Previne brasil e financiamento da atenção primária: facilidades e dificuldades de gestores municipais de saúde / Previne Brasil and primary care financing: facilities and difficulties for municipal health managers / Previne Brasil y financiamiento de la atención primaria: facilidades y dificultades para los gestores municipales de salud

Objetivo: compreender as facilidades e dificuldades enfrentadas por gestores municipais de saúde com o novo modelo de financiamento da Atenção Primária à Saúde. Método: estudo qualitativo, tipo Pesquisa Convergente Assistencial, fundamentado na Política Nacional de Atenção Básica. Participaram 77 gestores ou seus representantes, de 47 municípios de uma Macrorregião de saúde de Santa Catarina, Brasil. Foram realizadas três oficinas nas Gerências Regionais de Saúde, em agosto e setembro de 2022. Os dados foram analisados pela análise de conteúdo. Resultados: apresentam-se como facilidades do Previne Brasil informatização, comprometimento dos profissionais, e qualificação do cuidado. Foram descritas como dificuldades falta de informações, sistema informatizado e denominador estimado e, equipe de trabalho. Conclusão: o programa apresenta facilidades que qualificam o processo de trabalho e cuidado à saúde da população. Contudo, persistem dificuldades que devem ser consideradas pela gestão municipal para avanços na atenção integral e no financiamento da Atenção Primária à Saúde.

Objective: understand the facilities and difficulties faced by municipal health managers with the new Primary Health Care financing model. Method: this is a qualitative study, of the Convergent Care Research type, based on the National Primary Care Policy. The participants were 77 managers or their representatives from 47 municipalities in a health Macroregion in Santa Catarina, Brazil. Three workshops were held in the Regional Health Departments in August and September 2022. The data was analyzed using content analysis. Results: Previne Brasil's facilities include computerization, commitment of professionals, and qualification of care. Difficulties were described as lack of information, computerized system and estimated denominator, and work team. Conclusion: the program offers facilities that improve the work process and health care for the population. However, there are still difficulties that must be considered by municipal management in order to make progress in comprehensive care and Primary Health Care financing.

Objetivo: comprender las facilidades y dificultades que enfrentan los gestores municipales de salud con el nuevo modelo de financiamiento de la Atención Primaria de Salud. Método: estudio cualitativo, tipo Investigación Convergente Asistencial, basado en la Política Nacional de Atención Primaria. Participaron 77 gestores o sus representantes, de 47 municipios de una Macrorregión de salud de Santa Catarina, Brasil. Se realizaron tres talleres en las Gerencias Regionales de Salud, en agosto y septiembre de 2022. Los datos fueron analizados mediante análisis de contenido. Resultados: las instalaciones de Previne Brasil incluyen informatización, compromiso de los profesionales y calificación de la atención. Las dificultades fueron descritas como falta de información, sistema informatizado y denominador estimado y equipo de trabajo. Conclusión: el programa presenta facilidades que cualifican el proceso de trabajo y la atención de la salud de la población. Sin embargo, aún hay dificultades que la gestión municipal debe considerar para lograr avances en la atención integral y el financiamiento de la Atención Primaria de Salud.

Direct costs for outpatient excess body weight treatment in Brazilian children and adolescents attending a public children's hospital

Abstract Objective: To estimate the direct costs of treating excess body weight in children and adolescents attending a public children's hospital. Methods: This study analyzed the costs of the disease within the Brazilian Unified Health System (SUS) for 2,221 patients with excess body weight using a microcosting approach. The costs included operational expenses, consultations, and laboratory and imaging tests obtained from medical records for the period from 2009 to 2019. Healthcare expenses were obtained from the Table of Procedures, Medications, Orthoses/Prostheses, and Special Materials of SUS and from the hospital's finance department. Results: Medical consultations accounted for 50.6% (R$703,503.00) of the total cost (R $1,388,449.40) of treatment over the period investigated. The cost of treating excess body weight was 11.8 times higher for children aged 5-18 years compared to children aged 2-5 years over the same period. Additionally, the cost of treating obesity was approximately 4.0 and 6.3 times higher than the cost of treating overweight children aged 2-5 and 5-18 years, respectively. Conclusion: The average annual cost of treating excess body weight was R$138,845.00. Weight status and age influenced the cost of treating this disease, with higher costs being observed for individuals with obesity and children over 5 years of age. Additionally, the important deficit in reimbursement by SUS and the small number of other health professionals highlight the need for restructuring this treatment model to ensure its effectiveness, including a substantial increase in government investment.

