Variations in practice quality in five low-income countries: a conceptual overview

Country studies from Indonesia, Tanzania, India, Paraguay, and Mexico document the quality of medical advice and variation in practice quality across a number of dimensions. This overview paper serves three purposes. First, the studies use several different measures; we contextualize these measures and discuss how they relate to each other. Second, we propose a three-way decomposition to analyze variations in the quality of care. These variations can arise from inequalities in access, inequalities in choices, or inequalities arising from discrimination. We discuss common elements across the studies and draw policy implications for future research and advocacy.     

Safe Motherhood interventions in low-income countries: an economic justification and evidence of cost effectiveness

It is estimated that 1600 women die world-wide each day as a result of problems during pregnancy or childbirth. A large proportion of these deaths is preventable. This article examines the economic case for investing in safe motherhood interventions, and reviews key evidence of the cost effectiveness of safe motherhood interventions. According to one study, antenatal and maternal services comprise two of the six most cost effective sets of health interventions in low-income countries. However, little detailed evidence exists regarding the relative cost effectiveness of antenatal care, post-abortion care and essential obstetric care. Despite this there is clear evidence that interventions such as substituting manual vacuum aspiration for dilatation and curettage can result in significant savings both for health facilities and patients. The paper estimates first that 26% of maternal deaths are avoidable through antenatal/community-based interventions, costing around 30% of the WHO Mother Baby Package; and secondly that access to quality essential obstetric care can prevent a further 48% of maternal deaths, consuming 24% of total Mother Baby Package costs. Further work on the cost effectiveness of safe motherhood interventions would provide useful information for policy makers concerned with reducing maternal mortality in the most efficient manner possible.     

Improving hospital antibiotic use

Improving antibiotic use is an important component of efforts to prevent the emergence and spread of multi-resistant microorganisms in hospitals. There are many complex factors that influence clinical decision making such as antibiotic prescribing in hospitals. Guidelines for antibiotic use should be easily accessible and hospitals should develop their own antibiotic policies appropriate to their institutions. Effective implementation of guidelines requires support with strategies such as education, audit and feedback. Infection control practitioners (ICPs) need to be aware of the strategies used to improve hospital antibiotic use and may have an expanded role to play in the successful implementation of these programmes.     

Community-based health insurance in low-income countries: a systematic review of the evidence

Health policy makers are faced with competing alternatives, and for systems of health care financing. The choice of financing method should mobilize resources for health care and provide financial protection. This review systematically assesses the evidence of the extent to which community-based health insurance is a viable option for low-income countries in mobilizing resources and providing financial protection. The review contributes to the literature on health financing by extending and qualifying existing knowledge. Overall, the evidence base is limited in scope and questionable in quality. There is strong evidence that community-based health insurance provides some financial protection by reducing out-of-pocket spending. There is evidence of moderate strength that such schemes improve cost-recovery. There is weak or no evidence that schemes have an effect on the quality of care or the efficiency with which care is produced. In absolute terms, the effects are small and schemes serve only a limited section of the population. The main policy implication of the review is that these types of community financing arrangements are, at best, complementary to other more effective systems of health financing. To improve reliability and validity of the evidence base, analysts should agree on a more coherent set of outcome indicators and a more consistent assessment of these indicators. Policy makers need to be better informed as to both the costs and the benefits of implementing various financing options. The current evidence base on community-based health insurance is mute on this point.     

中国卫生应急管理体系建设调查分析

  目的  比较分析中国一线城市卫生应急管理评估体系。  方法  全面检索中国知网（CNKI）、万方数据知识服务平台(WANFANG DATA)和维普数据库（VIP））,限定从建库的1988年1月 — 2019年3月,制定纳入、排除标准,采用框架整合法,从卫生应急管理主体分类角度出发,对中国一线城市的卫生应急管理评估体系进行整合。  结果  纳入6篇研究,以政府和卫生行政部门、疾病预防控制机构、医疗卫生机构、卫生监督机构为卫生应急管理主体,共性指标分别为8、10、4和5项。个性指标更为细致化。  结论  共性指标统一性和引领性仍需加强,个性指标兼容性和关联性有待完善,应用性和推广性还需提高。另外,中国卫生应急管理评估体系多为“结果”式评估,“过程”式的评估体系和作用机制的探索还有极大的研究空间。     

Improving basic health service delivery in low-income countries: 'voice' to the poor

Public social services, such as basic health care, represent the effective option for the poor, especially in the rural areas of low-income countries. The quality of such services are at present extremely deficient, largely due to resource constraints and lack of political will to make them function effectively. The state can no longer provide the comprehensive services it has in the past and which were highly successful in a number of 'high-achieving' developing countries. Yet, the state must turn priority attention to providing public services for the poor, in order to close the widening gap between rich and poor. It needs to do this in partnership with the population it aims to reach, through effective linkage with grass-roots organizations and with the support of non-governmental organizations. Giving 'voice' and participation to the population can not only increase the resource base for public services, but can also significantly improve the accountability of providers and lead to a cost-effective option for the poor.     

