Health Policy and Planning

Glandon, Douglas; Hasan, Md Zabir; Mann, Mehak; Gupta, Shivam; Marsteller, Jill; Paina, Ligia; Bennett, Sara

doi: 10.1093/heapol/czad025pmid: 37148361

Multisectoral collaboration has been identified as a critical component in a wide variety of health and development initiatives. For India’s Integrated Child Development Services (ICDS) scheme, which serves >100 million people annually across more than one million villages, a key point of multisectoral collaboration—or ‘convergence’, as it is often called in India—is between the three frontline worker cadres jointly responsible for delivering essential maternal and child health and nutritional services throughout the country: the Accredited Social Health Activist (ASHA), Anganwadi worker (AWW) and auxiliary nurse midwife (ANM) or ‘AAA’ workers. Despite the long-recognized importance of collaboration within this triad, there has been relatively little documentation of what this looks like in practice and what is needed in order to improve it. Informed by a conceptual framework of collaborative governance, this study applies inductive thematic analysis of in-depth interviews with 18 AAA workers and 6 medical officers from 6 villages across three administrative blocks in Hardoi district of Uttar Pradesh state to identify the key elements of collaboration. These are grouped into three broad categories: ‘organizational’ (including interdependence, role clarity, guidance/support and resource availability); ‘relational’ (interpersonal and conflict resolution) and ‘personal’ (flexibility, diligence and locus of control). These findings underscore the importance of ‘personal’ and ‘relational’ collaboration features, which are underemphasized in India’s ICDS, the largest of its kind globally, and in the multisectoral collaboration literature more broadly—both of which place greater emphasis on ‘organizational’ aspects of collaboration. These findings are largely consistent with prior studies but are notably different in that they highlight the importance of flexibility, locus of control and conflict resolution in collaborative relationships, all of which relate to one’s ability to adapt to unexpected obstacles and find mutually workable solutions with colleagues. From a policy perspective, supporting these key elements of collaboration may involve giving frontline workers more autonomy in how they get the work done, which may in some cases be impeded by additional training to reinforce worker role delineation, closer monitoring or other top-down efforts to push greater convergence. Given the essential role that frontline workers play in multisectoral initiatives in India and around the world, there is a clear need for policymakers and managers to understand the elements affecting collaboration between these workers when designing and implementing programmes.

Hawkes, Sarah; Evagora-Campbell, Mireille; Zahidie, Aysha; Rabbani, Fauziah; Buse, Kent

doi: 10.1093/heapol/czad029pmid: 37162281

Labour migrants who travel overseas for employment can face deep health inequities driven in large part by upstream social and structural determinants of health. We sought to study the ‘labour migrant health ecosystem’ between one sending country (Pakistan) and one host country (Qatar), with a focus on how the ecosystem realizes the rights of labour migrants when addressing the social and structural determinants (e.g. housing, employment law, etc.) of health. Study objectives were to (1) undertake an in-depth review of policies addressing the structural and social determinants of the health of labour migrants in both Pakistan and Qatar, analysing the extent to which these policies align with global guidance, are equity-focused and have clear accountability mechanisms in place, and (2) explore national stakeholder perspectives on priority setting for labour migrant health. We used a mixed methods approach, combining policy content analysis and interviews with stakeholders in both countries. We found a wide range of guidance from the multilateral system on addressing structural determinants of the health of labour migrants. However, policy responses in Pakistan and Qatar contained a limited number of these recommended interventions and had low implementation potential and minimal reference to gender, equity and rights. Key national stakeholders had few political incentives to act and lacked inter-country coordination mechanisms required for an effective and cohesive response to labour migrant health issues. Effectively addressing such determinants to achieve health equity for labour migrants will depend on a shift in governments’ attitudes towards migrants—from a reserve army of transient, replaceable economic resources to rights-holding members of society deserving of equality, dignity and respect.

