Quality of care for under-fives in first-level health facilities in one district of Bangladesh

OBJECTIVE: The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. MCE studies are under way in Bangladesh, Brazil, Peru, Uganda and the United Republic of Tanzania. The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children under 5 years old in first-level government health facilities, to inform government planning of child health programmes. METHODS: Generic MCE Health Facility Survey tools were adapted, translated and pre-tested. Medical doctors trained in IMCI and these tools conducted the survey in all 19 health facilities in the study areas. The data were collected using observations, exit interviews, inventories and interviews with facility providers. FINDINGS: Few of the sick children seeking care at these facilities were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home. Over one-third of the sick children whose care was observed were managed by lower-level workers who were significantly more likely than higher-level workers to classify the sick child correctly and to provide correct information on home care to the caregiver. CONCLUSION: These results demonstrate an urgent need for interventions to improve the quality of care provided for sick children in first-level facilities in Bangladesh, and suggest that including lower-level workers as targets for IMCI case-management training may be beneficial. The findings suggest that the IMCI strategy offers a promising set of interventions to address the child health service problems in Bangladesh.     

层次分析法在公共卫生专业学生伤害预防核心能力评估指标建立中的应用

确定公共卫生专业学生伤害预防核心能力评价指标及其权重,以建立系统完整的伤害预防核心能力评估指标.方法 邀请22位国内外伤害预防领域的专家参与德尔菲专家咨询,根据咨询结果删选指标并采用层次分析法确定最终指标的权重.结果 根据德尔菲专家咨询结果构建的评估指标包括5个一级指标和31个二级指标,采用层次分析法得到了二级指标权重,其中一级指标权重:“伤害问题分析评估能力”为0.298,“伤害预防项目计划和实施能力”为0.237,“沟通交流能力”为0.199,“社区实践能力”为0.169,“领导和系统思维能力”为0.097.排在前5位的二级指标权重:“描述哪些因素会导致伤害的能力”为0.051,“获取、收集、分析、应用和传播伤害信息的能力”为0.046,“具备实施伤害预防和干预措施/活动的能力”为0.044,“向社区人员、其他专业人员、关键的政策制定者,有效地传播伤害预防信息的能力”为0.044,“具备制定伤害预防项目总目标和分目标的能力”为0.041.结论 本研究构建的公共卫生专业学生伤害预防核心能力评估指标及其权重客观可信,可用于推动我国医学院校建立科学的伤害预防课程体系及课程考核机制.     

Evaluating the WHO Assessment Instrument for Mental Health Systems by comparing mental health policies in four countries

Mental health is a low priority in most countries around the world. Minimal research and resources have been invested in mental health at the national level. As a result, WHO has developed the Assessment Instrument for Mental Health Systems (WHO-AIMS) to encourage countries to gather data and to re-evaluate their national mental health policy. This paper demonstrates the utility and limitations of WHO-AIMS by applying the model to four countries with different cultures, political histories and public health policies: Iraq, Japan, the Philippines and The former Yugoslav Republic of Macedonia. WHO-AIMS provides a useful model for analysing six domains: policy and legislative framework; mental health services; mental health in primary care; human resources; education of the public at large; and monitoring and research. This is especially important since most countries do not have experts in mental health policy or resources to design their own evaluation tools for mental health systems. Furthermore, WHO-AIMS provides a standardized database for cross-country comparisons. However, limitations of the instrument include the neglect of the politics of mental health policy development, underestimation of the role of culture in mental health care utilization, and questionable measurement validity.     