Understanding the Indigenous experience with radiation oncology in Treaty 6, 7, 8 (Alberta), Canada to inform health system transformation.

INTRODUCTION: Rates of common cancers are continuously increasing among Indigenous peoples and are above the incidence rates of non-Indigenous Canadians. When considering the intersecting social determinants of health such as culture, geography, funding, and access to basic health services, these all contribute to the unique cancer burden faced by Indigenous people. Indigenous patients sometimes feel alienated by the word "cancer", intimidated in the oncology setting and often avoid or delay seeking care, bypass screening and preventative care, and cease prescribed treatment before it is finished. Providing culturally competent, safe care to improve Indigenous health outcomes have been suggested and prioritized in health care systems across Canada. METHODS: Using an Indigenous methodology, sharing circles were held in Northern Alberta, Canada. Five Indigenous survivors of cancer and two Indigenous caregivers shared their experiences with oncology treatment in the radiation therapy centre. Results were transcribed verbatim and thematic analysis was conducted. RESULTS: This resulted in four main themes (1) historical and cultural understandings (2) reduce systemic harm by having dedicated Indigenous staff, cultural competency, and Indigenous specific supports (3) meaningful time commitment and relationship building (4) importance of kinship and Indigenous-centred, family-and-patient-centred care. These themes fed into the development of nine recommendations for policy and decision makers to improve cultural safety in the Alberta radiation therapy centres. CONCLUSION: Support for Indigenous patients and caregivers is essential to improve care in the radiation therapy centres. The findings from this work will support recommendations for health decision and policy makers within radiation therapy centres, which may be transferable to other centres within oncology and health.

Evolving role of the health system CIO: perspectives from 33 health systems.

OBJECTIVES: This study explores the evolving position of the health system chief information officer (CIO) by identifying new core roles for success. METHODS: An advisory board of industry executives and system leaders guided the study. Purposeful sampling was used to invite chief executive officer and CIOs from 65 not-for-profit US health systems to participate. Interviews were conducted with 51 executives from 33 different systems, using a comprehensive interview topic guide. Interview transcripts were analysed using NVivo software, focusing on themes related to the evolving role of the health system CIO. RESULTS: Analyses revealed three main themes, with the CIO as (1) enabler of strategic change and transformation, (2) strategic developer of technology and leadership talent and (3) driver of organisational culture. DISCUSSION: The role of CIO has undergone transformation from technology and information system management to strategic leadership within the broader health system context. It highlights the importance of comprehensive business knowledge for CIOs and the need for other C-suite executives to have a deeper understanding of information and technology. CONCLUSION: As healthcare continues to evolve, the role of the CIO is expected to expand further, requiring a blend of technical and strategic business skills. This evolution presents opportunities for health systems to enhance their leadership development programmes, preparing leaders for the complexities of the contemporary health system sector.

Reflection on 30 years of Taiwanese national health insurance: Analysis of Taiwanese health system progress, challenges, and opportunities.

On the eve of Taiwan's National Health Insurance's 30th birthday, this study reviews the policy and performance trajectory of the Taiwanese health system. Taiwan has controlled their health spending well and grown increasingly reliant on private financing. The floating-point global budget payment preferentially rewards outpatient-based services, but this has not affected the hospital-centric market composition, which persists despite several primary-care friendly developments. The outcomes suggest improving health care workforce and resource availability, good patient-centredness, respectable technical efficiency, and impressive patient care satisfaction. However, there are worrisome trends for financial barriers to access and allocative efficiency. Evidence on clinical quality suggests that hospitals are performing well though the primary care setting might not be. Overall, the public remains satisfied despite signs of lagging improvement in health outcomes, worsening maternal mortality rate, and persistently incomplete financial risk protection. Identifying what drives the worsening financial barriers of access and persistent financial risk is necessary for further discussions on potential financing adjustments. Improving allocative efficiency could draw on a combination of supporting the functions and quality of primary care alongside patient-oriented education and incentives. Further data on causes of slow health status improvement and rebounding maternal mortality rate is necessary.

Supplementing Systematic Review Findings with Healthcare System Data: Pilot Projects from the Agency for Healthcare Research and Quality Evidence-based Practice Center Program.

