The role of hospitals in strengthening primary health care in the Western Pacific.

Despite the imperative to strengthen primary health care (PHC) to respond to demographic and epistemological transitions, and meet commitments to achieve universal health coverage, health systems remain hospital-centric with health resources largely concentrated in urban centres. This paper examines islands of innovation that demonstrate the role hospitals can play in influencing the provision of PHC. Drawing on the literature and country case studies from the Western Pacific region, we illustrate mechanisms used to unlock hospital resources to improve PHC, with the transition towards "systems-focused hospitals". This paper identifies four "ideal types" of roles hospitals perform to strengthen PHC in different contexts. This provides a framework to inform health systems policy by examining existing and potential roles of hospitals to support the provision of frontline services and reorient health systems towards PHC.

Nurses in advanced roles as a strategy for equitable access to healthcare in the WHO Western Pacific region: a mixed methods study.

BACKGROUND: The Western Pacific region constitutes one-quarter of the world's population and has diverse health needs. While dialogue on and promotion of advanced practice nurses are ongoing, this study investigated the current responsibilities of nurses in advanced roles, future healthcare needs, and the implications of these components for nurses' professional development within the Western Pacific region. METHODS: This study employed three phases, a descriptive survey on the current status of nurses in advanced roles in the Western Pacific region, followed by a Delphi survey, and exploratory interviews. A total of 55 national experts with clinical, academic, and/or government-related backgrounds from 18 countries participated from December 2017 - December 2018. The descriptive survey via email to identify the status of nurses in advanced roles and a working definition was developed. This formed the basis for the Delphi survey, which identified key barriers and challenges for enhancing the development of nurses in advanced roles within the country (round 1) and for the region (rounds 2 and 3). Lastly, semi-structured individual interviews were conducted to identify strategies for establishing nurses in advanced roles to improve equitable access to healthcare. RESULTS: Thirty-seven roles and characteristics were identified and categorized for nurses performing advanced roles. Emergency care, critical care, elderly health, child health, and rural/remote communities were identified as fields with particular need for nurses in advanced roles in the Western Pacific region. Providing effective services, influencing government leadership, and advocating for health system sustainability were deemed necessary to improve equitable healthcare access. We found that nurses in advanced roles are not limited to clinical tasks within the hospital but are poised for active participation in primary healthcare, education/teaching, professional leadership, quality management, and research. CONCLUSIONS: Demand for nurses in advanced roles is high in the Western Pacific region and 15 items were identified across five core strategic areas to enhance development of nurses in advanced roles. Governmental-level recommendations include establishing legislative protection, improving systems for remuneration, strengthening supportive channels, and conducting national needs assessments.

Artificial intelligence: opportunities and implications for the health workforce.

Healthcare involves cyclic data processing to derive meaningful, actionable decisions. Rapid increases in clinical data have added to the occupational stress of healthcare workers, affecting their ability to provide quality and effective services. Health systems have to radically rethink strategies to ensure that staff are satisfied and actively supported in their jobs. Artificial intelligence (AI) has the potential to augment provider performance. This article reviews the available literature to identify AI opportunities that can potentially transform the role of healthcare providers. To leverage AI's full potential, policymakers, industry, healthcare providers and patients have to address a new set of challenges. Optimizing the benefits of AI will require a balanced approach that enhances accountability and transparency while facilitating innovation.

Regulation of nursing professionals in Cambodia and Vietnam: a review of the evolution and key influences.

BACKGROUND: In 2006, the countries of the Association of Southeast Asian Nations (ASEAN) signed the Mutual Recognition Arrangements (MRA) in relation to nursing services in the region. This agreement was part of a set of policies to promote the free flow of skilled labor among ASEAN members and required mutually acceptable professional regulatory frameworks. This paper presents a narrative review of the literature to (1) describe progress in the development of the regulatory framework for nursing professionals in Cambodia and Vietnam since 2000 and (2) identify key factors, including the MRA, that affect these processes. METHODS: For document review, policy documents, laws, regulations, and published peer-reviewed and gray literature were reviewed. Data were triangulated and analyzed using a tool developed by adapting McCarthy et al.'s regulatory function framework and covering eight functions (legislation, accreditation of preservice education, competency assessment, registration and licensing system, tools and data flow of registration, scope of practice, continuing professional development, professional misconduct and disciplinary powers). RESULTS: Cambodia and Vietnam have made remarkable progress in developing their regulatory frameworks for nursing. A number of key influences contributed to the development of nursing regulations, including the signing of the MRA in 2006 and the establishment of the Joint Coordinating Committee on Nursing (AJCCN) in 2007 as key milestones. Macroeconomic and political factors affecting the process were economic growth and an emerging private sector, social demand for quality care and professionalism, global attention to health workforce competencies, the role of development partners, and regular monitoring and mutual learning through AJCCN. A period of incubation enabled countries to develop consensus among stakeholders regarding regulatory arrangements; this trend accelerated after 2010 by bringing national regulatory schemes into conformity with the regional framework. Some similarities in the process (e.g., preservice education first, legislation later) and differences in key actors (e.g., professional councils and the capacity of nursing leaders) were observed in two countries. CONCLUSION: Further development of the regulatory framework will require strong nursing leadership to sustain achievements and drive continued progress. The adapted tool to assess regulatory capacity works well and may be of value in assessing the development of regulations in the nursing profession.