家庭医生签约服务评估指标体系构建研究

目的:构建家庭医生签约服务评估指标体系,以便从卫生服务的不同层面对家庭医生签约服务工作进行评估。方法:运用文献、现场调查以及专家咨询构建筛选评估指标的初步框架;通过Delphi法专家咨询后运用统计学方法进行分析,构建家庭医生签约服务评价指标体系。结果:建立了家庭医生签约模式评估指标体系,包括一级指标3个,分别为准备性、过程性和结果性评价指标;二级指标8个,主要有人力资源投入、基本医疗、基本公卫、服务效率和满意度等;三级指标39个,如每万人口家庭医生数、首诊率、签约居民医疗事故和医疗纠纷发生率等。结论:本研究构建的指标体系具有敏感性和可行性,能够对家庭医生签约工作进行综合评价,为家庭医生签约服务工作的管理、考核及评价提供了参考依据。     

Evaluating program effects on institutional delivery in Peru

We evaluate the joint effects of two targeted Peruvian health programs on a mother's choice of whether to deliver in a public emergency obstetric care (EmOC) facility. The national maternal and child health insurance, or SMI Program, provided delivery care coverage to Peru's poorest households beginning in 1998. During 1996-2002, Proyecto 2000 sought to improve the quality of EmOC and increase utilization of public EmOC facilities in the districts reporting the highest maternal and neonatal mortality levels. Our data come from the Proyecto 2000 endline evaluation, which sampled 5335 mothers living in the catchment areas of 29 treatment and 29 matched control EmOC facilities. Using propensity scoring and two quality of care indices, we find significantly higher quality of care in Proyecto 2000 treatment facilities. Using variance components logistic models, we find a mother enrolled in the SMI Program was more likely to have delivered her last child in a public EmOC, controlling for household constraints. Residence in a Proyecto 2000 treatment area did not significantly affect the choice. A cross-level interaction term was insignificant, indicating the two program effects were independent.     

构建综合性中医院后勤满意度评价体系

目的构建综合性中医院后勤满意度评价体系,提升医院后勤服务质量。方法基于德尔菲法和文献分析法,通过两轮专家咨询,构建后勤满意度评价体系,采用层次分析法确定各指标权重,并经现场调查对评价体系进行信效度检验。结果专家组成员共计21名,两轮专家积极系数均大于0.7,权威系数为0.87,专家意见协调系数分别为0.62、0.65。构建的患者后勤满意评价体系包括3个一级指标、28个二级指标,职工后勤满意度评价体系包括3个一级指标、34个二级指标。患者和职工后勤满意度评价体系Cronbach's α均大于0.9,所有条目相关系数均大于0.5。 结论综合性中医院患者和职工后勤满意度评价体系构建过程科学,信效度较高,能够真实反映后勤服务质量,可进一步推广使用。     

卫生检验与检疫专业人员岗位胜任力评价指标体系的构建

目的 构建科学、有效的卫生检验与检疫专业人员岗位胜任力评价指标体系,为卫生检验与检疫专业人员岗前培训提供参考。方法 通过文献分析、理论研究、现场访谈的方法初步构建卫生检验与检疫专业人员岗位胜任力评价指标体系,选取18位专家采用Delphi专家咨询法进行两轮的问卷咨询确定卫生检验与检疫专业人员岗位胜任力评价指标体系,用AHP层次分析法确定指标权重。结果 两轮专家咨询的问卷回收率均为100%,计算得专家权威系数为0.865,两轮调查专家意见的协调度分别为0.310和0.280。最终确定了一级指标6项,二级指标49项。一级指标医学基础知识、预防医学知识、卫生检验与检疫知识、实践技能、个人能力、综合素质的权重分别为0.1272、0.1655、0.2134、0.1530、0.1482、0.1927。结论 初步形成了卫生检验与检疫专业人员岗位胜任力评价指标体系,此体系构建较可靠,可为卫生检验与检疫专业人员的培训与考核提供科学依据。     

