Cardiac Implantable Devices Management in Medical Assistance in Dying (MAiD): Review and Recommendations for Cardiac Device Clinics.

The Medical Assistance in Dying (MAiD) program has been steadily expanding in Canada, and is expected to continue to do so. There are a substantial number of Canadians with pacemakers and defibrillators, many of whom are potential MAiD recipients. There is a need for review and reflection of standardisation of cardiac device management in MAiD patients, not only because of ethical concerns, but also because of the complexity of management at end of life. This document examines the status and role of cardiac devices (pacemakers and intracardiac defibrillators) and their physiologic interactions and influences during the MAiD process, and provides recommendations for their management.

Inclusion in limited distribution drug network reduces time to dalfampridine access in patients with multiple sclerosis at a health-system specialty pharmacy.

BACKGROUND: Dalfampridine improves walking speed in patients with multiple sclerosis (MS), but accessing specialty medications such as dalfampridine can be hindered by insurance restrictions, high costs, and limited distribution networks (LDNs) imposed by manufacturers. Some integrated health-systems specialty pharmacies (HSSPs) embed pharmacists in clinics and dispense medications from their internal pharmacies if included within the LDN. OBJECTIVE: To assess access to dalfampridine in patients at an HSSP before and after gaining admission to the LDN. METHODS: This study was conducted at Vanderbilt Specialty Pharmacy (VSP), an integrated HSSP at Vanderbilt University Medical Center (VUMC) with 2 clinical pharmacists embedded in the MS clinic. VSP gained access to the dalfampridine LDN on May 1, 2018, at which time the embedded pharmacists began to manage the comprehensive therapy initiation process. We performed a retrospective review of adult patients with MS who were prescribed dalfampridine from March 2010 to December 2018. Eligible prescriptions were new starts (no previous use) or restarts (after previous use and discontinuation). Prescriptions were classified as pre-VSP and post-VSP, which differentiates before and after VSP gained access to dispense dalfampridine. Study outcomes were insurance approval, initiation of therapy, and time from treatment decision to medication access. We used a proportional odds logistic regression model for time to medication access using the following covariates: pre-VSP versus post-VSP time period, insurance prior authorization (PA) denied versus approved/not needed, and baseline timed 25-foot walk. RESULTS: We included 262 patients and 290 prescriptions (260 pre-VSP and 30 post-VSP). In pre-VSP and post-VSP prescriptions, 97% were approved by insurance, and 93% of patients started therapy. Median time to medication access was 22 days (IQR = 11-45) for pre-VSP prescriptions and 1 day (IQR = 0-3) for post-VSP prescriptions. In the proportional odds logistic regression model, the odds of having a longer medication access time were significantly higher for pre-VSP prescriptions (OR = 83.219, P < 0.001) and prescriptions whose PA was initially denied (OR = 9.50, P < 0.001); 25-foot walk time was not significant (OR = 0.95, P = 0.277). CONCLUSIONS: After obtaining access to dispense dalfampridine, the time to access therapy was reduced, suggesting that LDNs delay patient access to therapy at HSSPs. DISCLOSURES: No funding was provided for this study. The authors have no conflicting interests to disclose. Preliminary results have been previously presented at the American Society of Health-Systems Pharmacy Midyear Meeting in December 2019, the Vanderbilt Health Systems Specialty Pharmacy Outcomes Research Summit in August 2020, and the National Association of Specialty Pharmacy Annual Meeting in September 2020.

Diabetes management interventions for homeless adults: a systematic review.

OBJECTIVES: Recent studies investigating diabetes show that inequalities to access appropriate care still persists. Whilst most of the general population are able to access a suitable quality of care, there are a number of groups who fail to receive the same standard. The objective of this review was to identify existing diabetes management interventions for homeless adults. METHODS: A literature search was conducted in February 2017, and repeated in September 2020. RESULTS: Of the 223 potentially relevant articles identified, only 26 were retrieved for detailed evaluation, and 6 met the inclusion criteria. Papers focusing on the management of diabetes in homeless people were included. The studies used interventions including diabetes education; medication support and supplies for blood monitoring; improvements in self-care behaviours; improvements in diabetes control; patient empowerment/engagement; and community engagement/partnerships. CONCLUSIONS: Effective strategies for addressing the challenges and obstacles that the homeless population face, requires innovative, multi-sectored, flexible and well-coordinated models of care. Without appropriate support, these groups of people are prone to experience poor control of their diabetes; resulting in an increased risk of developing major health complications.

