Collective insights of public-private partnership impacts and sustainability: A qualitative analysis.

The global Coronavirus or COVID-19 pandemic exposed the weakness of healthcare systems including laboratory systems and is a call to action for unprecedented collaboration and partnerships to deal with the global crisis. The United States (U.S.) President's Emergency Plan for AIDS Relief (PEPFAR) establishes the global HIV/AIDS treatment agenda in alignment with the UNAIDS 90-90-90 treatment targets to achieve epidemic control related to enhanced testing, treatment, and viral suppression. A strategic PEPFAR priority area recognizes that large-scale collective efforts and sharing of resources bear greater potential impact for lasting change than any single organization or entity can achieve alone. An important vehicle utilized within the global public health context is the public-private partnership (PPP) model whereby multiple international organizations forge unified project charters to collectively reach mutually agreed goals. While touted as an ideal mechanism to synthesize resources and maximize gain in numerous applications, little is known from a seasoned stakeholder perspective regarding PPP implementation and sustainability issues. The purpose of this research is to holistically examine perceptions of PPP model sustainability related to inputs and impacts among a collective network of stakeholders experienced with PEPFAR workforce development, laboratory-system strengthening project implementation. Interviews were conducted with frontline stakeholders from public and private sector organizations based in the US and select PEPFAR-supported priority countries. Analysis revealed three dominant themes: PPP impacts, keys of successful collaboration, and logistical challenges and opportunities to enhance sustainability of PPP outcomes in the future.

Partnership among hospitals to reduce healthcare associated infections: a quasi-experimental study in Brazilian ICUs.

BACKGROUND: Healthcare-associated infections (HAIs) are relevant in developing countries where frequencies can be at least 3 times higher than in developed countries. The purpose of this research was to describe the intervention implemented in intensive care units (ICUs) to reduce HAIs through collaborative project and analyze the variation over 18 months in the incidence density (ID) of the three main HAIs: ventilator associated pneumonia (VAP), central line-associated bloodstream infections (CLABSIs) and catheter-related urinary tract infections (CAUTIs) and also the length of stay and mortality in these ICUs. METHODS: A quasi-experimental study in five public adult clinical-surgical ICUs, to reduce HAIs, through interventions using the BTS-IHI "Improvement Model", during 18 months. In the project, promoted by the Ministry of Health, Brazilian philanthropic hospitals certified for excellence (HE), those mostly private, certified as excellence and exempt from security contributions, regularly trained and monitored public hospitals in diagnostics, data collection and in developing cycles to improve quality and to prevent HAIs (bundles). In the analysis regarding the length of stay, mortality, the IDs of VAP, CLABSIs and CAUTIs over time, a Generalized Estimating Equation (GEE) model was applied for continuous variables, using the constant correlation (exchangeable) between assessments over time. The model estimated the average difference (ß coefficient of the model) of the measures analyzed during two periods: a period in the year 2017 (prior to implementing the project) and in the years 2018 and 2019 (during the project). RESULT: A mean monthly reduction of 0.427 in VAP ID (p = 0.002) with 33.8% decrease at the end of the period and 0.351 in CAUTI ID (p = 0.009) with 45% final decrease. The mean monthly reduction of 0.252 for CLABSIs was not significant (p = 0.068). Length of stay and mortality rates had no significant variation. CONCLUSIONS: Given the success in reducing VAP and CAUTIs in a few months of interventions, the achievement of the collaborative project is evident. This partnership among public hospitals/HE may be applied to other ICUs including countries with fewer resources.

Experiences of violence among adolescent girls and young women in Nairobi's informal settlements prior to scale-up of the DREAMS Partnership: Prevalence, severity and predictors.