新疆县级医院突发公共卫生事件应急能力评估体系的构建

  目的  构建适用于新疆县级医院突发公共卫生事件的应急能力评估体系。
  方法  在文献回顾、突发事件调查报告分析及专家咨询的基础上,拟建立评估体系框架,邀请15位专家使用Delphi法为各级指标制定两轮重要性评审,并提出修正建议,按照专家的权威系数对各指标得分进行校正。
  结果  第一轮和第二轮的专家咨询协调系数分别为0.636、0.515,专家的权威程度平均为0.783。本研究的应急能力评估体系含9个一级指标、22个二级指标和52个三级指标。评估体系Cronbach's α系数为0.922,表明评估体系调查表信度良好。得到的应急能力评估体系的一级指标及其权重分别为应急制度0.121 7、应急机构0.120 1、疾病预警与监测0.118 9、现场救援和医疗救治0.125 5、后勤保障0.106 5、应急培训与演练0.114 3、公众宣传教育0.083 5、危机沟通与心理支持0.105 7、评估与改进0.104 0。运用该体系评估昌吉州14所医疗机构应急能力,按弱、中、强分级,分别占21.43%、50.00%和28.57%。
  结论  昌吉州领域内医疗机构的应急能力有待进一步提升。本研究构建的应急能力评估体系内容广泛,涉及突发事件的各个方面,具有良好的适用性。
     

Improving the implementation of cost recovery for health: lessons from Zimbabwe

In the current debate over health financing policy in developing countries, governments are increasingly focusing on cost recovery--having patients pay part or all of their health care costs--as a way to mobilize more resources for health, improve equity by selectively charging the wealthy, and increase efficiency by encouraging reinvestment of fee revenues into cost-effective primary care. Zimbabwe offers an important example of a country with a tradition of levying fees in government health facilities, but where enforcement became lax in the 1980s. In 1991, policymakers resolved to resuscitate and strengthen cost recovery, as part of a broader economic reform program. This paper discusses the strengths and weaknesses of Zimbabwe's cost recovery system, its potential for improvement, and the obstacles to change in revising the fee structure and billing and collection procedures. It argues that cost recovery can help to achieve Zimbabwe's health objectives, but only in conjunction with other measures to redirect public spending to essential public health and clinic care and improve the efficiency of government services. The paper finds that during the 1980s, the fee schedule became badly misaligned with actual medical care costs and created distortions in patient referral patterns. Billing and collection were also weak, because of deficiencies in personnel and information systems and lack of incentives for revenue generation. The paper concludes that if key steps were taken to raise the collections-to-billings ratio, recover fees from privately-insured patients, and adjust fees in line with medical cost inflation, recoveries could increase fourfold, from 5% to 20% of government spending for clinical care. At the same time, access to government health services for the poor could be maintained by improving exemption procedures.     

应用德尔菲法构建糖尿病患者健康信息素养评价指标体系

目的应用德尔菲法构建糖尿病患者健康信息素养评价指标体系。方法通过文献分析法初步构建糖尿病患者健康信息素养评价指标体系,在此基础上采用德尔菲法,通过对22名专家3轮问卷咨询来确定指标体系。结果确定的糖尿病患者健康信息素养指标体系,共有健康信息意识、健康信息知识和健康信息能力3个一级指标、9个二级指标和39个三级指标。3轮咨询专家积极系数为100%,专家平均权威程度为0.86,总指标的专家协调系数分别为0.292、0.464和0.482（P〈0.001）。结论专家代表性强,权威程度高,协调性好,初步构建的糖尿病患者健康信息素养评价指标体系较为科学合理。     

医防融合背景下临床医师的公共卫生知识与技能要点研究

目的 构建临床医师的一般公共卫生知识和技能体系,为培养临床医师的公共卫生知识和技能提供参考。方法通过文献研究、深度访谈、焦点小组访谈等方法归纳提炼临床医师的公共卫生知识和技能要点,并邀请16位专家采用德尔菲法对临床医师的一般公共卫生知识和技能进行筛选,根据专家咨询结果确立知识与技能要点。结果 经过两轮的专家咨询,建立了临床医师的一般公共卫生知识与技能体系,包含有7个一级维度、22个二级维度和99个三级维度。结论 构建了临床医师需掌握的一般公共卫生知识技能体系。     

The effects of free government health insurance among small children—evidence from the free care for children under six policy in Vietnam

