BMJ Global Health
Công bố khoa học tiêu biểu
* Dữ liệu chỉ mang tính chất tham khảo
In Morocco’s health systems, reforms were accompanied by increased tensions among doctors, nurses and health managers, poor interprofessional collaboration and counterproductive power struggles. However, little attention has focused on the processes underlying these interprofessional conflicts and their nature. Here, we explored the perspective of health workers and managers in four Moroccan hospitals.
We adopted a multiple embedded case study design and conducted 68 interviews, 8 focus group discussions and 11 group discussions with doctors, nurses, administrators and health managers at different organisational levels. We analysed what health workers (doctors and nurses) and health managers said about their sources of power, perceived roles and relationships with other healthcare professions. For our iterative qualitative data analysis, we coded all data sources using NVivo V.11 software and carried out thematic analysis using the concepts of ‘negotiated order’ and the four worldviews. For context, we used historical analysis to trace the development of medical and nursing professions during the colonial and postcolonial eras in Morocco.
Our findings highlight professional hierarchies that counterbalance the power of formal hierarchies. Interprofessional interactions in Moroccan hospitals are marked by conflicts, power struggles and daily negotiated orders that may not serve the best interests of patients. The results confirm the dominance of medical specialists occupying the top of the professional hierarchy pyramid, as perceived at all levels in the four hospitals. In addition, health managers, lacking institutional backing, resources and decision spaces, often must rely on soft power when dealing with health workers to ensure smooth collaboration in care.
The stratified order of care professions creates hierarchical professional boundaries in Moroccan hospitals, leading to partitioning of care and poor interprofessional collaboration. More attention should be placed on empowering health workers in delivering quality care by ensuring smooth interprofessional collaboration.
Conversations regarding qualitative research and qualitative data analysis in global public health programming often emphasize the product of data collection (audio recordings, transcripts, codebooks and codes), while paying relatively less attention to the process of data collection. In qualitative research, however, the data collector’s skills determine the quality of the data, so understanding data collectors’ strengths and weaknesses as data are being collected allows researchers to enhance both the ability of data collectors and the utility of the data. This paper defines and discusses a process for systematic debriefings. Debriefings entail thorough, goal-oriented discussion of data immediately after it is collected. Debriefings take different forms and fulfill slightly different purposes as data collection progresses. Drawing from examples in our health systems research in Tanzania and Sierra Leone, we elucidate how debriefings have allowed us to: enhance the skills of data collectors; gain immediate insights into the content of data; correct course amid unforeseen changes and challenges in the local context; strengthen the quality and trustworthiness of data in real time; and quickly share emerging data with stakeholders in programmatic, policy and academic spheres. We hope this article provides guidance and stimulates discussion on approaches to qualitative data collection and mechanisms to further outline and refine debriefings in qualitative research.
Maternal death outcome remains high in Guinea-Bissau. Delivery-related complications and maternal mortality could be prevented by increasing women’s access to skilled pregnancy care. Socioeconomic status (SES) is often associated with low health service utilisation in low/middle-income countries. In Guinea-Bissau, little is known on the relationship between SES and use of health facility for delivery. In this study, we examined the association between women’s choice of health facility delivery with their SES.
Current data from Multiple Indicator Cluster Survey conducted in Guinea-Bissau, 2014 were used in this study. The place of delivery (home or health facility) was the outcome variable of interest using 7532 women of reproductive age (15–49 years). Respondents’ characteristics were described by summary statistics, while multivariable logistic regression model was used to examine the association of demographic and socioeconomic characteristics on facility-based delivery. Adjusted ORs, 95% CIs and p values were computed to identify significant determinants.
Results show that in proportion of women delivering at home was higher than of delivery at a health facility. Overall percentage of women who delivered at health facility was 39.8%, with the rate being substantially higher among urban (67.8%) compared with their rural (30.2%) counterparts. Percentage of delivering at home was highest in Oio region (23.8%) and that of delivery at a health facility was highest in the Sector Autónomo de Bissau region (18.7%). In the multivariable analysis, women in urban areas compared those who had no education, those who had primary and secondary/higher level of education were 2.2 and 3.3 times more likely to deliver at a health facility. The odds of facility were also highest among the women from the richest households, 5.3 and 5 times among urban and rural women, respectively.
Based on these findings, the study concludes that the percentage of health facility delivery is low in Guinea-Bissau, which can be promoted through scaling up women’s SES. The findings could guide healthcare policy-makers to address the issue of unskilled delivery services and increase the use of facility-based delivery particularly among the disadvantaged women.
Access to malaria control interventions falls short of universal health coverage. The Global Technical Strategy for malaria targets at least 90% reduction in case incidence and mortality rates, and elimination in 35 countries by 2030. The potential to reach these targets will be determined in part by investments in malaria. This study estimates the financing required for malaria control and elimination over the 2016–2030 period.
