Implementation bottlenecks of the National Health Insurance program in Nepal: Paving the path towards Universal Health Coverage: A qualitative study.

Most low and low-middle income countries adopting National Health Insurance (NHI) programs to achieve Universal Health Coverage are struggling to implement the program due to underlying problems at implementation. However, there is a lack of research that focuses on these problems. The Nepal NHI program initiated in 2016 has experienced numerous implementation challenges. This qualitative study delves into the NHI program's inputs and throughputs/implementation bottlenecks. The study based in Nepal's four districts included 28 in-depth interviews, six focus group discussions, and identified 12 themes that pointed to the NHI program's inadequate inputs causing bottlenecks. The analysis employed the Grounded Theory. The main challenges identified were insufficiently defined NHI implementations guidelines, conflicting Act clauses, a lack of HIB organizational guidelines, and inadequate human resources. The major throughput bottlenecks were difficulty enrolling the insurees, the inability to select the health providers competitively and to act as a prudent purchaser of the services. These inadequate inputs and throughput bottlenecks led to negative outputs such as insurees' high dropouts, and low coverage of poor households. The NHI program's sustainability might be at stake if the identified problems persist, further exacerbated by the plummeting economic situation in the country due to COVID-19.

Predictors of annual membership renewal to increase the sustainability of the Nepal National Health Insurance program: A cross-sectional survey.

Expanding membership coverage and retention of the National Health Insurance (NHI) programs among informal sector workers (ISWs) continues to be a significant challenge in most low and lower-middle-income countries (LMICs). The Nepal NHI program is also facing a similar problem, but to date, there are no studies that focus on identifying key predictors of annual membership renewal and retention in Nepal. This study therefore aimed to determine the predictors of intention to renew annual subscription to the NHI program among enrolled members. This cross-sectional quantitative study was part of a larger mixed-methods study conducted in three districts in Nepal. A random sample of 182 current NHI members and 61 dropped out NHI members who met the inclusion criteria were interviewed. The study's dependent variable was the intention to renew annual membership and employed univariate regression to assess the bivariate associations with the independent variables. The multivariate logistic regression examined the net effect of the independent variables on the odds of intention to renew. Our results showed that the household (HH) with high monthly income had lower odds of renewing their annual NHI membership (adjusted OR: 0.14, 95% CI: 0.03-0.58). Similarly, households (HHs) with overall health service satisfaction (adjusted OR:3.59, 95%CI: 1.23-10.43) and increased frequency of visits after NHI membership (adjusted OR: 10.09, 95% CI: 1.39-73.28) had high odds of renewing their membership. The top three dropout reasons were health services underutilization (43.3%), poor health services (26.9%), and the inadequacy of the benefits package (14.9%). Almost 64% of the respondents were willing to renew their membership upon improved services. The study found that the Nepal NHI annual membership renewal key predictors are HH income, health service quality, and health service utilization. Among these three key predictors, health service quality and service utilization were among the top three dropout reasons. The study, however, did not differentiate between moral hazards or actual service utilization, demanding further studies on the health service utilization of the insured members.

Quality Of Life And Relationship Between Functioning And Symptoms Of Female Patients With Breast Cancer Before Chemotherapy In A Cancer Clinic At Yangon,Myanmar.

BACKGROUND: Better quality of life (QOL) is associated with longer survival in cancer patients. This study evaluated the QOL and relationship between functioning and symptoms among female breast cancer patients before chemotherapy. METHODS: Cross-sectional study was conducted by including 74 participants attending a cancer clinic. European Organization for Research and Treatment of Cancer Quality of Life Questionnaire(s)-Core30 was applied for assessing QOL. It was composed of three domains namely global health status/QOL, functioning (includes five categories) and symptoms (includes nine categories). Pearson correlation and multiple linear regression were performed to find the relationship between functioning and symptoms in participants. The study was approved by Institutional Review Board of Defence Services Medical Research Centre, Myanmar with approval number IRB/2018/34. RESULTS: Global health status/QOL score was fair (61.8±20.1). Among the five categories of functioning, cognitive functioning score (83.6±19.8) was the highest and role functioning score (66.4±29.3) was the lowest. Among symptoms, insomnia score (29.3±30.7) was the highest and diarrhoea score (0.9±5.4) was the lowest. When Pearson correlation was performed, functioning and symptoms were negatively correlated. Fatigue had significant (p<0.001) moderate negative correlation with physical functioning, role functioning and emotional functioning, whereas pain with role functioning (p<0.001). When linear regression was performed, nausea & vomiting was the strongest predictor for impaired global health status/QOL (p<0.05), while fatigue was the strongest predictor for impairment in all five categories of functioning (p<0.05). CONCLUSIONS: Functioning and symptoms were negatively correlated in breast cancer patients. Nausea & vomiting and fatigue were the strongest predictors for impaired QOL.