OBJECTIVES: The US Agency for Healthcare Research and Quality (AHRQ), through the Evidence-based Practice Center (EPC) Program, aims to provide health system decision makers with the highest-quality evidence to inform clinical decisions. However, limitations in the literature may lead to inconclusive findings in EPC systematic reviews (SRs). The EPC Program conducted pilot projects to understand the feasibility, benefits, and challenges of utilizing health system data to augment SR findings to support confidence in healthcare decision-making based on real-world experiences. STUDY DESIGN AND SETTING: Three contractors (each an EPC located at a different health system) selected a recently completed systematic review conducted by their center and identified an evidence gap that electronic health record (EHR) data might address. All pilot project topics addressed clinical questions as opposed to care delivery, care organization, or care disparities topics that are common in EPC reports. Topic areas addressed by each EPC included infantile epilepsy, migraine, and hip fracture. EPCs also tracked additional resources needed to conduct supplemental analyses. The workgroup met monthly in 2022-2023 to discuss challenges and lessons learned from the pilot projects. RESULTS: Two supplemental data analyses filled an evidence gap identified in the systematic reviews (raised certainty of evidence, improved applicability) and the third filled a health system knowledge gap. Project challenges fell under three themes: regulatory and logistical issues, data collection and analysis, and interpretation and presentation of findings. Limited ability to capture key clinical variables given inconsistent or missing data within the EHR was a major limitation. The workgroup found that conducting supplemental data analysis alongside an SR was feasible but adds considerable time and resources to the review process (estimated total hours to complete pilot projects ranged from 283-595 across EPCs), and that the increased effort and resources added limited incremental value. CONCLUSION: Supplementing existing systematic reviews with analyses of EHR data is resource intensive and requires specialized skillsets throughout the process. While using EHR data for research has immense potential to generate real-world evidence and fill knowledge gaps, these data may not yet be ready for routine use alongside systematic reviews.

Trends in Gonorrhea and Chlamydia Testing and Infections Across the COVID-19 Pandemic in Adolescents and Young Adults in an Integrated Health System.

PURPOSE: The COVID-19 pandemic impacted testing and incidence of sexually transmitted infections (STIs), with some studies showing uneven effects across sociodemographic groups. We aim to determine whether rates of gonorrhea and chlamydia testing and infections were affected by the pandemic, overall and by subgroups, defined by sociodemographic factors and comorbidities. METHODS: We conducted a retrospective cohort study from January 1, 2016, through December 31, 2022, among adolescents and young adults ages 15-29 years within Kaiser Permanente Northern California (KPNC). We determined the rate of testing for gonorrhea/chlamydia, and the incident rates of infections before and during the COVID-19 pandemic by sociodemographic factors. We compared incidence rates of gonorrhea/chlamydia testing and infection before and during the pandemic using Poisson regression. RESULTS: Gonorrhea/chlamydia testing during the pandemic was 19% lower than prepandemic baseline. Testing among Black patients was 1.8-fold higher than White patients. Black patients had 5.5 and 3.6-fold higher rate of gonorrhea and chlamydia infections, respectively, compared with White patients. Patients living in more deprived neighborhoods also had higher rates of infection compared to those in the least deprived neighborhoods. In multivariable analyses stratified by the period before and during the COVID-19 pandemic, there were no significant differences in the incidence rate ratios of testing or infections for any specific sociodemographic factor. DISCUSSION: STI testing in adolescents and young adults dropped dramatically after the start of the pandemic and has not recovered to its prior levels. Preexisting disparities in STI testing and infections were not exacerbated by the pandemic.

Transforming the Effectiveness and Equity of a Psychological Therapy Service: A Case Study in the English NHS Talking Therapies Program.