Translating evidence into policy in low-income countries: lessons from co-trimoxazole preventive therapy

In the April 2010 issue of this journal, Date et al. expressed concern over the slow scale-up in low-income settings of two therapies for the prevention of opportunistic infections in people living with the human immunodeficiency virus: co-trimoxazole prophylaxis and isoniazid preventive therapy. This short paper discusses the important ways in which policy analysis can be of use in understanding and explaining how and why certain evidence makes its way into policy and practice and what local factors influence this process. Key lessons about policy development are drawn from the research evidence on co-trimoxazole prophylaxis, as such lessons may prove helpful to those who seek to influence the development of national policy on isoniazid preventive therapy and other treatments. Researchers are encouraged to disseminate their findings in a manner that is clear, but they must also pay attention to how structural, institutional and political factors shape policy development and implementation. Doing so will help them to understand and address the concerns raised by Date et al. and other experts. Mainstreaming policy analysis approaches that explain how local factors shape the uptake of research evidence can provide an additional tool for researchers who feel frustrated because their research findings have not made their way into policy and practice.     

Socioeconomic determinants of outpatient antibiotic use in Europe

Objectives  

Outpatient antibiotic consumption widely varies across Europe. The investigation of the causes of such variation may help to identify interventions that would improve the efficient use of antibiotics. The aim of this study was to assess the impact of socioeconomic determinants and the role played by information about bacterial resistance.     

Mobile health use in low- and high-income countries: an overview of the peer-reviewed literature

The evolution of mobile phone technology has introduced new possibilities to the field of medicine. Combining technological advances with medical expertise has led to the use of mobile phones in all healthcare areas including diagnostics, telemedicine, research, reference libraries and interventions. This article provides an overview of the peer-reviewed literature, published between 1 August 2006 and 1 August 2011, for the application of mobile/cell phones (from basic text-messaging systems to smartphones) in healthcare in both resource-poor and high-income countries. Smartphone use is paving the way in high-income countries, while basic text-messaging systems of standard mobile phones are proving to be of value in low- and middle-income countries. Ranging from infection outbreak reporting, anti-HIV therapy adherence to gait analysis, resuscitation training and radiological imaging, the current uses and future possibilities of mobile phone technology in healthcare are endless. Multiple mobile phone based applications are available for healthcare workers and healthcare consumers; however, the absolute majority lack an evidence base. Therefore, more rigorous research is required to ensure that healthcare is not flooded with non-evidence based applications and is maximized for patient benefit.     

The use of private-sector contracts for primary health care: theory, evidence and lessons for low-income and middle-income countries

Contracts for the delivery of public services are promoted as a means of harnessing the resources of the private sector and making publicly funded services more accountable, transparent and efficient. This is also argued for health reforms in many low- and middle-income countries, where reform packages often promote the use of contracts despite the comparatively weaker capacity of markets and governments to manage them. This review highlights theories and evidence relating to contracts for primary health care services and examines their implications for contractual relationships in low- and middle-income countries.     

Socioeconomic determinants of regional differences in outpatient antibiotic consumption: evidence from Switzerland

This paper investigates the determinants of regional variations in outpatient antibiotic consumption using Swiss data. The analysis contributes to the debate on appropriate antibiotic use by improving the understanding of its determinants, and may help to define more effective health care policies to reduce the resistance phenomenon. Findings suggest that Switzerland exhibits relatively low levels of consumption among European countries. There are significant differences between cantons both in the per capita antibiotic sales and defined daily doses per 1000 inhabitants (DID). Econometric estimations suggest that DID are significantly related to per capita income, antibiotic price, the density of medical practices, demographic, cultural and educational factors. The incidence of bacterial infections is also relevant. Appropriate policies affecting antibiotic consumption in the community can be designed by looking at crucial determinants in the model and their related impact.     