INTRODUCTION: We sought to estimate the prevalence, severity and identify predictors of violence among adolescent girls and young women (AGYW) in informal settlement areas of Nairobi, Kenya, selected for DREAMS (Determined Resilient Empowered AIDS-free, Mentored and Safe) investment. METHODS: Data were collected from 1687 AGYW aged 10-14 years (n = 606) and 15-22 years (n = 1081), randomly selected from a general population census in Korogocho and Viwandani in 2017, as part of an impact evaluation of the "DREAMS" Partnership. For 10-14 year-olds, we measured violence experienced either in the past 6 months or ever using a different set of questions from those used for 15-22 year-olds. Among 15-22 year-olds we measured prevalence of violence, experienced in the past 12 months, using World Health Organization (WHO) definitions for violence typologies. Predictors of violence were identified using multivariable logit models. RESULTS: Among 606 girls aged 10-14 years, about 54% and 7% ever experienced psychological and sexual violence, respectively. About 33%, 16% and 5% experienced psychological, physical and sexual violence in the past 6 months. The 10-14 year old girls who engaged in chores or activities for payment in the past 6 months, or whose family did not have enough food due to lack of money were at a greater risk for violence. Invitation to DREAMS and being a non-Christian were protective. Among 1081 AGYW aged 15-22 years, psychological violence was the most prevalent in the past year (33.1%), followed by physical violence (22.9%), and sexual violence (15.8%). About 7% experienced all three types of violence. Severe physical violence was more prevalent (13.8%) than moderate physical violence (9.2%). Among AGYW aged 15-22 years, being previously married/lived with partner, engaging in employment last month, food insecure were all risk factors for psychological violence. For physical violence, living in Viwandani and being a Muslim were protective; while being previously married or lived with a partner, or sleeping hungry at night during the past 4 weeks were risk factors. The odds of sexual violence were lower among AGYW aged 18-22 years and among Muslims. Engaging in sex and food insecurity increased chances for sexual violence. CONCLUSIONS: Prevalence of recent violence among AGYW is high in this population. This calls for increased effort geared towards addressing drivers of violence as an early entry point of HIV prevention effort in this vulnerable group.

Unlocking the Hidden Hunger Crises: The Power of Public-Private Partnerships.

The global burden of malnutrition remains unacceptably high. Malnutrition is a universal issue restricting development and slowing progress. Malnutrition is responsible for more illness and ill-health than any other cause worldwide. Despite underlying determinants of undernutrition being well understood for decades, millions of children worldwide face multiple malnutrition burdens, and women face a higher burden than men when it comes to malnutrition due to higher nutrient needs. Despite these alarming statistics, significant strides are being made. Globally, stunting rates among children have declined and many countries are on their way to achieving at least one nutritional status target for 2025. However, a broader range of stakeholders must be more fully engaged if malnutrition is to be reduced in a sustainable manner, including increased engagement from the private sector. To support achievement of the 2030 Sustainable Development Goal of ending all forms of malnutrition (goal 2.2), there must be urgent and decisive actions by all stakeholders to address existing data gaps, present new food systems innovations, ensure nutritious diets for all, fully finance nutrition action, and adhere to global commitments.

Incentivizing Healthy Snacks During Out-of-School Time Through Grocery Store Partnerships.

CONTEXT: Volunteer-led out-of-school-time (OST) programs, such as 4-H, scouting, and youth sports, reach a large population of children and are positioned to offer opportunities for healthy eating. However, cost is a barrier to providing healthy snacks such as fruits and vegetables (FVs) during OST. OBJECTIVE: Offering discounts through grocery store partnerships has shown promise in addressing this barrier in structured, staff-led after-school programs. We tested this model in volunteer-led OST programs and evaluated it using mixed methods. DESIGN/SETTING: The Snack It Up (SIU) intervention was designed to promote FV snacks to volunteer-led OST programs through weekly $5 grocery store discounts. Participation was limited to 1 leader per program. PARTICIPANTS: Thirty-five of 36 recruited OST program leaders completed the study; 16 were enrolled in SIU and 19 in a comparison group. MAIN OUTCOME MEASURES: We assessed the following: (1) discount redemption among SIU leaders; (2) snacks served by SIU and comparison group leaders via photographs from 3 to 4 OST program sessions during SIU implementation; and (3) SIU leader perspectives using key informant interviews before and after implementation. RESULTS: SIU leaders saved an average of $48.75 on FV snacks throughout the intervention ($2.90 per week, more than one-fifth of typical self-reported spending on snacks). SIU leaders also served a greater frequency (100% of sessions vs 75%, P < .001) and variety of FVs (an average of 3.5 types per session vs 1.3, P < .001) and fewer salty/sweet snacks (0.0 vs 1.3 types per session, P < .001) than those in the comparison group and expressed positive impressions of SIU. CONCLUSIONS: Partnerships between OST programs and grocery stores are a promising avenue for promoting healthier snacks during OST.