A mathematical transmission model was used to explore the impact of increasing intervention coverage on burden and costs. The cost analysis took a public provider perspective covering all 97 malaria endemic countries and territories in 2015. All control interventions currently recommended by the WHO were considered. Cost data were sourced from procurement databases, the peer-reviewed literature, national malaria strategic plans, the WHO-CHOICE project and key informant interviews.
Annual investments of $6.4 billion (95% uncertainty interval (UI $4.5–$9.0 billion)) by 2020, $7.7 billion (95% UI $5.4–$10.9 billion) by 2025 and $8.7 billion (95% UI $6.0–$12.3 billion) by 2030 will be required to reach the targets set in the Global Technical Strategy. These are equivalent to annual investment per person at risk of malaria of US$3.90 by 2020, US$4.30 by 2025 and US$4.40 by 2030, compared with US$2.30 if interventions were sustained at current coverage levels. The 20 countries with the highest burden in 2015 will require 88% of the total investment.
Given the challenges in increasing domestic and international funding, the efficient use of currently available resources should be a priority.
A recent symposium and workshop in Khartoum, the capital of the Republic of Sudan, brought together broad expertise from three universities to address the current burden of communicable and non-communicable diseases facing the Sudanese healthcare system. These meetings identified common challenges that impact the burden of diseases in the country, most notably gaps in data and infrastructure which are essential to inform and deliver effective interventions. Non-communicable diseases, including obesity, type 2 diabetes, renal disease and cancer are increasing dramatically, contributing to multimorbidity. At the same time, progress against communicable diseases has been slow, and the burden of chronic and endemic infections remains considerable, with parasitic diseases (such as malaria, leishmaniasis and schistosomiasis) causing substantial morbidity and mortality. Antimicrobial resistance has become a major threat throughout the healthcare system, with an emerging impact on maternal, neonatal and paediatric populations. Meanwhile, malnutrition, micronutrient deficiency and poor perinatal outcomes remain common and contribute to a lifelong burden of disease. These challenges echo the United Nations (UN) sustainable development goals and concentrating on them in a unified strategy will be necessary to address the national burden of disease. At a time when the country is going through societal and political transition, we draw focus on the country and the need for resolution of its healthcare needs.
Responsiveness is a key objective of national health systems. Responsive health systems anticipate and adapt to existing and future health needs, thus contributing to better health outcomes. Of all the health systems objectives, responsiveness is the least studied, which perhaps reflects lack of comprehensive frameworks that go beyond the normative characteristics of responsive services. This paper contributes to a growing, yet limited, knowledge on this topic. Herewith, we review the current frameworks for understanding health systems responsiveness and drawing on these, as well as key frameworks from the wider public services literature, propose a comprehensive conceptual framework for health systems responsiveness. This paper should be of interest to different stakeholders who are engaged in analysing and improving health systems responsiveness. Our review shows that existing knowledge on health systems responsiveness can be extended along the three areas. First, responsiveness entails an actual experience of people’s interaction with their health system, which confirms or disconfirms their initial expectations of the system. Second, the experience of interaction is shaped by both the people and the health systems sides of this interaction. Third, different influences shape people’s interaction with their health system, ultimately affecting their resultant experiences. Therefore, recognition of both people and health systems sides of interaction and their key determinants would enhance the conceptualisations of responsiveness. Our proposed framework builds on, and advances, the core frameworks in the health systems literature. It positions the experience of interaction between people and health system as the centrepiece and recognises the determinants of responsiveness experience both from the health systems (eg, actors, processes) and the people (eg, initial expectations) sides. While we hope to trigger further thinking on the conceptualisation of health system responsiveness, the proposed framework can guide assessments of, and interventions to strengthen, health systems responsiveness.
The WHO recommends human papillomavirus (HPV) cervical self-sampling as an additional screening method and HPV DNA testing as an effective approach for the early detection of cervical cancer for women aged ≥30 years. This systematic review assesses end user’s values and preferences related to HPV self-sampling.
We searched four electronic databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature and Embase) using search terms for HPV and self-sampling to identify articles meeting inclusion criteria. A standardised data extraction form was used to capture study setting, population, sample size and results related to values and preferences.
Of 1858 records retrieved, 72 studies among 52 114 participants published between 2002 and 2018 were included in this review. Almost all studies were cross-sectional surveys. Study populations included end users who were mainly adolescent girls and adult women. Ages ranged from 14 to 80 years. Most studies (57%) were conducted in high-income countries. Women generally found HPV self-sampling highly acceptable regardless of age, income or country of residence. Lack of self-confidence with collecting a reliable sample was the most commonly cited reason for preferring clinician-collected samples. Most women preferred home-based self-sampling to self-sampling at a clinic. The cervical swab was the most common and most accepted HPV DNA sampling device.
HPV self-sampling is generally a highly accepted method of cervical cancer screening for end users globally. End user preferences for self-sampling device, method and setting can inform the development of new and expanded interventions to increase HPV screening.
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