Over the last few years, there have been an increasing number of impact evaluations of health insurance and other demand‐side financing programs in developing countries. Yet the literature on insurance impact among small children is limited. This paper evaluates the effects of a Vietnamese government's policy in 2005, which granted free access to health services in public facilities to all children younger than 6 years. In particular, we focus on children among households who are not eligible for a program for the poor, which has been administered concurrently in the country. Using two waves of the Vietnam Household Living Standard Surveys conducted right before and after the policy started and a difference‐in‐differences method, we found a major increase in both inpatient and outpatient care in the secondary public hospitals. At the same time, there is evidence indicating a reduction in the use of tertiary hospitals. Compared with the policy's non‐beneficiaries, beneficiaries in the age group 4–5 years also experienced fewer sick days, incurred less out‐of‐pocket spending on healthcare, and were less likely to encounter catastrophic expenditure. Evidence thus suggests that insurance provided by the policy has served the function as a safety net and helped improving efficiency of the health system by reducing the use of costly tertiary care. Copyright © 2012 John Wiley & Sons, Ltd.     

Quality of care and the demand for health services in Bamako,Mali: the specific roles of structural,process, and outcome components

The public finance and foreign exchange crisis of the 1980s aggravated the unfavourable economic trends in many developing countries and resulted in budget cuts in the health sector. Policymakers, following the suggestions of World Bank experts, introduced user fees. Economic analysis of the demand for health care in these countries focused on the impact of price and income on health service utilisation. But the lesson to date from experiences in cost recovery is that without visible and fairly immediate improvements in the quality of care, the implementation of user fees will cause service utilisation to drop. For this reason, the role of quality of health care has been recently a subject of investigation in a number of health care demand studies. In spite of using the data from both households and facilities, recent studies are quite limited because they measure quality only by structural attributes (availability of drugs, equipment, number and qualifications of staff, and so on). Structural attributes of quality are necessary but not sufficient conditions for demand. A unique feature of this study is that it also considers the processes followed by practitioners and the outcome of care, to determine simultaneously the respective influence of price and quality on decision making. A nested multinomial logit was used to examine the choice between six alternatives (self-treatment, modern treatment at home, public hospital, public dispensary, for-profit facility and non-profit facility). The estimations are based on data from a statistically representative sample of 1104 patients from 1191 households and the data from a stratified random sample of 42 out of 84 facilities identified. The results indicate that omitting the process quality variables from the demand model produces a bias not only in the estimated coefficient of the "price" variable but also in coefficients of some structural attributes of the quality. The simulations suggest that price has a minor effect on utilisation of health services, and that health authorities can simultaneously double user fees and increase utilisation by emphasising improvement of both the structural and process quality of care in public health facilities.     

中小学校传染病流行风险评价指标体系构建

  目的  建立中小学校传染病流行风险评价指标体系,做好学校传染病预警工作,将学校传染病防控的关口前移。  方法  通过文献查阅,业内相关专家咨询以及结合实际工作经验等方法,形成指标条目池。采用德尔菲法进行两轮专家咨询(第1轮13名,第2轮20名),统计分析每轮咨询时专家意见的集中程度(平均分、满分比)和协调程度(变异系数、协调系数W),其中协调系数W采用多个样本的非参数Kendall's W检验得到。根据专家反馈意见对指标进行必要的增、减、修,最终确定评价的指标体系,并采用层次分析法计算各指标权重。  结果  两轮咨询的专家权威系数分别为0.89和0.88,表格回收率均为100%;各三级指标变异系数范围分别为0.07~0.31和0.06~0.19,协调系数W分别为0.25和0.47,说明专家意见的一致性和可信度均较好。最终建立由5个一级指标、23个二级指标、86个三级指标组成的中小学校传染病流行风险评价指标体系。采用层次分析法计算指标的级别内权重,学校卫生管理与保障制度、学校卫生人员设施、健康监测与认知水平、严重性和应对措施5个一级指标的变异系数分别为0.09,0.06,0.08,0.12和0.06,权重系数分别为20.42%,21.19%,19.87%,17.45%和21.08%。  结论  研究构建了适用于中小学校的学校传染病流行风险评价指标体系,专家积极性、协调性和权威程度均较好,对于落实中小学校传染病预警工作具有实际指导意义。     

