Health Policy and Planning

Silva, Amauri Duarte da; Veiga, Ana Beatriz Gorini da; Cruz, Oswaldo Gonçalves; Bastos, Leonardo Soares; Gomes, Marcelo Ferreira da Costa

doi: 10.1093/heapol/czac050pmid: 35766892

Epidemiological surveillance and notification of respiratory infections are important for management and control of epidemics and pandemics. Fact-based decisions, like social distancing policies and preparation of hospital beds, are taken based on several factors, including case numbers; hence, health authorities need quick access to reliable and well-analysed data. We aimed to analyse the role of the Brazilian public health system in the notification and hospitalization of patients with severe acute respiratory infection (SARI). Data of SARI cases in Brazil (2013–20) were obtained from SIVEP-Gripe platform, and legal status of each healthcare unit (HCU) responsible for case notification and hospitalization was obtained from the National Registry of Health Facilities (CNES) database. HCUs that are part of the hospital network were classified as ‘Public Administration’, ‘Business Entities’, ‘Philanthropic Entities’ or ‘Individuals’. SARI notification data from Brazilian macro-regions (North, Northeast, Midwest, Southeast and South) were analysed and compared between administrative spheres. This study reveals that hospitalizations due to SARI increased significantly in Brazil during the coronavirus disease 2019 (COVID-19) pandemic, especially in HCUs of Public Administration. In the Southeast and South, where incidence of SARI is high, philanthropic HCUs also contribute to hospitalization of SARI cases and attend up to 7.4% of the cases notified by the Public Administration. The number of cases is usually lower in other regions, but in 2020 the Northeast showed more hospitalizations than the South. In the South, SARI season occurs later; however, in 2020, an early peak was observed because of COVID-19. Notably, the contribution of each administrative sphere that manages hospital networks in Brazil in the control and management of SARI varies between regions. Our approach will allow managers to assess the use of public resources, given that there are different profiles of healthcare in each region of Brazil and that the public health system has a major role in notifying and attending SARI cases.

Lyra, Tereza Maciel; Veloso de Albuquerque, Maria Socorro; Santos de Oliveira, Raquel; Morais Duarte Miranda, Gabriella; Andréa de Oliveira, Márcia; Eduarda Carvalho, Maria; Fernandes Santos, Helena; Penn-Kekana, Loveday; Kuper, Hannah

doi: 10.1093/heapol/czac051pmid: 35771660

The purpose of this article is to analyse the circumstances in which the National Health Policy for Persons with Disabilities (PNSPCD) came into place in 2002 and the factors supporting or impeding its implementation from 2002 to 2018. The analysis was based on the Comprehensive Policy Analysis Model proposed by Walt and Gilson and focussed on understanding the context, process, content and actors involved in the formulation and implementation of the Policy. Data were obtained from two sources: document analysis of the key relevant documents and seven key informant interviews. Content analysis was undertaken using the Condensation of Meanings technique. The research demonstrates that the development and implementation of PNSPCD is marked by advances and retreats, determined, above all, by national and international macro-political decisions. The policy was formulated during Fernando Henrique’s governments, under pressure from social movements and the international agenda and constituted a breakthrough for the rights of persons with disabilities. However, progress on implementation only took place under subsequent centre-left governments with the establishment of a care network for people with disabilities and a defined specific budget. These developments resulted from the mobilization of social movements, the ratification of the United Nations Convention on the rights of people with disabilities and the adherence of these governments to the human rights agenda. The coming to power of ultra-right governments triggered fiscal austerity, a setback in the implementation of the care network and a weakening in the content of various social policies related to the care of people with disabilities. During this era, the political approach changed, with the attempt to evade the role of the State, and the perspective of guaranteeing social rights. Undoubtedly, the neoliberal offensive on social policies, especially the Unified Health System, is the main obstacle to the effective implementation of the PNPCD in Brazil.