Typological analysis of public-private partnerships in the veterinary domain.

Public-Private Partnerships (PPPs) are defined as a collaborative approach in which the public and private sector share resources, responsibilities and risks to achieve common objectives and mutual benefits in a sustainable manner. PPPs are identified as a key solution to reinforce Veterinary Services. However only limited information is available on the scope, added value and enabling factors of PPPs in this sector. The aims of this study were to develop a typology of PPPs in the veterinary field and to identify key success factors and obstacles to their implementation. A structured questionnaire was sent to all 181 World Organisation for Animal Health (OIE) Member Countries and to 47 private contacts. 36 different variables characterizing PPP initiatives were collected. 97 examples of PPPs were retrieved from 76 countries. Dimensionality reduction techniques were combined with clustering and discrimination methods to establish a typology of PPPs and to derive a set of simple rules to classify new instances of PPPs. Three clusters were identified, separated according to two main variables: the type of private partners and the type of interaction. Cluster 1, transactional PPPs, represented the traditional understanding of PPPs by Veterinary Services, initiated and funded by the public sector, giving service delivery accreditation to mostly private veterinarians; cluster 2, collaborative PPPs, included partnerships between producer associations and public Veterinary Services, driven by trade interests; cluster 3, transformational PPPs, represented joint programs initiated and funded by private companies and initially driven by business development objectives. Specific success factors and key obstacles affecting the performances and sustainability of these initiatives were identified for each cluster. This study represents the first practical attempt to develop a meaningful typology of PPPs in the field of animal health and to identify fundamental obstacles currently inhibiting the development of PPPs, and suggests ways to support national Veterinary Services in overcoming these obstacles.

Assessment of the public-private-partnerships model of a national health insurance scheme in India.

A single hospital admission can deplete household resources so considerably as to induce impoverishment, especially in the Indian context of low government healthcare expenditure. Rashtriya Swasthya Bima Yojana (RSBY) was a national health insurance scheme for below-poverty-line Indian families, to provide improved access to hospitalization and greater financial protection via a public-private-partnership employing private sector implementation capacity. Study objectives were to understand governance (including regulatory) environment and contract arrangements; evaluate expansion of services to beneficiaries; and assess compliance of providers and user satisfaction. A case study approach in two districts met the need for in-depth information on scheme functioning, and RSBY implementation was examined between 2011 and 13 in Patiala (Punjab) and Yamunanagar (Haryana). Methods included 20 key stakeholder interviews, analysis of secondary datasets on beneficiaries and claims, primary data collection in 31 public and private hospitals and in greater depth in 12 hospitals, and an exit survey of 751 patients. Enrolled and non-enrolled hospitals were mapped in each district and service availability of enrolled hospitals assessed; enrollee characteristics were analysed; for the 12 hospitals, information was obtained on structural quality and process of care, and patient satisfaction and out-of-pocket payments. The Indian states and the government of India did not specify formal regulatory and implementation procedures in detail and states largely contracted out their functions to private insurance firms. Findings show regulatory weaknesses, and contractual breaches. Enrolment rates were low in both districts and more so for Patiala and there was limited access to services. There was little difference in process of care between public and private hospitals, though the structural capacity of private hospitals was better than public hospitals. RSBY helped improve accessibility and gave some degree of financial protection to patients. It also actively engaged with existing resources in the Indian health care and insurance markets.