Osei Afriyie, Doris; Masiye, Felix; Tediosi, Fabrizio; Fink, Günther

doi: 10.1093/heapol/czad022pmid: 37022137

Improving the quality of care is essential for progress towards universal health coverage. Health financing arrangements offer opportunities for governments to incentivize and reward improvements in the quality of care provided. This study examines the extent to which the purchasing arrangements established within Zambia’s new National Health Insurance can improve equitable access to high-quality care. We adopt the Strategic Purchasing Progress and the Lancet Commission for High-Quality Health Systems frameworks to critically examine the broader health system and the purchasing dimensions of this insurance scheme and its implications for quality care. We reviewed policy documents and conducted 31 key-informant interviews with stakeholders at national, subnational and health facility levels. We find that the new health insurance could boost financial resources in higher levels of care, improve access to high-cost interventions, improve care experiences for its beneficiaries and integrate the public and private sectors. Our findings also suggest that health insurance will likely improve some aspects of structural quality but may not be able to influence process and outcome measures of quality. It is also not clear if health insurance will improve the efficiency of service delivery and whether the benefits realized will be distributed equitably. These potential limitations are attributable to the existing governance and financial challenges, low investments in primary care and shortcomings in the design and implementation of the purchasing arrangements of health insurance. Although Zambia has made progress in a short span, there is a need to improve its provider payment mechanisms, and monitoring and accounting for a higher quality of care.

Gómez-Dantés, Octavio; Fuentes-Rivera, Evelyn; Escobar, Joaquín; Serván-Mori, Edson

doi: 10.1093/heapol/czad028pmid: 37133247

This paper offers a comprehensive picture of the performance of the Mexican health system during the period 2000–18. Using high-quality and periodical data from the Organization for Economic Cooperation and Development, the World Bank, the Institute for Health Metrics and Evaluation and Mexico’s National Survey of Household Income and Expenditure, we assess the evolution of seven types of indicators (health expenditure, health resources, health services, quality of care, health care coverage, health conditions and financial protection) over a period of 18 years during three political administrations. The reform implemented in Mexico in the period 2004–18―which includes the creation of ‘Seguro Popular’―and other initiatives helped improve the financial protection levels of the Mexican population, expressed in the declining prevalence of catastrophic and impoverishing health expenditures, and various health conditions (consumption of tobacco in adults and under-five, maternal, cervical cancer and human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) mortality rates). We conclude that policies intended to move towards universal health coverage should count on strong financial mechanisms to guarantee the consistent expansion of health care coverage and the sustainability of reform efforts. However, the mobilization of additional resources for health and the expansion of health care coverage do not guarantee by themselves major improvements in health conditions. Interventions to deal with specific health needs are also needed.

Garg, Charu C; Goyanka, Roopali

doi: 10.1093/heapol/czad033pmid: 37148326

Aam Admi Mohalla Clinics (AAMCs) were introduced in Delhi in 2015 as neighbourhood clinics to strengthen the delivery of primary care. To inform the policies on government investments for outpatient care, this study estimated the cost of outpatient care per visit in Delhi for 2019–20 for AAMCs and compared it with urban primary health centres (UPHCs), public hospitals, private clinics and private hospitals. Facility costs for AAMCs and UPHCs were also estimated. Using the data from a national health survey, government annual budgets and reports, a modified top-down methodology was adopted to measure the true cost of public facilities, taking into account both government expenditure and out-of-pocket expenditure (OOPE). Inflation-adjusted OOPE was used to measure the cost of private facilities. The cost per visit at a private clinic at ₹1146 (US$16) was more than 3-times higher than that at a UPHC (₹325/US$5) and 8-times higher than that at AAMCs (₹143/US$2.0). These costs were ₹1099 (US$15) and ₹1818 (US$25) at public and private hospitals respectively. The annual economic cost per facility of a UPHC at ₹ 9 280 000/$130 000 is ∼4-times that at AAMC (₹2 474 000/$35 000). Unit costs are found to be lower at AAMCs. Utilization for outpatient care has shifted in favour of public primary care facilities. Higher investment in public primary care facilities with expanded services for prevention and promotion, upscaled infrastructure and a gate-keeping mechanism can strengthen the delivery of primary care and promote universal health care at a lower cost.

Smith, Stephanie L

doi: 10.1093/heapol/czad034pmid: 37217184

The global health agenda—a high stakes process in which problems are defined and compete for the kind of serious attention that promises to help alleviate inequities in the burden of disease—is comprised of priorities set within and among a host of interacting stakeholder arenas. This study informs crucial and unanswered conceptual and measurement questions with respect to civil society priorities in global health. The exploratory two-stage inquiry probes insights from experts based in four world regions and pilots a new measurement approach, analysing nearly 20 000 Tweets straddling the COVID-19 pandemic onset from a set of civil society organizations (CSOs) engaged in global health. Expert informants discerned civil society priorities principally on the basis of observed trends in CSO and social movement action, including advocacy, programme, and monitoring and accountability activities—all of which are widely documented by CSOs active on Twitter. Systematic analysis of a subset of CSO Tweets shows how their attention to COVID-19 soared amidst mostly small shifts in attention to a wide range of other issues between 2019 and 2020, reflecting the impacts of a focusing event and other dynamics. The approach holds promise for advancing measurement of emergent, sustained and evolving civil society priorities in global health.