Etges, Ana Paula Beck da Silva; Marcolino, Miriam Allein Zago; Ogliari, Leonardo Alves; de Souza, Ana Claudia; Zanotto, Bruna Stella; Ruschel, Renata; Safanelli, Juliana; Magalhães, Pedro; Diegoli, Henrique; Weber, Karina Tavares; Araki, Ana Paula; Nunes, Altacílio; Ponte Neto, Octávio Marques;

Haakenstad, Annie; Coates, Matthew; Bukhman, Gene; McConnell, Margaret; Verguet, Stéphane

doi: 10.1093/heapol/czac053pmid: 35819006

The growing burden of non-communicable diseases (NCDs) in low- and middle-income countries may have implications for health system performance in the area of financial risk protection, as measured by catastrophic health expenditure (CHE). We compare NCD CHE to the CHE cases caused by communicable diseases (CDs) across health systems to examine whether: (1) disease burden and CHE are linked, (2) NCD CHE disproportionately affects wealthier households and (3) whether the drivers of NCD CHE differ from the drivers of CD CHE. We used the Study on Global Aging and Adult Health survey, which captured nationally representative samples of 44 089 adults in China, Ghana, India, Mexico, Russia and South Africa. Using two-part regression and random forests, we estimated out-of-pocket spending and CHE by disease area. We compare the NCD share of CHE to the NCD share of disability-adjusted life years (DALYs) or years of life lost to disability and death. We tested for differences between NCDs and CDs in the out-of-pocket costs per visit and the number of visits occurring before spending crosses the CHE threshold. NCD CHE increased with the NCD share of DALYs except in South Africa, where NCDs caused more than 50% of CHE cases but only 30% of DALYs. A larger share of households incurred CHE due to NCDs in the lowest than the highest wealth quintile. NCD CHE cases were more likely to be caused by five or more health care visits relative to communicable disease CHE cases in Ghana (P = 0.003), India (P = 0.004) and China (P = 0.093). Health system attributes play a key mediating factor in how disease burden translates into CHE by disease. Health systems must target the specific characteristics of CHE by disease area to bolster financial risk protection as the epidemiological transition proceeds.

Prinja, Shankar; Kumar, Sumit; Sharma, Atul; Kar, Sitanshu Sekhar; Tripathi, Narayan; Dumka, Neha; Sharma, Sandeep; Mukhopadhyay, Indranil; Rana, Saroj Kumar; Garg, Samir; Kotwal, Atul; Aggarwal, Arun Kumar

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Frimpong, Albert Opoku; Amporfu, Eugenia; Arthur, Eric

doi: 10.1093/heapol/czac068pmid: 35975469

Financing healthcare in sub-Saharan Africa (SSA) is characterized by high levels of out-of-pocket (OOP) payments for healthcare. This renders many individuals vulnerable to poverty and deviates from the Universal Health Coverage (UHC) goal of providing financial protection for healthcare. We examined the relative effects of public and external health spending on OOP healthcare payments in SSA. We used the system generalized method of moments (GMM) estimator and data from the World Bank’s World Development Indicators for 43 SSA countries from 2000 to 2017. The results show that reductions in OOP payments are higher with increases in public spending than external spending. This means increases in public health spending, compared with external health spending, will increase the pace towards achieving the financial protection goal of UHC in SSA. But since government spending is limited by fiscal space and parliamentary approval, public health spending through social health insurance might provide a regular means of financing healthcare to speed up achieving the financial protection goal in SSA countries.

Aizawa, Toshiaki

doi: 10.1093/heapol/czac067pmid: 35997638

India, which suffers from the largest number of infant deaths in the world, introduced the conditional maternity benefit programme, ‘Indira Gandhi Matritva Sahyog Yojana’ (IGMSY), to provide cash directly to pregnant and lactating women contingent on specified maternal and infant healthcare uses. This study estimates the impact of this programme on infant mortality for the first 12 months after birth, exploiting the pilot phase of IGMSY as a natural experiment in which 52 districts were randomly chosen as pilot districts. In the matched-pair difference-in-differences framework, the treatment effect on survival rate is estimated through the fully data-driven random survival forest approach. The results show that IGMSY reduced the infant mortality rate by 8.32% in treatment districts, with 1.53 fewer deaths per 1000 live births [95% prediction interval: 1.26–1.80]. The size of the effect substantially varies even within the first 12 months, indicating larger reductions in the neonatal period, and after the first 6 months. The results also reveal greater reductions among boys and children in urban areas.