Partnership integration for rural health resource access.

Increasing numbers of older adults are residing in rural areas of the USA. Many of these individuals experience greater rates of chronic diseases and lower income levels compared to their urban-residing counterparts. Aging in rural environments creates greater challenges in the provision of funding, staff and resources to meet the needs of these older adults, and contributes to immense health disparities and health inequities. Urban and rural older adult residents alike need healthcare, gerontological and public health resources to promote successful aging in place. Due to the nature of rural environments, many of these resources often exist great distances from these residents, which creates access challenges. There are also limitations in locally available facilities and trained practitioners, resulting in resource shortages for addressing chronic health conditions. The creation and use of interdisciplinary partnerships provides this much-needed support while addressing ever-increasing funding and staffing limitations. This article provides an innovative conceptual interdisciplinary partnership model that combines nursing, public health and gerontology to address the health and social challenges that rural-residing older adults face. Although well-trained practitioners who work within their discipline are an important contributor to assist with the needs of rural-residing older adults, this silo approach is expensive, inefficient, and clearly cannot support all of the needs for older adults in this type of environment. There is a need to blend the complementary skills provided by each of the presented disciplines so that the focus of the interdisciplinary partnership is on person-centered care addressing the health disparities and health inequities experienced by these older adults. To illustrate the integration of nursing, public health and gerontology disciplines, these disciplines are initially combined and presented as dyads, and are then incorporated into the full conceptual model. The dyads are public health and gerontology, public health and nursing, and gerontology and nursing. Steps are provided for the development of this (or any) interdisciplinary partnership. An example of the model's use through clinical and non-clinical disciplines and a community engagement framework is also described. Interdisciplinary approaches focused on person-centered care provide more well-rounded health and social support for rural older adults than any one discipline in isolation. Allocation of shared resources, roles, responsibilities and expenses allows practitioners engaged in interdisciplinary teams to provide superior economic and capacity efficiency. This efficiency is crucial at a time when many entities experience limitations in sustainable resources. Thus, practitioners and community agencies collaborating through interdisciplinary partnerships are better able to address the complex issues experienced by rural-residing community members.

Analysis of Public-Private Partnership in Providing Primary Health Care Policy: An Experience From Iran.

Background: This study aims to analyze the public-private partnership (PPP) policy in primary health care (PHC), focusing on the experience of the East Azerbaijan Province (EAP) of Iran. Methods: This research is a qualitative study. Data were gathered using interviews with stakeholders and document analysis and analyzed through content analysis. Results: Participants considered political and economic support as the most important underlying factors. Improving system efficiency was the main goal of this policy. Most stakeholders were supporters of the plan, and there was no major opponent. Implementing the health evolution plan (HEP) was an opportunity to design this policy. Participants considered the lack of provision of infrastructure as the main weakness, changing the role of the public sector as the main strength, and promoting social justice as the main achievement of policy. The results of the quantitative data review showed that following the implementation of this policy, health indicators have been improved. Conclusions: Based on the results of this study, the PPP model in EAP is a new and successful experience in PHC in Iran. Supporting and developing this policy may improve the quality and quantity of providing care.

Increased Employment for Segregated Roma May Improve Their Health: Outcomes of a Public-Private Partnership Project.

Increasing employment opportunities for segregated Roma might prevent major economic losses and improve their health. Involvement of the private sector in Roma employment, on top of intensified governmental actions, is likely to be a key to sustainable improvement, but evidence on this is scarce. Our aim was to determine the potential outcomes of such a partnership regarding increased employability and the resulting improved well-being and health. We therefore investigated a Roma employment project called Equality of Opportunity, run since 2002 by a private company, U.S. Steel Kosice, in eastern Slovakia. We conducted a multi-perspective qualitative study to obtain the perspectives of key stakeholders on the outcomes of this project. We found that they expected the employability of segregated Roma to increase in particular via improvements in their work ethic and working habits, education, skills acquisition, self-confidence, courage and social inclusion. They further expected as the main health effects of increased employability an improvement in Roma well-being and health via a stable income, better housing, crime reduction, improved hygienic standards, access to prevention and improved mental resilience. Social policies regarding segregated Roma could thus be best directed at increasing employment and at these topics in particular to increase their effects on Roma health.