Need and inequality in the use of health care services in a fragmented and decentralized health system: evidence for Argentina.

BACKGROUND: The high fragmentation and decentralization in the provision of health care services that characterizes Argentina's health system, as well as the economic and social inequalities, challenge the achievement of the Universal Health Coverage (UHC). The objective of this study is to measure socioeconomic-related inequality and horizontal inequity in the use of health care services in Argentina as well as identify the factors that contribute to these disparities. METHODS: The 2013 National Risk Factor Survey, developed by the Ministry of Health of Argentina, was used to measure socioeconomic-related inequality and inequity in the use of health care services through concentration curves, the Erreygers concentration index, and the index of horizontal inequity. Econometric micro-decomposition was applied to estimate the contribution of each determining factor to inequality in the use of health care services. RESULTS: The Erreygers concentration index for the use of health care services was 0.1223, evidencing pro-rich inequalities. By adding variables of health care needs, the horizontal inequity index was 0.1296. Non-need factors such as education and health coverage with social security increase pro-rich inequality. CONCLUSIONS: The Argentine health system shows pro-rich inequality in the use of health care services. It is necessary to design strategies to improve articulation between the three coverage subsectors and national, provincial, and municipal governments to keep the commitment of "not leaving anyone behind." The results showed here could provide lessons for countries with similar contexts and challenges in public health.

Contextual factors affecting the integration of community health workers into the health system in Limpopo Province, South Africa.

BACKGROUND: Community health workers (CHWs) are an essential cadre in the health systems of many low- and middle-income countries. These workers provide a wide variety of services and are key to ongoing processes of task shifting within human immunodeficiency virus programmes in particular. Ward-based outreach teams (WBOTs) are South Africa's latest iteration of the CHW programme and have been introduced as part of the National Department of Health's Primary Health Care Re-engineering programme. METHODS: In order to assess the perceived effectiveness of the WBOTs in supporting the ongoing rollout of antiretroviral therapy, tuberculosis care and patient support, we conducted a qualitative investigation focusing on the perceived successes and challenges of the programme among CHWs, community leaders, healthcare workers and community members in the Mopani district, Limpopo province, South Africa. RESULTS: The CHW programme operates across these contexts, each associated with its own set of challenges and opportunities. CONCLUSIONS: While these challenges may be interrelated, a contextual analysis provides a useful means of understanding the programme's implementation as part of ongoing decision-making processes.

Principios y deberes en el ejercicio de la dirección médica de los hospitales y centros sanitarios / Principles and duties in the exercise of the medical direction of hospitals and health centers

No disponible

Institutionalization of integrated community case management into national health systems in low- and middle-income countries: a scoping review of the literature.

Background: Integrated community case management (iCCM) for malaria, pneumonia and diarrhea continues to be a recommended strategy to address child mortality in areas where access to health facilities is limited.Objective: To identify models of, and gaps in, institutionalization of benchmark components of iCCM into national health systems of low-and-middle-income countries, in order to draw lessons for future iCCM implementation and sustainability.Methods: A scoping review of relevant searchable policy documents and publications available in English literature was undertaken. Data were selected, collated and characterized by three reviewers using the Arksey and O'Malley framework.Results: Overall 19 countries were reviewed. Despite the existence of discrete policies, most iCCM programs relied heavily on implementing partners and donor financing. Parallel implementing partner-run systems were often used to procure and supply iCCM medicines. These modes of implementation occasionally violated some health system strengthening principles. Drug stock-outs were still prominent in several countries, and iCCM indicators were sometimes not integrated into the national health management information system. There were no clearly defined motivation packages for both salaried and unsalaried workers, and there were several supervision challenges. Community-based performance-financing, use of technology with mobile devices (mHealth), small procedural improvements, and provision of targeted rather than universal services, were some of the promising interventions for improved iCCM institutionalization.Conclusion: Sustainable iCCM will require improved ownership by the benefiting communities and the local and central governments. Government commitment should be evident in budgeting processes and implementation strategies.

Targeting subsidised inpatient services to the poor in a setting with limited state capacity: proxy means testing in Myanmar's hospital equity fund scheme.