To work with a psychological therapies service to implement a recovery plan, as required by a government body, aimed at improving patient outcomes (effectiveness) and decreasing practitioner variability (equity). A case-study utilizing components of a learning health system, including nationally mandated patient outcome data, comprising three 18-month phases: (1) retrospective baseline; (2) improving patient outcomes (management-led); and (3) reducing practitioner variability (clinician-led). Primary analyses focused on 35 practitioners (NPR = 35) who were constant across the three phases and their patients in each phase (NPA = 930, 1226, 1217, respectively). Reliable improvement rates determined patient outcomes and multilevel modeling yielded practitioner effects. To test generalizability, results were compared to the whole practitioner sample for each phase: (1) NPR = 81, NPA = 1982; (2) NPR = 80, NPA = 2227; (3) NPR = 74, NPA = 2267. Ethical approval was granted by the Health Research Authority. Patient outcomes improved in successive phases for both the core and whole practitioner samples with the largest impact occurring in the management-led intervention. Practitioner variability decreased in successive phases in both the core and whole practitioner samples except in the management-led intervention of the whole sample. Compared with the management-led intervention, the practitioner-led intervention yielded a decrease in practitioner effect exceeding 60% in the core sample and approaching 50% in the whole sample. The implementation of multiple components of a learning health system can lead to improvements in both the effectiveness and equity of a psychological therapy service.

Burden of disease and costs for the Unified Health System in Brazil due to diseases whose alcohol consumption is a necessary cause: an ecological study.

OBJECTIVE: This study aimed to quantify the health and economic impacts of alcohol consumption in Brazil for 2019. STUDY DESIGN: Ecological study using secondary data sources. METHODS: We calculated the disease burden using estimates from the Global Burden of Disease study, which incorporated data from health surveys and hospital records. Costs were estimated based on direct expenses recorded in the Hospital and Outpatient Information System of the Unified Health System, with data by sex, age group, cause, and Federative Units. RESULTS: Alcohol consumption was a necessary cause for 30,355 deaths and approximately 1.69 million disability-adjusted life years in Brazil, representing 2.2% and 2.6% of the national totals, respectively. The impact was more pronounced among men, in the Northeast region and within the 40- to 64-year-old age group. The total costs attributed to these outcomes reached approximately Int$43.1 million, with hospital admissions accounting for 94.16% of these expenses. CONCLUSION: In 2019, alcohol consumption had a significant impact on both the health of Brazilians and the expenses of the health system. As a preventable risk factor, alcohol consumption necessitates effective intersectoral strategies to mitigate its burden.

Direct and indirect effects of economic sanctions on health: a systematic narrative literature review.

BACKGROUND: Economic sanctions are defined as restrictions imposed by other countries against individuals, groups, or governments of other countries. These sanctions have a detrimental impact on the economies of countries and can also limit access to healthcare services for people as a secondary consequence. This study aims to systematically review the literature to examine the direct and indirect effects of economic sanctions on health through a narrative synthesis. METHODS: This systematic literature review was limited to papers published between January 1990 and July 2023. Relevant documents published in English and Persian were searched for in databases including Cochrane Library, PubMed, Embase, Scopus, Web of Science, SID, Magiran, and Irandoc. The direct and indirect effects of sanctions on health were classified using two frameworks proposed by the World Health Organization (WHO): the Health System Building Blocks and "Social Determinants of Health". RESULTS: Out of a total of 18,219 articles, 59 were selected based on inclusion criteria. The effects of sanctions were divided into direct and indirect groups. Direct effects encompassed seven main themes: access to essential medicine, medical products, vaccines and technologies; financing; health workforce; service delivery; research and health information systems; health outcomes; and financial risk protection. Indirect effects also were classified into six main themes: socioeconomic status; food and agricultural products; stress; early life conditions; high-risk behaviors and addiction; and transport. Most studies focused on the access to medicines, food, economic and social status. CONCLUSIONS: Economic sanctions have had profoundly negative impacts on all aspects of the healthcare system. The international community must address these effects on health and take necessary measures to prevent or mitigate them, particularly in ensuring the provision of basic and essential healthcare needs for individuals and communities.

A Review of COVID-19 Hotels in New York City During the Early 2020 Outbreak: An Alternative Care Model.

New York City (NYC) was the epicenter of the early US COVID-19 pandemic. From March to May 2020, overburdened healthcare centers precipitated an emergent need for non-traditional facilities to meet patient care demands. Given travel restrictions and NYC's underutilized tourist infrastructure, hotels were available to support emergency response needs. This article describes the process by which NYC's non-medical COVID-19 hotel programs were selected, mobilized, and operated, including lessons learned. NYC agencies and organizations collaborated, creating an interagency initiative that activated hotels to provide safe isolation and quarantine spaces for those diagnosed with or exposed to COVID-19, aiming to reduce community spread, increase capacity for NYC's strained healthcare system, and mitigate interagency redundancy. Interagency groups addressed hotel challenges, including infection prevention and control; behavioral health, intellectual, and developmental disorders; social determinants of health; and coordination, operations, and planning. NYC's COVID-19 hotel program successfully supported overburdened hospitals by providing alternate locations for non-inpatient COVID-19 individuals. Community engagement required a methodical approach, balancing quality assurance with efficient access. An interagency coordinating body developed and shared clinical criteria for hotel admissions, infection prevention and control (IPC) procedures, and discharge plans, enhancing the program's ability to scale and address complex needs. Lessons learned from this program can be applied for smoother implementation of similar programs in the future.