When do vertical programmes strengthen health systems? A comparative assessment of disease-specific interventions in India.

OBJECTIVE: Disease-specific programmes have had a long history in India and their presence has increased over time. This study has two objectives: first, it reports on the interaction between local health systems and key disease-specific programmes in India­National AIDS Control Program (NACP) (HIV/AIDS), Revised National Tuberculosis Control Program (RNTCP) (TB) and National Vector Borne Disease Control Program (NVBDCP) (Malaria), and second, it examines which factors create an enabling environment for disease-specific programmes to strengthen health systems. METHODS: A total of 103 in-depth interviews were conducted in six states in 2009 and 2010. Key informants included managers of disease control programmes and health systems, central and state health ministry and staff from peripheral health facilities. Analytical themes were derived from the World Health Organization (WHO) building block and the Systems Rapid Assessment framework. FINDINGS: Disease-specific programmes contribute to strengthening some components of the health system by sharing human and material resources, increasing demand for health services by improving public perceptions of service quality, encouraging civil society involvement in service delivery and sharing diseasespecific information with local health system managers. These synergies were observed more frequently in the RNTCP and NVBDCP compared with the NACP. CONCLUSIONS: Disease-specific programmes in India are widely regarded as having made a substantial contribution in disease control. They can have both positive and negative effects on health systems. Certain conditions are necessary for them to have a positive influence on health systems­the programme needs to have an explicit policy to strengthen local health systems, and should also be embedded within the health system administration.

Health workforce in India: assessment of availability, production and distribution.

BACKGROUND: India faces an acute shortage of health personnel. Together with inequalities in distribution of health workers, this shortfall impedes progress towards achievement of the Millennium Development Goals. The aim of this study was to assess health-workforce distribution, identify inequalities in health-worker provision and estimate the impact of this maldistribution on key health outcomes in India. MATERIALS AND METHODS: Health-workforce availability and production were assessed by use of year-end data for 2009 obtained from the Indian Ministry of Statistics and Programme Implementation. Inequalities in the distribution of doctors, dentists, nurses and midwives were estimated by use of the Gini coefficient and the relation between health-worker density and selected health outcomes was assessed by linear regression. RESULTS: Inequalities in the availability of health workers exist in India. Certain states are experiencing an acute shortage of health personnel. Inequalities in the distribution of health workers are highest for doctors and dentists and have a significant effect on health outcomes. CONCLUSION: Although the production of health workers has expanded greatly in recent years, the problems of imbalances in their distribution persist. As India seeks to achieve universal health coverage by 2020, the realization of this goal remains challenged by the current lack of availability and inequitable distribution of appropriately trained, motivated and supported health workers.

India at the crossroads of millennium development goals 4 and 5.

The current year marks the completion of two thirds of the period between the adoption of the millennium development goals (MDGs) and the target date of 2015. Although there has been some progress, it is incontestable that much more needs to be done. India contributes to 20% of births worldwide and has the highest proportion of children younger than 5 years. Global progress toward MDG 4 and 5 depends significantly on improvements in maternal and child health indicators in India. Although it has been reported that the country has made substantial progress, the pace has been slow and marred by vast regional variability. Certain states continue to have unacceptably high mortality and morbidity rates. This article provides a context to the current status of maternal and child health in India, highlights the achievements, and uses the available data effectively to emphasize the progress. The authors acknowledge the new initiatives and make recommendations for reinforcing the continuum of care.

Role of Private Sector in Providing Tuberculosis Care: Evidence from a Population-based Survey in India.