OBJECTIVES: Many low- and middle-income countries (LMICs) provide subsidised access to health services for the poor. Proxy means tests (PMTs) for income are typically employed to identify eligible beneficiaries for subsidised services but often result in significant mistargeting of benefits. We assessed the PMT approach used in Myanmar's hospital equity fund (HEF). METHODS: We analysed inclusion/exclusion errors by comparing household eligibility under the PMT used for HEF with household consumption (the gold standard proxy for income in LMICs). We assessed receipt of benefits post-hospitalisation against HEF eligibility rules and household income. Focus groups/interviews were conducted to understand administrative factors that influence targeting. We modelled (linear regression) predictors of household consumption to improve PMT accuracy. RESULTS: We found large targeting errors (86% of households in the bottom consumption quartile would be excluded and 15% of households in the top consumption quartile deemed eligible). HEF scores for PMT held little explanatory power for household income: 93% of individuals meeting the HEF eligibility criteria did not receive benefits post-hospitalisation, while 23% of ineligible individuals received programme support. Re-weighting PMT indicators on electricity access, land ownership and livestock ownership, and assigning weights to home-ownership, households with elderly/disabled members and household head education levels could significantly improve targeting accuracy. Poor programme awareness and uneven adherence to official eligibility determination procedures among staff likely affected targeting. CONCLUSIONS: Re-weighting PMT indicators and increasing training and communication about qualification procedures could improve allocation of limited funds, though accurate targeting may continue to be challenging in contexts of low state capacity.

OBJECTIFS: De nombreux pays à revenu faible ou intermédiaire (PRFI) offrent un accès subventionné aux services de santé pour les pauvres. Les tests des proxys moyens (TPM) de revenus sont généralement utilisés pour identifier les bénéficiaires éligibles pour les services subventionnés, mais aboutissent souvent à un ciblage erroné important des avantages. Nous avons évalué l'approche TPM utilisée dans le fonds d'équité des hôpitaux (FEH) du Myanmar. MÉTHODES: Nous avons analysé les erreurs d'inclusion/exclusion en comparant l'éligibilité d'un ménage selon le TPM utilisé pour le FEH avec la consommation du ménage (indicateur de référence par excellence du revenu dans les PRFI). Nous avons évalué la réception des prestations après l'hospitalisation par rapport aux règles d'éligibilité du FEH et au revenu du ménage. Des discussions de groupes ont été menées pour comprendre les facteurs administratifs qui influencent le ciblage. Nous avons modélisé (régression linéaire) les prédicteurs de la consommation des ménages afin d'améliorer la précision du TPM. RÉSULTATS: Nous avons constaté d'importantes erreurs de ciblage (86% des ménages du quartile de consommation le plus bas seraient exclus et 15% des ménages du quartile de consommation le plus haut jugés éligibles). Les scores FEH du TPM ont peu de pouvoir explicatif sur le revenu du ménage: 93% des personnes répondant aux critères d'éligibilité du FEH ne bénéficiaient pas de prestations post hospitalisation, tandis que 23% des personnes non éligibles recevaient un soutien du programme. La repondération des indicateurs du TPM sur l'accès à l'électricité, la propriété foncière et la propriété du bétail, et l'attribution de pondérations à la propriété du logement, aux ménages composés de personnes âgées/handicapées et au niveau d'éducation des chefs de ménage pourraient améliorer considérablement la précision du ciblage. La faible sensibilisation du programme et le respect inégal des procédures officielles de détermination de l'éligibilité parmi le personnel ont probablement affecté le ciblage. CONCLUSIONS: Une repondération des indicateurs du TPM et une augmentation de la formation et de la communication sur les procédures de qualification pourraient améliorer l'allocation de fonds limités, bien qu'un ciblage précis puisse continuer à être un défi dans des contextes de faible capacité de l'Etat.

Precision medicines need precision patient assistance programs.

The competing strategies of patient assistance programs and co-pay accumulator adjustment programs create confusion and administrative burden for clinicians and patients, potentially reducing adherence to clinically indicated services and worsening patient outcomes.

[Undergraduate studies in health: supply and institutional strategies in the context of the Brazilian Unified National Health System regionalization]. / Graduação em saúde: oferta e estratégias para o fortalecimento da regionalização do Sistema Único de Saúde.