Innovating to increase access to diabetes care in Kenya: an evaluation of Novo Nordisk's base of the pyramid project.

Background: The Base of the Pyramid (BoP) project is a public-private partnership initiated by Novo Nordisk that aims to facilitate access to diabetes care for people at the base of the economic pyramid in low- and middle-income countries (LMICs). In Kenya, the BoP, through a partnership model, aims to strengthen five pillars of diabetes care: increased awareness of diabetes; early diagnosis of diabetes; access to quality care by trained professionals; stable and affordable insulin supply; and improved self-management through patient education. Objectives: This study evaluates the extent to which BoP Kenya is scalable and sustainable, whether stakeholders share in its value, and whether BoP Kenya has improved access to diabetes care. Method: The Rapid Assessment Protocol for Insulin Access (RAPIA), an approach developed to provide a broad situational analysis of diabetes care, was used to examine health infrastructure and diabetes care pathways in Kenya. At the national level, the RAPIA was applied in a SWOT analysis of the BoP through in-depth interviews with key stakeholders. At individual and county health system levels, RAPIA was adapted to explore the impact of the BoP on access to diabetes care through a comparison of an intervention and control county. Results: The BoP was implemented in 28 of 47 counties in Kenya. Meru, a county where BoP was implemented, had 35 of 62 facilities (56%) participating in the BoP. Of the five pillars of the BoP, most notable progress was made in achieving the fourth (stable and affordable insulin supply). A price ceiling of 500KSh (US$5) per vial of insulin was established in the intervention county, with greater fluctuation and stock-outs in the non-intervention county. Despite reduced insulin costs, many patients with diabetes could not afford the additive expenses of monitoring, medicines, and travel. Less progress was made over the other pillars, which also faced challenges to sustainability and scalability. Conclusion: In the context of the rising prevalence of non-communicable diseases in LMICs, cross-sector approaches to improving access to care are increasingly needed. Public-private partnerships such as the BoP are necessary but not sufficient to ensure access to health care for people with diabetes at the base of the economic pyramid in Kenya.

Barriers and facilitators to adoption, implementation and sustainment of obesity prevention interventions in schoolchildren- a DEDIPAC case study.

BACKGROUND: The aim of the study was to explore the implementation of school based diet and physical activity interventions with respect to the barriers and facilitators to adoption, implementation and sustainability; supportive actions required for implementation and recommendations to overcome identified barriers. Two interventions rolled out nationally in Ireland were chosen; Food Dudes, a programme to encourage primary school children to consume more fruit and vegetables and Green Schools Travel (GST), an active travel to school programme in primary and secondary schools. Trained school coordinators (teachers) cascade the programmes to other teaching staff. METHODS: Multiple case study design using qualitative semi-structured interviews with key stakeholders: primary and secondary school teachers, school coordinators, project coordinators/managers, funders and intermediaries. Fifteen interviews were conducted. Data were coded using a common categorization matrix. Thematic analysis was undertaken using the Adoption, Implementation and Maintenance elements of the RE-AIM implementation framework. RESULTS: Good working relationships within and across government departments, intermediaries and schools were critical for intervention adoption, successful implementation and sustainability. Organisational and leadership ability of coordinators were essential. Provision of participation incentives acted as motivators to engage children's interest. A deep understanding of the lives of the target children was an important contextual factor. The importance of adaptation without compromising core components in enhancing intervention sustainability emerged. Successful implementation was hindered by: funding insecurity, school timetable constraints, broad rather than specific intervention core components, and lack of agreement on conduct of programme evaluation. Supportive actions for maintenance included ongoing political support, secure funding and pre-existing healthy lifestyle policies. CONCLUSIONS: Successful implementation and scale up of public health anti-obesity interventions in schools is dependent on good contextual fit, engagement and leadership at multiple levels and secure funding. Recommendations to overcome barriers include: capacity to deliver within an already overcrowded curriculum and clear specification of intervention components within a conceptual framework to facilitate evaluation. Our findings are generalisable across different contexts and are highly relevant to those involved in the development or adaptation, organisation or execution of national public health interventions: policy makers, guidelines developers, and staff involved in local organisation and delivery.