Progress towards antibiotic use targets in eight high-income countries

ObjectiveTo compare antibiotic sales in eight high-income countries using the 2019 World Health Organization (WHO) Access, Watch and Reserve (AWaRe) classification and the target of 60% consumption of Access category antibiotics.MethodsWe analysed data from a commercial database of sales of systemic antibiotics in France, Germany, Italy, Japan, Spain, Switzerland, United Kingdom of Great Britain and Northern Ireland, and United States of America over the years 2013–2018. We classified antibiotics according to the 2019 AWaRe categories: Access, Watch, Reserve and Not Recommended. We measured antibiotic sales per capita in standard units (SU) per capita and calculated Access group sales as a percentage of total antibiotic sales.FindingsIn 2018, per capita antibiotic sales ranged from 7.4 SU (Switzerland) to 20.0 SU (France); median sales of Access group antibiotics were 10.9 SU per capita (range: 3.5–15.0). Per capita sales declined moderately over 2013–2018. The median percentage of Access group antibiotics was 68% (range: 22–77 %); the Access group proportion increased in most countries between 2013 and 2018. Five countries exceeded the 60% target; two countries narrowly missed it (> 55% in Germany and Italy). Sales of Access antibiotics in Japan were low (22%), driven by relatively high sales of oral cephalosporins and macrolides.ConclusionWe have identified changes to prescribing that could allow countries to achieve the WHO target. The 60% Access group target provides a framework to inform national antibiotic policies and could be complemented by absolute measures and more ambitious values in specific settings.     

Franchising of health services in low-income countries

Grouping existing providers under a franchised brand, supported by training, advertising and supplies, is a potentially important way of improving access to and assuring quality of some types of clinical medical services. While franchising has great potential to increase service delivery points and method acceptability, a number of challenges are inherent to the delivery model: controlling the quality of services provided by independent practitioners is difficult, positioning branded services to compete on either price or quality requires trade-offs between social goals and provider satisfaction, and understanding the motivations of clients may lead to organizational choices which do not maximize quality or minimize costs. This paper describes the structure and operation of existing franchises and presents a model of social franchise activities that will afford a context for analyzing choices in the design and implementation of health-related social franchises in developing countries.     

Methods of nutrition surveillance in low-income countries

Background

In 1974 a joint FAO/UNICEF/WHO Expert Committee met to develop methods for nutrition surveillance. There has been much interest and activity in this topic since then, however there is a lack of guidance for practitioners and confusion exists around the terminology of nutrition surveillance. In this paper we propose a classification of data collection activities, consider the technical issues for each category, and examine the potential applications and challenges related to information and communication technology.

Analysis

There are three major approaches used to collect primary data for nutrition surveillance: repeated cross-sectional surveys; community-based sentinel monitoring; and the collection of data in schools. There are three major sources of secondary data for surveillance: from feeding centres, health facilities, and community-based data collection, including mass screening for malnutrition in children. Surveillance systems involving repeated surveys are suitable for monitoring and comparing national trends and for planning and policy development. To plan at a local level, surveys at district level or in programme implementation areas are ideal, but given the usually high cost of primary data collection, data obtained from health systems are more appropriate provided they are interpreted with caution and with contextual information. For early warning, data from health systems and sentinel site assessments may be valuable, if consistent in their methods of collection and any systematic bias is deemed to be steady. For evaluation purposes, surveillance systems can only give plausible evidence of whether a programme is effective. However the implementation of programmes can be monitored as long as data are collected on process indicators such as access to, and use of, services. Surveillance systems also have an important role to provide information that can be used for advocacy and for promoting accountability for actions or lack of actions, including service delivery.

Conclusion

This paper identifies issues that affect the collection of nutrition surveillance data, and proposes definitions of terms to differentiate between diverse sources of data of variable accuracy and validity. Increased interest in nutrition globally has resulted in high level commitments to reduce and prevent undernutrition. This review helps to address the need for accurate and regular data to convert these commitments into practice.

     

AmBisome: an overview of current use.

Although amphotericin B has been the gold standard in treating systemic fungal infections, its use is limited by side-effects including nephrotoxicity. In contrast the empiric or therapeutic use of AmBisome is better tolerated, with less nephrotoxicity.     

Improving the use of research evidence in guideline development: introduction

In 2005 the World Health Organisation (WHO) asked its Advisory Committee on Health Research (ACHR) for advice on ways in which WHO can improve the use of research evidence in the development of recommendations, including guidelines and policies. The ACHR established the Subcommittee on the Use of Research Evidence (SURE) to collect background documentation and consult widely among WHO staff, international experts and end users of WHO recommendations to inform its advice to WHO. We have prepared a series of reviews of methods that are used in the development of guidelines as part of this background documentation. We describe here the background and methods of these reviews, which are being published in Health Research Policy and Systems together with this introduction.