This article aims to provide an overview of the territorial distribution of health training supply and to identify the strategies for strengthening regionalization adopted by teaching institutions that offer health courses and the changes in the regional surroundings as a function of these institutions. This is a descriptive-exploratory multiple-case study conducted at the national level in Brazil from December 2015 to September 2016. The study analyzed secondary data on health training supply and interviewed 68 administrators of undergraduate health courses, whose commentary was submitted to content analysis. There was an increase in health training institutions in smaller regions and municipalities (counties), although such institutions were still concentrated mainly in more socioeconomically developed regions. Policies have been implemented for access and enrollment in higher education from the perspective of promoting provision and professional retention in the region where the health course is located. The university's presence promotes regional development and has the potential to strengthen health regionalization.

Este artigo objetiva descrever o panorama de distribuição territorial da oferta de formação em saúde, bem como identificar as estratégias para o fortalecimento da regionalização adotadas pelas instituições de ensino que ofertam cursos de saúde e as mudanças verificadas no entorno regional em função dessas instituições. Trata-se de estudo descritivo-exploratório, do tipo estudo de casos múltiplos, desenvolvido em âmbito nacional no período de dezembro de 2015 a setembro de 2016. Foram analisados dados secundários de oferta de formação em saúde e foram entrevistados 68 gestores de ensino de cursos de graduação em saúde, cujos depoimentos foram submetidos a análise de conteúdo. Percebe-se um aumento de equipamentos para formação em saúde em regiões e municípios de menor porte, não obstante a concentração em locais com maior desenvolvimento socioeconômico. Políticas de acesso ao ensino superior de estudantes vêm sendo empreendidas, na perspectiva de promover a provisão e fixação profissional do entorno onde se localizam os cursos da saúde. Constata-se que a presença da universidade promove desenvolvimento regional e tem potencial para o fortalecimento da regionalização da saúde.

El objetivo de este artículo es describir el panorama de la distribución territorial, en cuanto a la oferta de formación en salud, e identificar estrategias para el fortalecimiento de la regionalización, adoptadas por las instituciones de enseñanza que ofrecen cursos de salud, además de analizar los cambios verificados en el entorno regional, en función de estas instituciones. Se trata de un estudio descriptivo-exploratorio, de casos múltiples, desarrollado en el ámbito nacional de Brasil durante el período de diciembre de 2015 a septiembre de 2016. Se analizaron datos secundarios de oferta de formación en salud, y se entrevistaron a 68 gestores de enseñanza de cursos de grado en salud, cuyas declaraciones fueron sometidas a análisis de contenido. Se percibe un aumento de equipamientos para la formación en salud en regiones y municipios de menor porte, pese a la concentración en lugares con mayor desarrollo socioeconómico. Se están emprendiendo políticas de acceso e ingreso en la enseñanza superior de estudiantes, desde la perspectiva de promover la provisión y emplazamiento del profesional en el entorno donde se localizan los cursos de salud. Se constata que la presencia de la universidad promueve el desarrollo regional y tiene potencial para el fortalecimiento de la regionalización de la salud.

European aid and health system strengthening: an analysis of donor approaches in the DRC, Ethiopia, Uganda, Mozambique and the global fund.

Background: In the field of international health assistance (IHA), there is a growing consensus on the limits of disease-specific interventions and the need for more health system strengthening (HSS). European donors are considered to be strong supporters of HSS. Nevertheless, little is known about how their support for HSS translates into concrete policies at partner country level. Furthermore, as development cooperation is a shared policy between the EU and its Member States, it remains unclear to what extent European donors share a similar approach. Objective: This article reviews a PhD thesis on European aid and HSS. The thesis investigated (1) the approaches of European donors towards IHA, and (2) the extent to which there are similarities or differences between them. An original analytical framework was developed to make a fine-grained analysis of European donors' approaches in the DRC, Ethiopia, Uganda and Mozambique. In addition, the relation of European donors with the Global Fund was investigated. Methods: An abductive research approach was used during which literature review, data generation, analysis and research design mutually influenced each other. The research built on a wide range of empirical data, including semi-structured interviews with 123 respondents, policy documents and descriptive statistical analysis. Results and conclusion: Four 'types' of European donors were identified, which vary in their focus (issue-specific versus comprehensive) and their level of support to and involvement of recipient states. Despite this heterogeneity at a specific level, there is still a general degree of 'unity' among European donors, especially compared with the US. Yet, there are signs that the 'transatlantic' divide on HSS may be converging, as European donors tend to focus more explicitly on result-oriented approaches traditionally associated with the US and Global Health Initiatives. Consequently, European donors play a limited role in bringing HSS more to the forefront in IHA.