[On certain issues of modern health care system development].

Nowadays, the reforming of health care system in the Russian Federation is the most actual since country survives difficult economic conditions and is in need of development of new enhanced scientific and methodological approaches to various aspects of public health and health care, targeting increase of all types of efficiency in this system (medical, social, economic ones). For proper functioning of health care system, not only physicians, but also such specialists as physicists, engineers, mathematicians, biologists, chemists, lawyers, economists, psychologists, teachers and others are to be involved in process of developing new approaches. The multidisciplinary approach and effective interdisciplinary interaction can input into improvement of health care system based on needs of patients. To achieve the highest benefit for patient, development of comfortable conditions for all participants of diagnostic and treatment process, appropriate quality of medical care and maximal level of satisfaction of subjects in given system, it is necessary to consider segmentation of medical services market i.e. characteristics of consumers and providers. The systematic approach is to be applied to achieve this target, involving organizations of private and public sector of practical health care and scientific and educational organizations. it is needed to develop methods of early diagnostic, disease prevention programs and training of personnel in health care system, taking into account approaches of integrative and preventive medicine.

Mental health stigma and health-seeking behaviors amongst pregnant women in Vietnam: a mixed-method realist study.

BACKGROUND: Approximately 15% of women in low-and middle-income countries experience common perinatal mental disorders. Yet, many women, even if diagnosed with mental health conditions, are untreated due to poor quality care, limited accessibility, limited knowledge, and stigma. This paper describes how mental health-related stigma influences pregnant women's decisions not to disclose their conditions and to seek treatment in Vietnam, all of which exacerbate inequitable access to maternal mental healthcare. METHODS: A mixed-method realist study was conducted, comprising 22 in-depth interviews, four focus group discussions (total participants n = 44), and a self-administered questionnaire completed by 639 pregnant women. A parallel convergent model for mixed methods analysis was employed. Data were analyzed using the realist logic of analysis, an iterative process aimed at refining identified theories. Survey data underwent analysis using SPSS 22 and descriptive analysis. Qualitative data were analyzed using configurations of context, mechanisms, and outcomes to elucidate causal links and provide explanations for complexity. RESULTS: Nearly half of pregnant women (43.5%) would try to hide their mental health issues and 38.3% avoid having help from a mental health professional, highlighting the substantial extent of stigma affecting health-seeking and accessing care. Four key areas highlight the role of stigma in maternal mental health: fear and stigmatizing language contribute to the concealment of mental illness, rendering it unnoticed; unconsciousness, normalization, and low literacy of maternal mental health; shame, household structure and gender roles during pregnancy; and the interplay of regulations, referral pathways, and access to mental health support services further compounds the challenges. CONCLUSION: Addressing mental health-related stigma could influence the decision of disclosure and health-seeking behaviors, which could in turn improve responsiveness of the local health system to the needs of pregnant women with mental health needs, by offering prompt attention, a wide range of choices, and improved communication. Potential interventions to decrease stigma and improve access to mental healthcare for pregnant women in Vietnam should target structural and organizational levels and may include improvements in screening and referrals for perinatal mental care screening, thus preventing complications.

Revitalizing medical schools in late sixteenth-century China: Lü Kun and the medical reform program in his Shizheng Lu.

This article takes a glance at the medial reform program recorded in the book Shizheng Lu (Records of Practical Policies for Governing) by Lü Kun, a scholar-official from Ming China who was active more than 400 years ago. The Shizheng Lu is a compilation of varied policies and plans designed by Lü Kun as a local official to restore and improve administration of civic affairs. A sub-chapter in this book is devoted to the subject of public health service. Analysis of this text yields knowledge of how the local public health system in Ming China was supposed to operate, pivoting on the key role of medical schools and highlighting the severe malfunction of this system in Lü Kun's time. The same text also sheds light on a handful of popular medical books from the era that could have been used for medical education.