The Effect of a Club in Making Differences in Knowledge, Attitude, and Practices on Family Planning Among Married Adolescent Girls in Urban Slums in Bangladesh.

Early marriage and childbearing have led to Bangladesh having the highest adolescent fertility rate in the Asia Pacific region. Adolescent pregnancy is correlated with pregnancy-related complications, preterm delivery, delivery of low-birth weight babies, and spousal violence. A quasi-experimental study was conducted in four urban slums (two intervention and two control areas) of Dhaka from July 2014 to August 2016 to assess the effectiveness of a married adolescent girls club (MAG club) in reducing the unmet need for family planning (FP) among married girls between the ages of 14 and 19 (n = 1601, 799 in intervention and 802 in control areas). The percentages of the targeted population using any modern method of contraception were significantly higher among respondents in the intervention areas than those in the control areas (72.6% versus 63.5%). The unmet need for FP was significantly lower among respondents in the intervention areas than that of the control areas (16.2% versus 20.7%). The MAG club was a well-received strategy to provide comprehensive information on FP, which in turn helped improve contraceptive method practices and reduced the unmet need for FP among married adolescent girls in urban slums in Bangladesh. The government could leverage its existing resources to expand the MAG Club model in rural parts of the country to achieve the targets outlined in its Adolescent Reproductive Health Strategy.

Effectiveness of robotics fall prevention program among elderly in senior housings, Bangkok, Thailand: a quasi-experimental study.

OBJECTIVE: This study aimed at investigating the effectiveness of a robotic fall prevention program on knowledge, exercises, balance, and incidence of falls among elderly in senior housings. PATIENTS AND METHODS: This is a quasi-experimental study. Sixty-four elderly in two senior housings in Bangkok with Barthel Index scale ≥12, who had either at least one fall experience in the past 12 months and/or had Timed Up and Go (TUG) test ≥20 seconds were recruited and purposively assigned to the intervention group (received a small robot-installed fall prevention software, personal coaching, and handbook, n=32) and control group (received only handbook, n=32). Outcomes were knowledge score evaluated by structured questionnaire through face-to-face interviews, number of exercises measured by self-recorded diary, and balance score assessed by TUG and Berg Balance Scale (BBS). The incidence of falls was assessed by face-to-face interviews. Both groups were assessed at baseline, 3rd, and 6th month after the intervention. RESULTS: There was a statistically significant improvement in knowledge mean score at 6th month in both the groups. However, the intervention group showed faster increase in knowledge mean score than the control group at 3rd month (P<0.01). The intervention group showed a statistically significant higher number of exercises than the control group at 3rd and 6th month (P<0.05). There was no statistically significant difference on TUG and BBS mean scores between the two groups at baseline, 3rd, and 6th month. However, the intervention group showed a statistically significant improvement in TUG and BBS at 6th month post-intervention (P<0.01). There was one fall reported in the control group. CONCLUSION: The robotic fall prevention program increased knowledge on fall prevention and promoted exercises and balance among elderly in senior housings.

Knowledge, skills and competency retention among health workers one year after completing helping babies breathe training in South Sudan

