, the aim of this study is to explore how and to what extent NGOs with an interest in global health have dealt with unexpected shocks on the health systems of their partner countries and to reflect on the practical implications of resilience for the multiple actors involved. Consequently, this paper analyses the key attributes of resilience that targeted investments may influence, and the different roles key stakeholders may assume to build resilience. METHODS: This is a descriptive and exploratory qualitative study analysing the perspectives on health system resilience of Swiss-based NGOs through 20 in-depth interviews. Analysis proceeded using a data-driven thematic analysis closely following the framework method. An analytical framework was developed and applied systematically resulting in a complete framework matrix. The results are categorised into the expected role of the governments, the role of the NGOs, and practical future steps for building health system resilience. RESULTS: The following four key 'foundations of resilience' were found to be dominant for unleashing greater resilience attributes regardless of the nature of shocks: 'realigned relationships,' 'foresight,' 'motivation,' and 'emergency preparedness.' The attribute to 'integrate' was shown to be one of the most crucial characteristics of resilience expected of the national governments from the NGOs, which points to the heightened role of governance. Meanwhile, as a key stakeholder group that is becoming inevitably more powerful in international development cooperation and global health governance, non-state actors namely the NGOs saw themselves in a unique position to facilitate knowledge exchange and to support long-term adaptations of innovative solutions that are increasing in demand. The strongest determinant of resilience in the health system was the degree of investments made for building long-term infrastructures and human resource development which are well-functioning prior to any potential crisis. CONCLUSIONS: Health system resilience is a collective endeavour and a result of many stakeholders' consistent and targeted investments. These investments open up new opportunities to seek innovative solutions and to keep diverse actors in global health accountable. The experiences and perspectives of Swiss NGOs in this article highlight the vital role NGOs may play in building resilient health systems in their partner countries. Specifically, strong governance, a bi-directional knowledge exchange, and the focus on leveraging science for impact can draw greater potential of resilience in the health systems. Governments and the NGOs have unique points of contribution in this journey towards resilience and bear the responsibility to support governments to prioritise investing in the key 'foundations of resilience' in order to activate greater attributes of resilience. Resilience building will not only prepare countries for future shocks but bridge the disparate health and development agenda in order to better address the nexus between humanitarian aid and development cooperation.
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Programas Governamentais , Assistência Médica , Saúde Global , Humanos , Cooperação Internacional , SuíçaRESUMO
BACKGROUND: A country's health system faces pressure when hit by an unexpected shock, such as what we observe in the midst of the coronavirus disease 2019 (COVID-19) pandemic. The concept of resilience is highly relevant in this context and is a prerequisite for a health system capable of withstanding future shocks. By exploring how the key dimensions of the resilient health system framework are applied, the present systematic review synthesizes the vital features of resilient health systems in low- and middle-income countries. The aim of this review is to ascertain the relevance of health system resilience in the context of a major shock, through better understanding its dimensions, uses and implications. METHODS: The review uses the best-fit framework synthesis approach. An a priori conceptual framework was selected and a coding framework created. A systematic search identified 4284 unique citations from electronic databases and reports by non-governmental organisations, 12 of which met the inclusion criteria. Data were extracted and coded against the pre-existing themes. Themes outside of the a priori framework were collated to form a refined list of themes. Then, all twelve studies were revisited using the new list of themes in the context of each study. RESULTS: Ten themes were generated from the analysis. Five confirmed the a priori conceptual framework that capture the dynamic attributes of a resilient system. Five new themes were identified as foundational for achieving resilience: realigned relationships, foresight and motivation as drivers, and emergency preparedness and change management as organisational mechanisms. CONCLUSION: The refined conceptual model shows how the themes inter-connect. The foundations of resilience appear to be critical especially in resource-constrained settings to unlock the dynamic attributes of resilience. This review prompts countries to consider building the foundations of resilience described here as a priority to better prepare for future shocks.
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COVID-19 , Humanos , Países em Desenvolvimento , Programas Governamentais , PandemiasRESUMO
OBJECTIVE: The aim of this study is to improve the understanding of the characteristics of health system resilience in Myanmar's response to Cyclone Nargis and to explore ways to improve resilience at the system level. DESIGN AND SETTING: This is an explanatory qualitative study exploring the institutional capacity of resilience in Myanmar's health system. Analysis proceeded using a data-driven thematic analysis closely following the framework method. This process enabled comparisons and contrasts of key emergent themes between the participants, which later generated key results describing the foundational assets, barriers and opportunities for achieving resilience in Myanmar. PARTICIPANTS: The study comprised of 12 in-depth interviews conducted with representatives from international organisations and non-governmental organisations (NGOs). The inclusion criteria to recruiting the participants were that they had directly been a part of the Cyclone Nargis response at the time. There was a balanced distribution of participants across UN, bilateral and NGOs, and most of them were either Myanmar citizens or expatriates with extensive working experience based in Myanmar. RESULTS: Key findings elucidate the characteristics of resilience that have been salient or absent in Myanmar's response to Cyclone Nargis. Strong social capital and motivation propelled by its deep-rooted culture and religion served as Myanmar's greatest assets that filled major gaps in the system. Meanwhile, its postcolonial and military legacy posed barriers towards investing in building its long-term foundations towards resilience. CONCLUSIONS: This study revealed that resilience in the health system can be built through strategic investments towards building the foundations of resilience to better prepare for future shocks. In the case of Myanmar, social capital and motivation, which surfaced as its foundational assets, can be channelled into opportunities that can help achieve its long-term health goals, accelerating its journey towards resilience in the health system.