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa.

BACKGROUND: Sustained implementation of facility-level quality improvement (QI) processes, such as plan-do-study-act cycles, requires enabling meso-level environments and supportive macro-level policies and strategies. Although this is well recognised, there is little systematic empirical evidence on roles and capacities, especially at the immediate meso-level of the system, that sustain QI strategies at the frontline. METHODS: In this paper we report on qualitative research to characterize the elements of a quality and outcome-oriented meso-level, focused on sub/district health systems (DHSs), conducted within a multi-level initiative to improve maternal-newborn health (MNH) in three provinces of South Africa. Drawing on the embedded experience and tacit knowledge of core project partners, obtained through in-depth interviews (39) and project documentation, we analysed thematically the roles, capacities and systems required at the meso-level for sustained QI, and experiences with strengthening the meso-level. RESULTS: Meso-level QI roles identified included establishing and supporting QI systems and strengthening delivery networks. We propose three elements of system capacity as enabling these meso-level roles: (1) leadership stability and capacity, (2) the presence of formal mechanisms to coordinate service delivery processes at sub-district and district levels (including governance, referral and outreach systems), and (3) responsive district support systems (including quality oriented human resource, information, and emergency medical services [EMS] management), embedded within supportive relational eco-systems and appropriate decision-space. While respondents reported successes with system strengthening, overall, the meso-level was regarded as poorly oriented to and even disabling of quality at the frontline. CONCLUSION: We argue for a more explicit orientation to quality and outcomes as an essential district and sub-district function (which we refer to as meso-level stewardship), requiring appropriate structures, processes, and capacities.

Piecing together Pakistan's health system and global health security.

Pakistan's health system has a critical role to play in global health security, however, it faces numerous structural and systemic challenges while contributing to international health efforts. Understanding the dynamics of health system is essential for developing effective strategies to prevent, detect, and respond to health emergencies, ensuring regional stability, and the overall global health security This paper documents the strengths and weaknesses of Pakistan's health systems, the impact of the COVID-19 pandemic, challenges such as funding constraints and fragmented healthcare delivery, threats including antimicrobial resistance, and the importance of international collaboration. Anti-microbial particularly multi-drug resistance, food safety in emergencies, surge capacity of the frontline workforce, patient safety at the health care facilities to curtail healthcare associated infections, and strengthening the points of entry are still the areas that need special attention. To optimise the system's performance, governance and accountability mechanisms are necessary to be put in place under the auspices of national public health agency. Pakistan has the potential to transform its health system by addressing these critical areas and improve its preparedness and readiness for any future health emergency of this scale.

We Need a Combination of Approaches to Evaluate Health System Resilience Comment on "Re-evaluating Our Knowledge of Health System Resilience During COVID-19: Lessons From the First Two Years of the Pandemic".

Health system resilience has become a desirable health system attribute in the current permacrisis environment. The article by Saulnier and colleagues reviews the literature on health system resilience and refines the concept, pinpointing dimensions of resilience governance that have not reached consensus, or that are missing from the literature. In this commentary we complement the findings by discussing different conceptual frameworks for understanding resilience and introducing resilience testing, a method to assess health system resilience using a hypothetical shock scenario. Resilience testing is a mixed-methods approach that combines a review of existing data with a structured workshop, where health system experts collaboratively assess the resilience of their health system. The new method is proposed as a tool for policy-making, as the results can identify attributes of the current health system that may hinder or boost a resilient response to the next crisis.

Decentralisation of the Health System Derailed by Organisational Inertia in Machinga, Malawi.