Using mobile transport vouchers to improve access to skilled delivery.

INTRODUCTION: Reducing maternal death remains a challenge in many low-income countries. Preventing maternal deaths depends significantly on the presence of a skilled birth attendant at child delivery. The main objective of this study was to find out whether use of mobile transport vouchers would result in an increased number of pregnant women choosing to deliver at a health facility rather than at home. METHOD: A total of 86 expectant mothers living in Samburu County (Kenya), all having access to a mobile phone with Safaricom mobile SIM card, were enrolled into the project. Mixed methods research design was used to generate quantitative data on the voucher transactions and qualitative data from telephone interviews on technical usability of the transport voucher. RESULTS: The study demonstrated that the mobile transport voucher was a major driver for pregnant women to access healthcare facilities for skilled delivery. Illiteracy and resource scarcity were the main challenges experienced during implementation. CONCLUSION: Mobile technology can be successfully used in remote rural settings in Africa for targeting funds and guiding individuals towards better health care. The combination of such technology with communication agents (community health volunteers, ambulance drivers) proved particularly effective.

Questioning "choice": A multinational metasynthesis of research on directly funded home-care programs for older people.

In many developed contexts, home-care services have been overhauled with the intent of increasing control and flexibility for those using social and health services. This change is associated with providing funds directly to individuals, and sometimes their families and supports, to arrange at home-care assistance with the activities of daily living. Directly funded home-care programs, or "direct funding" (DF), are not value-neutral policy interventions, but complex and politicised tools for the enactment of care in contemporary times. In this qualitative metasynthesis, we consider 47 research articles published between 2009 and 2017 that explore various DF programs for older persons in the United Kingdom, Australia, and the United States to identify core concepts in the literature. We find that choice emerges as a central concern. We then assess the literature to explore the questions: How does the existing literature conceptualise choice, and the mechanisms through which choice is enhanced, in DF programs for older persons? How is choice, and the benefit of choice to older service users, understood in relevant studies? We argue that the concept of "choice" manifests as a normative goal with presumed benefits among the studies reviewed. Particularly when discussing DF for older people, however, it is essential to consider which mechanisms improve care outcomes, rather than focusing on which mechanisms increase choice writ large. In the case of DF, increased choice comes with increased legal responsibilities and often administrative tasks that many older people and their supports find burdensome. Furthermore, there is no evidence that choice over all elements of one's services is the mechanism that improves care experiences. We conclude by presenting alternative models of understanding care emerging from feminist and other critical scholarship to consider if we are, perhaps, asking the wrong questions about why DF is so often preferred over conventional home-care delivery.

A Framework for Rigorous Qualitative Research as a Component of Mixed Method Rapid-Cycle Evaluation.

As federal, state, and local governments continue to test innovative approaches to health care delivery, the ability to produce timely and reliable evidence of what works and why it works is crucial. There is limited literature on methodological approaches to rapid-cycle qualitative research. The purpose of this article is to describe the advantages and limitations of a broadly applicable framework for in-depth qualitative analysis placed within a larger rapid-cycle, multisite, mixed-method evaluation. This evaluation included multiple cycles of primary qualitative data collection and quarterly and annual reporting. Several strategies allowed us to be adaptable while remaining rigorous; these included planning for multiple waves of qualitative coding, a hybrid inductive/deductive approach informed by a cross-program evaluation framework, and use of a large team with specific program expertise. Lessons from this evaluation can inform researchers and evaluators functioning in rapid assessment or rapid-cycle evaluation contexts.