Implementation and Evaluation of a Military-Civilian Partnership to Train Mental Health Specialists.

INTRODUCTION: Mental health specialists (MHS, or 68X) play a central role in meeting the growing demand for combat stress care among Service Members. Partnering with civilian institutions may enhance the MHS training experience beyond Advanced Individual Training (AIT). METHODS: We describe a novel military-civilian collaboration to train U.S. Army Reserve MHS's in the psychiatric emergency service (PES) of a public, safety-net hospital. Details of implementation are described. The training rotation was evaluated after 1 year through a comprehensive chart abstraction of patients seen as well as surveys of MHS's and civilian partners. RESULTS: The roles of MHS and physician officers in this rotation are described. Over 9 days in the PES, the MHS team evaluated 26 patients. MHS's described a high-quality training environment (83% rated very good or excellent) in which they frequently saw high-risk patients relevant to military practice. Experience with a certain patient presentation was correlated with comfort assessing and managing that presentation (p < 0.01). Many civilian staff (40%) felt the PES operated better with the presence of the Army team and 50% of civilians agreed their impression of the U.S. Army Reserve improved as a result of the partnership. Hundred percent of specialists and 80% of civilians reported very good to excellent rapport between military and civilian staff. Two civilian respondents (11%) expressed concern that the military team's presence impeded patient care. CONCLUSION: This is the first military-civilian training collaboration for behavioral health specialists, who have already completed AIT. This program provided well-received and mission-relevant training for MHS's without notable adverse effects on patient care or team functioning in a civilian environment. Our findings are based on a small sample size, and no other such programs exist against which to compare these results. We propose that such educational partnerships, which have long been effective for other clinical specialists, may benefit the military, civilian communities, and the country.

Maternal and Child Health Nutrition Faculty and Trainees Work Collaboratively with Community Partners to Assess Afterschool Nutrition Environments.

Purpose The purpose of this paper is to describe a collaborative service learning experience (SLE) which was part of the degree requirements of the Public Health Nutrition Graduate Program at the University of Tennessee. The SLE was collaboratively developed by the University of Tennessee's maternal and child health (MCH) nutrition leadership education and training (NLET) Program Director and the Knox County Health Department's healthy weight program manager. Description The SLE was a semester long project that included instructional time and fieldwork. Coursework focused on development of a community nutrition needs assessment, how to interpret and analyze assessment data, and how to use assessment data for program planning and policy development. Fieldwork consisted of interacting with an interprofessional team, assessing the nutrition environment at two afterschool sites, conducting a plate waste study to determine the amount of food consumed by children at the sites' dinner meals, interpreting and analyzing data, and developing and presenting recommendations for improvement. Assessment Trainees successfully completed all aspects of the SLE. They completed a community needs assessment of the neighborhoods surrounding the two afterschool program sites, conducted nutrition environment audits, including meal observations, and measured and analyzed plate waste from dinner meals served at the sites. Using the data gathered and collected, they prepared suggestions for nutrition environment improvements and policy development for community partners. Conclusion The SLE allowed trainees to develop MCH competencies and professional skills required in public health nutrition, while providing valuable data that subsequently was used to establish nutrition-related policies and interventions.

A comparative performance analysis of a renowned public private partnership for health care provision in Spain between 2003 and 2015.