BACKGROUND: Managing the transition of a health system (HS) from a centralised to a decentralised model has been touted as a panacea to the complex challenges in developing countries like Malawi. However, recent studies have demonstrated that decentralisation of the HS has had mixed effects in service provision with more dominant negative outcomes than positive results. The aim of this study was to develop a substantive grounded theory (GT) that elaborates on how activities of central decision-makers and local healthcare mangers shape the process of shifting the HS to a decentralised model in Machinga, Malawi. METHODS: The study was qualitative in nature and employed the Straussian version of GT. Some participants were interviewed twice, and a total of 36 semi-structured interviews were conducted with 25 purposively selected participants using an interview guide. The interviews were conducted at the headquarters of the Ministry of Health (MoH) and other ministries and agencies, and in Machinga District. Data were analysed using open, axial, and selective coding processes of the GT methodology; and the conditional matrix and paradigm model were used as data analysis tools. RESULTS: The findings of this study revealed seven different activities, forming two opposing and interactional sub-processes of enabling and impeding patterns that derailed the decentralisation drive. The study generated a GT labelled "decentralisation of the HS derailed by organisational inertia," which elaborates that decentralisation of the HS produced mixed results with more predominant negative outcomes than positive effects due to resistance at the upper organisational echelons and members of the District Health Management Team (DHMT). CONCLUSION: This article concludes that organisational inertia at the personal and strategic levels of leadership entrusted with decentralising the HS in Malawi, contributed immensely to the derailment of shifting the HS from the centralised to the decentralised model of health service provision.

Addressing the UHC Challenge Using the Disease Control Priorities 3 Approach: Lessons Learned and an Overview of the Pakistan Experience.

BACKGROUND: Pakistan developed its first national Essential Package of Health Services (EPHS) as a key step towards accelerating progress in achieving Universal Health Coverage (UHC). We describe the rationale, aims, the systematic approach followed to EPHS development, methods adopted, outcomes of the process, challenges encountered, and lessons learned. METHODS: EPHS design was led by the Ministry of National Health Services, Regulations & Coordination. The methods adopted were technically guided by the Disease Control Priorities 3 Country Translation project and existing country experience. It followed a participatory and evidence-informed prioritisation and decision-making processes. RESULTS: The full EPHS covers 117 interventions delivered at the community, health centre and first-level hospital platforms at a per capita cost of US$29.7. The EPHS also includes an additional set of 12 population-based interventions at US$0.78 per capita. An immediate implementation package (IIP) of 88 district-level interventions costing US$12.98 per capita will be implemented initially together with the population-based interventions until government health allocations increase to the level required to implement the full EPHS. Interventions delivered at the tertiary care platform were also prioritised and costed at US$6.5 per capita, but they were not included in the district-level package. The national EPHS guided the development of provincial packages using the same evidence-informed process. The government and development partners are in the process of initiating a phased approach to implement the IIP. CONCLUSION: Key ingredients for a successful EPHS design requires a focus on package feasibility and affordability, national ownership and leadership, and solid engagement of national stakeholders and development partners. Major challenges to the transition to implementation are to continue strengthening the national technical capacity, institutionalise priority setting and package design and its revision in ministries of health, address health system gaps and bridge the current gap in financing with the progressive increase in coverage towards 2030.

Barriers and facilitators for strengthening physiotherapy services in Nepal: perspectives from physiotherapists and health providers.

BACKGROUND: Physiotherapy provides non-invasive and non-pharmaceutical intervention for curative, rehabilitation and preventative purposes. Physiotherapy is also a central provider of health promotion. As the global burden of non-communicable diseases and chronic health conditions is rising, the importance of physiotherapy services increases. Unfortunately, physiotherapy services in low- and middle-income countries (LMICs) are generally unsatisfactory. In Nepal, the earthquake in 2015 and the COVID pandemic have clearly illuminated the importance of physiotherapy. OBJECTIVE: This qualitative study aimed to identify barriers and facilitators at different system levels for strengthening physiotherapy services in Nepal. METHODS: Forty semi-structured individual interviews were performed with different health providers. Transcribed interviews were assessed with thematic analysis. A five-level socioecological framework conceptualised multilevel determinants of barriers and facilitators. RESULTS: The study revealed various factors that were potential barriers and facilitators across five different levels, namely individual (taking the lead, need for advocacy), interpersonal (lack of recognition and autonomy, networking for referrals and coordination), community (lack of knowledge and awareness, social and family support), organisational (accessibility, workplace and clinical practice, educational opportunities, role of organisations and rehabilitation centres), and public policy level (planning and implementation of policies and programs, medical hegemony, priorities). Government officials, local leaders, and clinicians, half of whom were physiotherapists, agreed on many of the same issues, where a lack of awareness of what physiotherapy is and knowledge about what physiotherapists do was central. CONCLUSIONS: The results provide information for the development of physiotherapy by pointing out key elements that need attention. Our broad and structured investigation strategy is applicable to others for a comprehensive analysis of barriers and facilitators for physiotherapy services.