BACKGROUND: In India, a large segment of the population seeks health care services from individual or institutional private health-care providers for health care. We analyzed a nationally representative data to identify the role of private providers in delivering health care for patients with tuberculosis. MATERIALS AND METHODS: The primary data source for the present analysis was the 60(th) round of the National Sample Survey. Distribution frequencies were used to analyze the distribution of key sociodemographic variables and multiple logistic regression was used to analyze the association between these variables and healthcare seeking behavior. RESULTS: A sample of 2203 respondents who had received ambulatory care for tuberculosis, and 4568 respondents who had received inpatient treatment were analyzed. About half of the respondents had attended private facilities for TB care. Sociodemographic variables such as paediatric age group, females, higher level of education, and economic groups were associated with attendance at private sector. Dissatisfaction with services in government facilities was cited as the main reason for preferring private facilities. CONCLUSIONS: Private providers play an important role in providing health care services to a large proportion of patients with tuberculosis. There is a need for innovative measures to increase participation of the private sector in the national TB control program and to improve the quality of services in government facilities.

Factors that determine the use of skilled care during delivery in India: implications for achievement of MDG-5 targets.

The objective of this study is to identify individual level factors that determine the use of skilled birth attendants in India. Data from the cross-sectional, population-based NFHS 3 Survey 2005-06 was used. A sample of 31,797 women, aged 15-49 years, who gave births in the 3 months preceding the survey and for whom information was available on most variables, were included in the analysis. Both bivariate and multivariate techniques were used to determine factors associated with the use of skilled attendants at birth. In the study we found that wealth is one of the strongest determinants of skilled birth attendant use, with the poor being at a disadvantage. There are significant differences in the use of skilled delivery care among the urban and rural populations in India. Women in urban areas are more likely to use skilled attendants. Muslim women and women with lower levels of education are also less likely to avail skilled delivery services. The use of skilled care depended significantly on the place of delivery. Women who gave history of antenatal visits were more likely to have skilled attendants at birth. Our analysis demonstrates that there are several financial, social, regional and cultural barriers to skilled birth attendant use in India. Effective strategies need to be planned to generate demand for skilled birth attendants and reduce barriers to care seeking, especially among rural poor.

Women's reproductive health in slum populations in India: evidence from NFHS-3.

The urban population in India is one of the largest in the world. Its unprecedented growth has resulted in a large section of the population living in abject poverty in overcrowded slums. There have been limited efforts to capture the health of people in urban slums. In the present study, we have used data collected during the National Family Health Survey-3 to provide a national representation of women's reproductive health in the slum population in India. We examined a sample of 4,827 women in the age group of 15-49 years to assess the association of the variable slum with selected reproductive health services. We have also tried to identify the sociodemographic factors that influence the utilization of these services among women in the slum communities. All analyses were stratified by slum/non-slum residence, and multivariate logistic regression was used to analyze the strength of association between key reproductive health services and relevant sociodemographic factors. We found that less than half of the women from the slum areas were currently using any contraceptive methods, and discontinuation rate was higher among these women. Sterilization was the most common method of contraception (25%). Use of contraceptives depended on the age, level of education, parity, and the knowledge of contraceptive methods (p < 0.05). There were significant differences in the two populations based on the timing and frequency of antenatal visits. The probability of ANC visits depended significantly on the level of education and economic status (p < 0.05). We found that among slum women, the proportion of deliveries conducted by skilled attendants was low, and the percentage of home deliveries was high. The use of skilled delivery care was found to be significantly associated with age, level of education, economic status, parity, and prior antenatal visits (p < 0.05). We found that women from slum areas depended on the government facilities for reproductive health services. Our findings suggest that significant differences in reproductive health outcomes exist among women from slum and non-slum communities in India. Efforts to progress towards the health MDGs and other national or international health targets may not be achieved without a focus on the urban slum population.

Emergence of manifestations of HIV infection in a case of systemic lupus erythematosus following treatment with IV cyclophosphamide.

Systemic lupus erythematosus (SLE) and infection with human immunodeficiency virus are rarely seen in the same patient. We describe a case of a 32-year-old lady, who was diagnosed with systemic lupus erythematosus (anti-dsDNA antibody positive) and was initially serologically negative for human immunodeficiency virus (HIV) infection. Following three cycles of IV cyclophosphamide, she was subsequently found to be infected with HIV, with marked depletion of peripheral CD4-positive T lymphocytes. While her SLE remained completely inactive, the course of HIV was rapidly progressive, suggesting that retroviral replication may have been enhanced by the underlying immunomodulation caused by cyclophosphamide and also by SLE per se.