BACKGROUND: Recently, the once archetype of the public private partnership (PPP) in the Spanish National Health System (SNHS), namely the Alzira's Model, has come to an end. Advocates defended the superiority of PPPs over public-tenured provision, in terms of quality and technical efficiency. This paper profiles and compares Alzira's life-cycle performance with similar public-tenured providers. METHODS: Observational study on secondary data from virtually all hospital care episodes produced in 51 integrated providers (i.e., administrative healthcare areas) and 67 hospitals, in 2003 and 2015. Alzira's 2015 performance (and its variation since 2003) was compared with all public-tenured peers in the SNHS, using 26 indicators analysing the differences in age-sex standardized rates of events or risk-adjusted mortality, severity-adjusted hospital expenditure and hospital technical efficiency. RESULTS: In comparison with the corresponding public-tenured peers, Alzira's 2015 performance was statistically worse than the benchmark in the majority of indicators (15 out of 26); yet, its performance was one of the best in the SNHS in adjusted-mortality after Percutaneous Coronary Intervention (PCI). Over time, Alzira showed a statistically greater 2003-2015 improvement than its peers' average in eleven of the indicators, and a lower improvement in nine. CONCLUSIONS: In this comprehensive comparative study on Alzira's performance, this PPP has not generally outperformed public-tenured providers, although in some areas of care its developments have been outstanding.

Health financing strategies to reduce out-of-pocket burden in India: a comparative study of three states.

BACKGROUND: To achieve the Sustainable Development Goals, Indian States have implemented different strategies to arrest high out-of-pocket expenditure (OOPE) and to increase equity into healthcare system. Tamil Nadu (TN) and Rajasthan have implemented free medicine scheme in all public hospitals and West Bengal (WB) has devised Fair Price Medicine Shop (FPMS) scheme, a public-private-partnership model in the state. In this background, the objectives of the paper are to - 1. Study the utilization pattern of public in-patient care facilities for the states, 2. Examine the effectiveness of the strategies adopted by the states to arrest high OOPE and 3. Analyze the extent of equity in public in-patient care services in the states. METHODS: National Sample Survey (71st and 60th round) data, Detailed Demand for Grants of the state governments and the National Rural/Urban Health Mission data have been used for the study. Exploratory data analysis and benefit incidence analysis have been applied to estimate the utilization, OOPE and extend of equity in the states. RESULTS: The results show that overall utilization of public facilities in TN and Rajasthan has increased substantially; whereas, utilization of public facility has decreased in WB even among the poorest. In addition, OOPE for both medical and medicine is the highest in WB among three states for public sector hospitalizations. Surprisingly, OOPE on medicine is the highest for the poorest class of WB. Analysis showed that the mismatch between actual need and FPMS drug-list has led to high OOPE in the state. Overall, benefit incidence of public subsidy is the highest among the poorest class in all the states. However, geographical sector-wise inequity in public subsidy distribution persists in the states. Analysis of cost of inpatient care shows that TN provides the maximum subsidy for hospitalization and WB provides the minimum. An inverse relationship between utilization of inpatient care and public subsidy has been observed from the analysis. CONCLUSION: In conclusion we could say that TN & Rajasthan have successfully implemented their health financing strategies to reduce the health expenditure burden. However, policy-level changes are required to improve the situation in WB.

TB case notification by private health-sector; retrospective study in 13 metro districts of Pakistan.