Canick, Julia; Petrucci, Beatriz; Patterson, Rolvix; Saunders, James; Htoo Thaw, May; Omosule, Ikeoluwa; Denton, Alexa; Xu, Mary Jue; Chadha, Shelly; Young, Gabrielle; Siafa, Lyna; Mortel, Olivier; Shamshad, Alizeh; Reddy, Ashwin; McCalla, Monet;

Rodriguez-Villamizar, Laura Andrea; Linares García, Johanna; Ruiz-Rodriguez, Myriam

doi: 10.1093/heapol/czad027pmid: 37140244

The COVID-19 pandemic highlighted the importance of strengthening collaborations between academia and government. The development and maintenance of these collaborative relationships is a complex and dynamic process, particularly during public health emergencies. This study was aimed at identifying and analysing factors that acted as barriers and facilitators in the collaboration process between academia and government during the COVID-19 pandemic in the five largest cities in Colombia. The study used a qualitative approach based on the systematization of experiences. A total of 25 semi-structured interviews were conducted with local actors from government and academia during 2021. Participants identified a variety of situations that involved individual, institutional and relational factors that acted as barriers and facilitators, and which have been previously reported in other countries and contexts not related to pandemics. Based on participant reports, two additional factors emerged, one corresponding to situations related to the pandemic management process itself and another related to structural or systemic conditions that involved government processes and the Colombian health system. Despite the challenges posed by the pandemic, the health emergency brought about shared feelings of local commitment and a willingness to work through interdisciplinary teams to address the pandemic with the least adverse effects on the community. Other facilitators of the collaborative process that were recognized were the importance of timely access to data and transparent analyses, as well as government decisions being informed by the perspectives of academics. The main barriers identified by both actors were excessive centralization of the pandemic’s management and the need for rapid decision-making processes under high levels of uncertainty. In addition, the fragmentation of services in the health system posed a barrier to the interventions that were suggested by the collaborative work. Our results suggest that government–academia collaborations should be implemented as ongoing participatory processes integrating various sectors, actors and disciplines.

Minatto, Giseli; Silva, Kelly Samara; Bandeira, Alexsandra da Silva; dos Santos, Priscila Cristina; Sandreschi, Paula Fabricio; Manta, Sofia Wolker; da Silva, Juliana Rezende Melo; Parente, Raphael Câmara Medeiros; Barbosa Filho, Valter Cordeiro

doi: 10.1093/heapol/czad024

Panjwani, Sonya; Garney, Whitney R; Wilson, Kelly; Goodson, Patricia; Hamie, Silva

doi: 10.1093/heapol/czad030pmid: 37162283

Latin America has experienced substantial development over the last three decades; however, development has been uneven with persistent inequalities, especially in the areas of maternal and child health. Since the early 1990s, most Latin American health-care systems have undergone a series of reforms to improve access to services, with the most recent being the implementation of integrated health service delivery networks (IHSDNs). This model posits that patients will receive better continuity of care and higher-quality health services and avoid duplicated efforts. While decreased maternal and infant mortality rates have been observed in the region since IHSDN implementation, there is limited evidence on this model’s implications for maternal and infant care. The purpose of this study is to explore how IHSDNs affect access to and continuity of maternal and infant care in Latin America, according to the peer-reviewed literature. A scoping review was conducted systematically to identify peer-reviewed articles published since 2007 on studies that took place in Latin America, include IHSDNs, focus on the antenatal and/or postnatal period, include women and/or infants under 2 years of age and are written in English, Spanish or Portuguese. Seven studies (n = 7) met the inclusion criteria for this review. Barriers identified were related to person-centred care (n = 5) and logistical challenges (n = 5). The most cited facilitator encompassed social support for women when accessing care (n = 3). Potential solutions to improve care access included an improvement in the network structure and a greater focus on care provision, rather than regulations and compliance. Findings from this study suggest that the IHSDN model has the potential to improve care for women during pregnancy and post-birth if the model is implemented to its full extent. However, implementation of the model in Latin America is still weak, creating barriers for women when seeking care, particularly for disparate populations and those residing in rural areas.