Out-of-pocket payments for under-five health care in rural southern Tanzania

Catastrophic payments and fairness in financial contributions for health care are becoming increasing concerns for many governments. Out-of-pocket financing for health care is common in many developing countries, including Tanzania. As part of the Multi-Country Evaluation of the Integrated Management of Childhood Illness (MCE-IMCI), the objective of this paper is to explore the determinants of variation and the level of out-of-pocket payments for child health care in rural Tanzania, with and without IMCI, using data from two household surveys conducted in 1999 and 2002. We analyzed data for 833 visits to health providers for 764 children who had been sick in the 2 weeks prior to the survey and who had sought care at a 'Western' or formal health care provider. We found evidence that IMCI was associated with lower out-of-pocket costs at government facilities (Tshs.3.5 compared with Tshs.6.9 without IMCI) and in NGOs (Tshs.95.1 compared with Tshs.267.3). Out-of-pocket payments were on average Tshs.110.1 when care was sought at government primary health care facilities running a cost-sharing scheme, about 15 times higher than in those not part of the scheme (p<0.0001). Those who visited NGO facilities paid about 30 times more than those seeking care at government facilities not operating the cost-sharing scheme (p<0.0001). In conclusion, there is no doubt that health care financing mechanisms and equitable access to government facilities have a major impact on household economic burden related to under-five illness. Increasing access to IMCI-based care, however, offers an additional opportunity to reduce out-of-pocket payments, mainly through more rational use of medicines. Increasing access to IMCI-based care would not only improve inequities in financial contributions, but also in health, an important consideration for its own sake.     

儿童专科医院科室科技评价指标体系构建研究

目的构建儿童专科医院科室科技评价指标体系。方法基于文献研究法初步构建儿童专科医院科室科技评价指标体系框架。采用德尔菲法,邀请21名专家进行三轮专家咨询,确定儿童专科医院科室科技评价指标体系。通过层次分析法确定各指标权重。采用统计学方法计算专家积极系数、权威系数与协调系数。结果三轮专家咨询积极系数分别为100%、100%和76.19%,专家权威系数为0.79~1,专家协调系数分别为0.39、0.37。初步构建的儿童专科医院科室科技评价指标体系,包括4个一级指标、15个二级指标、40个三级指标。结论专家咨询结果可靠性较好,初步构建的科室科技评价指标体系科学性较好,可为我国儿童专科医院科研决策提供信息支持,但仍需进一步开展实证研究。     

妇幼保健机构信用等级评价指标体系的构建

目的建立适用于我国妇幼保健机构的信用等级评价指标体系,为推进妇幼保健机构信用等级评价工作提供参考。方法综合运用文献分析法、专家咨询访谈、课题组研讨等方式构建初步指标体系,通过两轮德尔菲专家调查形成最终指标并赋予权重。结果建立了主要包含7个一级指标、38个二级指标的妇幼保健机构信用等级评价指标体系。结论研究建立的妇幼保健...     

Leveraging Geospatial Data,Technology, and Methods for Improving the Health of Communities: Priorities and Strategies from an Expert Panel Convened by the CDC

In 2008, CDC convened an expert panel to gather input on the use of geospatial science in surveillance, research and program activities focused on CDC’s Healthy Communities Goal. The panel suggested six priorities: spatially enable and strengthen public health surveillance infrastructure; develop metrics for geospatial categorization of community health and health inequity; evaluate the feasibility and validity of standard metrics of community health and health inequities; support and develop GIScience and geospatial analysis; provide geospatial capacity building, training and education; and, engage non-traditional partners. Following the meeting, the strategies and action items suggested by the expert panel were reviewed by a CDC subcommittee to determine priorities relative to ongoing CDC geospatial activities, recognizing that many activities may need to occur either in parallel, or occur multiple times across phases. Phase A of the action items centers on developing leadership support. Phase B focuses on developing internal and external capacity in both physical (e.g., software and hardware) and intellectual infrastructure. Phase C of the action items plan concerns the development and integration of geospatial methods. In summary, the panel members provided critical input to the development of CDC’s strategic thinking on integrating geospatial methods and research issues across program efforts in support of its Healthy Communities Goal.