OBJECTIVE: To evaluate the impact of structured engagement of private providers in tuberculosis case notification and to investigate demographic profile, disease pattern and treatment outcome of tuberculosis patients seeking care from private care providers. METHODS: This retrospective study was carried out in 13 districts of Pakistan with the data of tuberculosis patients registered and diagnosed from July 2015 to June 2016 at directly observed treatment, short-course trained private providers. These facilities in collaboration with Greenstar Social Marketing Pakistan, a private organisation and the National Tuberculosis Control Programme, Pakistan, provided free anti-tuberculosis drugs and sputum smear microscopy. Study variables included socio-demographic character, disease patterns and treatment outcomes of patients along with details of the registering facility. Data was analysed using SPSS 23. RESULTS: There were 1317 directly observed treatment, short-course trained private health facilities and 123 private laboratories. Of the health facilities, 880(67%) reported 13769 tuberculosis patients. Of them, 7388(53.65%) were females and 6381(46.34%) were males. Overall, 10232(74.31%) were diagnosed with pulmonary tuberculosis and 3537(25.68%) were extra pulmonary tuberculosis patients. Among the pulmonary patients, 4195(41%) were diagnosed through sputum smear microscopy as bacteriologically confirmed (B+ve), while the remaining 6037(59%) were diagnosed through X-ray or other tests. Out of all the diagnosed patients 13218(96%) were treated successfully.. CONCLUSIONS: Private healthcare sector has great potential of supporting tuberculosis control. Gender and age had critical implications in service utilisation.

Evaluating the impact of the DREAMS partnership to reduce HIV incidence among adolescent girls and young women in four settings: a study protocol.

BACKGROUND: HIV risk remains unacceptably high among adolescent girls and young women (AGYW) in southern and eastern Africa, reflecting structural and social inequities that drive new infections. In 2015, PEPFAR (the United States President's Emergency Plan for AIDS Relief) with private-sector partners launched the DREAMS Partnership, an ambitious package of interventions in 10 sub-Saharan African countries. DREAMS aims to reduce HIV incidence by 40% among AGYW over two years by addressing multiple causes of AGYW vulnerability. This protocol outlines an impact evaluation of DREAMS in four settings. METHODS: To achieve an impact evaluation that is credible and timely, we describe a mix of methods that build on longitudinal data available in existing surveillance sites prior to DREAMS roll-out. In three long-running surveillance sites (in rural and urban Kenya and rural South Africa), the evaluation will measure: (1) population-level changes over time in HIV incidence and socio-economic, behavioural and health outcomes among AGYW and young men (before, during, after DREAMS); and (2) causal pathways linking uptake of DREAMS interventions to 'mediators' of change such as empowerment, through to behavioural and health outcomes, using nested cohort studies with samples of ~ 1000-1500 AGYW selected randomly from the general population and followed for two years. In Zimbabwe, where DREAMS includes an offer of pre-exposure HIV prophylaxis (PrEP), cohorts of young women who sell sex will be followed for two years to measure the impact of 'DREAMS+PrEP' on HIV incidence among young women at highest risk of HIV. In all four settings, process evaluation and qualitative studies will monitor the delivery and context of DREAMS implementation. The primary evaluation outcome is HIV incidence, and secondary outcomes include indicators of sexual behavior change, and social and biological protection. DISCUSSION: DREAMS is, to date, the most ambitious effort to scale-up combinations or 'packages' of multi-sectoral interventions for HIV prevention. Evidence of its effectiveness in reducing HIV incidence among AGYW, and demonstrating which aspects of the lives of AGYW were changed, will offer valuable lessons for replication.

Cross-Sectoral Partnerships By Area Agencies On Aging: Associations With Health Care Use And Spending.

Area Agencies on Aging (AAAs)-which coordinate social services for older adults in communities across the US-regularly address social determinants of health, sometimes in partnership with other social services and health care organizations. Using data from a 2013 national survey of these agencies, we examined whether their partnership activities were associated with 2014 levels of avoidable health care use and spending for older adults in counties served by each AAA. Multivariate regression models adjusted for agency characteristics, county demographic characteristics, and health care supply factors. We found that counties whose AAAs maintained informal partnerships with a broad range of organizations in health care and other sectors had significantly lower hospital readmission rates, compared to counties whose AAAs had informal partnerships with fewer types of organizations. Counties whose AAAs had programs to divert older adults from nursing home placement had significantly lower avoidable nursing home use, compared to counties whose AAAs lacked such programs. Our findings suggest that AAAs may be a promising source of leadership for cross-sectoral partnerships that effectively address both social and medical determinants of health for older adults, who account for a substantial share of overall health care spending.