Introduction: this study aimed to evaluate the long-term retention of knowledge, skills, and competency of health workers who completed a Helping Babies Breathe (HBB) training program and its effect on newborn mortality. Methods: a quasi-experimental pre- and post-intervention study was conducted. Participants were health workers selected based on their previous training on HBB protocols. Participants were assessed for knowledge, skills, and competency in March 2017 (immediately before and after training), June 2017 (three months after training), and September 2018 (one year after training). Assessments were conducted using HBB questionnaires, checklists and practical skill drills. Mean scores were obtained and ANOVA, chi-squared test, and Pearson's test were used for pre intervention, post intervention, and one-year-after comparisons. The effect of training on the management of newborn asphyxia was assessed based on a review of the delivery registry at a maternity and children's ward. The scores were group into percentages and averages means and were computed using chi-squared tests.Results: despite improvements in knowledge, skills, and competency three months after training, participants showed a marked decline one year after training. Knowledge increased from 42.5% pretest to 97% posttest but decreased to 84.5% three months' post training and further decreased to 69.4% one year post training. Skills increased from 26.1% pretest to 94.4% posttest, remained at 94.4% at three months, and decreased to 77.0% at one year. Simple resuscitation scores increased from 26.9% to 88.8% pre- and posttest, remained roughly at three months and decreased to 76.4% at one year. For complex resuscitation, scores decreased from 90.9% posttest to 76.9% at one year. The assessments at one year indicated a need for support and practice, especially with bag-mask ventilation.Conclusion: the immediate evaluation of health workers after HBB training showed significant increases in knowledge, skills and competency in neonatal resuscitation. However, this declined after one year. The training also resulted in decreased neonatal mortality

Falls among physically active elderly in senior housings, Bangkok, Thailand: situations and perceptions.

PURPOSE: A mixed-method study aimed to assess situations in which falls occur including prevalence and associated risk factors of falls among physically active elderly who are at risk of experiencing a fall in senior housings, Bangkok, Thailand, and their perceptions regarding falls. PATIENTS AND METHODS: In the first phase, a cross-sectional study was conducted on 64 physically active elderly senior housing residents. Data on sociodemographics, health status, Barthel Index (BI) of activities of daily living, and fall experiences were collected through face-to-face interviews. Data on balance scores were obtained from Time Up and Go (TUG) test and Berg Balance Scale (BBS). In the second phase, a qualitative study was conducted on 41 physically active elderly who had experienced falls. Data regarding perception on falls, fall preventions, and fall management, were gathered through in-depth interviews from November 2017 to December 2017. RESULTS: The prevalence of falls among participants in senior housings was 64.1%. Univariate analysis found that a higher BI was associated with fall (P<0.004). Multivariate analysis using binary logistic regression showed that a higher BI (OR=6.00, 95% CI=1.24-29.10) together with ≥2 environmental hazards (OR=6.33, 95% CI=1.24-32.29) were associated with fall. The result from content analysis indicated that the elderly were aware that they were at risk of fall. In addition, the elderly also perceived that fall could be avoided even though they did not know how to prevent it. CONCLUSION: The prevalence of fall among physically active elderly in senior housings was relatively high. A higher BI scale and having ≥2 environmental hazards were associated risk factors of falls. Although the elderly perceived that fall could be avoided, they did not know how to prevent it. The intervention that focuses on environmental modification, balancing enchantment, and education on fall prevention is highly required.

Effectiveness Of A School-Based Multicomponent Intervention On Nutritional Status Among Primary School Children In Bangkok, Thailand.

BACKGROUND: Childhood obesity has become a major public health issue today. The prevalence of obesity and overweight is increasing in both adults and children. Childhood obesity in Thailand has more than doubled since the 1960s and a recent study reported that overweight and obesity in Thais is the 5th highest in Asia. The present study objective was to evaluate the effectiveness of a life-skills, multicomponent, school-based intervention on child nutritional status. METHODS: A quasi-experimental design was conducted in two-groups (control and intervention schools) on 453 students attending grade levels 4-5 in Bangkok. Two schools were selected for control, and two schools for intervention groups. The interventions included education, diet, physical activity (PA), food-environment, school builtenvironment, and life-skills components. Subjects were measured at baseline and at 6 months post-treatment. RESULTS: The intervention group had significant differences in overall healthy practices (+1.5 mean difference, p=0.048), dietary habits, physical activity, lower total cholesterol (TC) levels (-2.43 mean, p=0.019) and higher high density lipoprotein cholesterol (HDL-C) levels (+4.06 p=0.028) as compared to the control. A higher reduction of overweight individuals among the intervention group over the intervention period was observed. Physical activity and consumption of vegetables increased while consumption of high-caloric snacks and fast foods decreased in children after the intervention. CONCLUSIONS: This study indicated that a multidisciplinary approach in school-based interventions is most likely to be effective in preventing children from becoming overweight in the long term. More research should be conducted on school-based interventions with longer intervention periods and higher sustainability.

Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey.

BACKGROUND: Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation's lowest scores on key development and health indicators and presents a substantial challenge to Uganda's stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided. METHODS: A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated. RESULTS: There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section. CONCLUSIONS: To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.