Chan, Olivia Sinn Kay; Wernli, Didier; Liu, Ping; Tun, Hein Min; Fukuda, Keiji; Lam, Wendy; Xiao, YongHong; Zhou, Xudong; Grépin, Karen A

doi: 10.1093/heapol/czac052pmid: 35775460

Against the backdrop of universal healthcare coverage and pre-existing policies on antimicrobial use, China has adopted a state-governed, multi-level, top-down policy governance approach around an antimicrobial resistance (AMR) national action plan (NAP). The Plan relies on tightening control over antimicrobial prescription and use in human and animal sectors. At the same time, medical doctors and veterinarians operate in an environment of high rates of infectious diseases, multi-drug resistance and poor livestock husbandry. In exploring the way that policy responsibilities are distributed, this study aims to describe how Guangdong as a province adopts national AMR policies in a tightly controlled public policy system and an economy with high disparity. We draw on an analysis of 225 AMR-relevant Chinese policy documents at the national and sub-national levels. We adopt a multi-level governance perspective and apply a temporal sequence framework to identify and analyse documents. To identify policy detail, we conducted keyword analysis using the Consolidated Framework for Implementation Research (CFIR) on policies that conserve antimicrobials. We also identify pre-existing medical and public policies associated with AMR. Our findings highlight the emphasis and policies around antimicrobial use regulation to address AMR in China.

Thapa, Poshan; Hall, John J; Jayasuriya, Rohan; Mukherjee, Partha Sarathi; Beek, Kristen; Das, Dipesh Kr; Mandal, Tushar; Narasimhan, Padmanesan

doi: 10.1093/heapol/czac062pmid: 35920775

India is the highest TB burden country, accounting for an estimated 26% of the global TB cases. Systematic engagement of the private sector is a cornerstone of India’s National Strategic Plan for TB Elimination (2017–25). However, informal healthcare providers (IPs), who are the first point of contact for a large number of TB patients, remain significantly underutilized in the National TB Elimination Program of India. Non-prioritization of IPs has also resulted in a limited understanding of their TB care practices in the community. We, therefore, undertook a descriptive study to document IPs’ TB care practices, primarily focusing on their approach to screening, diagnosis, treatment and referral. This cross-sectional study was carried out from February to March 2020 in the Birbhum District of West Bengal, India. Interviews were conducted utilizing the retrospective case study method. A total of 203 IPs participated who reported seeing at least one confirmed TB patient in 6 months prior to the study. In that duration, IPs reported interacting with an average of five suspected TB cases, two of which were later confirmed as having TB. Antibiotic use was found to be common among IPs (highest 69% during the first visit); however, they were prescribed before the patient was suspected or confirmed as having TB. We noted the practice of prolonged treatment among IPs as patients were prescribed medicines until the second follow-up visit. Referral was the preferred TB case management approach among IPs, but delayed referral was observed, with only one-third (34%) of patients being referred to higher health facilities during their first visit. This study presents important findings on IPs’ TB care practices, which have consequences for achieving India’s national goal of TB elimination.

Watermeyer, Jennifer; Scott, Megan; Kapueja, Lethu; Ware, Lisa Jayne

doi: 10.1093/heapol/czac060pmid: 35880606

As South Africa debates the implementation of mandatory vaccination policies to address coronavirus disease 2019 (COVID-19) vaccine hesitancy, many adults remain unpersuaded of the need and benefits of vaccination. Several surveys suggest that this is particularly true for younger adults and for those living in low-income communities. Therefore, we sought the views of youth training to become community health workers (CHWs) as a youth group at the intersection of the community and the health system. This research was conducted in a township of South Africa, a country with a long history of political mistrust. Using semi-structured interviews and an interview guide, we explored young CHWs’ perceptions (n = 20) of vaccine hesitancy for themselves, their peers and the community. Audio-recorded interviews were transcribed, and thematic analysis was undertaken. Findings suggest widespread COVID-19 vaccine hesitancy in this community, especially amongst young people. Reported reasons for this hesitancy appear linked to a complex interrelated network of factors, including ‘uncertainty’ about the outcome and effectiveness of the vaccines; ‘fear’ of the vaccines, driven by a myriad of rumours and conspiracy theories within the community; a ‘lack of control’ over other people’s behaviour and a desire not to be controlled especially by the government but at the same time a resignation towards impending mandatory vaccine policies and a ‘lack of trust’ particularly in the government’s intentions with vaccine roll-out and their health messaging. While mandatory vaccination policies in several organizations have shown success, with South Africa’s complex social history and recent civil unrest, the roll-out of any mandatory vaccination policy will require careful health messaging with a focus on trust-building between communities, health systems and authorities through more personalized approaches that consider contextual nuances.