Graduação em saúde: oferta e estratégias para o fortalecimento da regionalização do Sistema Único de Saúde / Undergraduate studies in health: supply and institutional strategies in the context of the Brazilian Unified National Health System regionalization / Grado en salud: oferta y estrategias institucionales contextualizadas respecto a la regionalización del Sistema Único de Salud brasileño

Resumo: Este artigo objetiva descrever o panorama de distribuição territorial da oferta de formação em saúde, bem como identificar as estratégias para o fortalecimento da regionalização adotadas pelas instituições de ensino que ofertam cursos de saúde e as mudanças verificadas no entorno regional em função dessas instituições. Trata-se de estudo descritivo-exploratório, do tipo estudo de casos múltiplos, desenvolvido em âmbito nacional no período de dezembro de 2015 a setembro de 2016. Foram analisados dados secundários de oferta de formação em saúde e foram entrevistados 68 gestores de ensino de cursos de graduação em saúde, cujos depoimentos foram submetidos a análise de conteúdo. Percebe-se um aumento de equipamentos para formação em saúde em regiões e municípios de menor porte, não obstante a concentração em locais com maior desenvolvimento socioeconômico. Políticas de acesso ao ensino superior de estudantes vêm sendo empreendidas, na perspectiva de promover a provisão e fixação profissional do entorno onde se localizam os cursos da saúde. Constata-se que a presença da universidade promove desenvolvimento regional e tem potencial para o fortalecimento da regionalização da saúde.

Abstract: This article aims to provide an overview of the territorial distribution of health training supply and to identify the strategies for strengthening regionalization adopted by teaching institutions that offer health courses and the changes in the regional surroundings as a function of these institutions. This is a descriptive-exploratory multiple-case study conducted at the national level in Brazil from December 2015 to September 2016. The study analyzed secondary data on health training supply and interviewed 68 administrators of undergraduate health courses, whose commentary was submitted to content analysis. There was an increase in health training institutions in smaller regions and municipalities (counties), although such institutions were still concentrated mainly in more socioeconomically developed regions. Policies have been implemented for access and enrollment in higher education from the perspective of promoting provision and professional retention in the region where the health course is located. The university's presence promotes regional development and has the potential to strengthen health regionalization.

Resumen: El objetivo de este artículo es describir el panorama de la distribución territorial, en cuanto a la oferta de formación en salud, e identificar estrategias para el fortalecimiento de la regionalización, adoptadas por las instituciones de enseñanza que ofrecen cursos de salud, además de analizar los cambios verificados en el entorno regional, en función de estas instituciones. Se trata de un estudio descriptivo-exploratorio, de casos múltiples, desarrollado en el ámbito nacional de Brasil durante el período de diciembre de 2015 a septiembre de 2016. Se analizaron datos secundarios de oferta de formación en salud, y se entrevistaron a 68 gestores de enseñanza de cursos de grado en salud, cuyas declaraciones fueron sometidas a análisis de contenido. Se percibe un aumento de equipamientos para la formación en salud en regiones y municipios de menor porte, pese a la concentración en lugares con mayor desarrollo socioeconómico. Se están emprendiendo políticas de acceso e ingreso en la enseñanza superior de estudiantes, desde la perspectiva de promover la provisión y emplazamiento del profesional en el entorno donde se localizan los cursos de salud. Se constata que la presencia de la universidad promueve el desarrollo regional y tiene potencial para el fortalecimiento de la regionalización de la salud.

Contracting-out urban primary health care in Bangladesh: a qualitative exploration of implementation processes and experience.

BACKGROUND: Contracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh's two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries. METHODS: This qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes. RESULTS: In Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project's ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts. CONCLUSIONS: This study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.

Towards universal health coverage: a mixed-method study mapping the development of the faith-based non-profit sector in the Ghanaian health system.

BACKGROUND: Faith-based non-profit (FBNP) providers have had a long-standing role as non-state, non-profit providers in the Ghanaian health system. They have historically been considered to be important in addressing the inequitable geographical distribution of health services and towards the achievement of universal health coverage (UHC), but in changing contexts, this contribution is being questioned. However, any assessment of contribution is hampered by the lack of basic information about their comparative presence and coverage in the Ghanaian health system. In response, since the 1950s, there have been repeated calls for the 'mapping' of faith-based health assets. METHODS: A historically-focused mixed-methods study was conducted, collecting qualitative and quantitative data and combining geospatial mapping with varied documentary resources (secondary and primary, current and archival). Geospatial maps were developed, providing a visual representation of changes in the spatial footprint of the Ghanaian FBNP health sector. RESULTS: The geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts. CONCLUSION: FBNPs have had a long-standing role in the provision of health services and remain a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. Collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of UHC.