Component Of Health System Research Articles

Spending on primary healthcare in two government administrations in Chile since the dictatorship

Since the Declaration of Alma-Ata in 1978, primary healthcare (PHC) is considered an essential component of health systems. In the Chilean case, management of primary care was municipalized during the dictatorship and maintained by the subsequent governments, with some reforms. The aim of this article was to estimate and analyze spending in PHC in Chile, during the governments of Sebastián Piñera and Michelle Bachelet. Collection of financial data was oriented by the model of National Health Accounts (CNS), and later the amounts were deflated according to the Consumer Price Index. The principal source of information was the National System of Municipal Information (SINIM). The results show that during the period there was a permanent increase in spending in PHC; however, the average percent change was slightly higher in the first government compared to the second. The percentage of spending in PHC in relation to public spending in health was 21.4% for the eight years, with few variations. Indicators show that inequalities between administrative and health regions are increasing steadily. Therefore, although transfers to fund primary care services are increasing, they may be poorly distributed. This and other problems like the commodification of services and dismantlement of the network compromise the consolidation of PHC, especially in a health system based on contributive insurance like the Chilean system.

Institutional Clashes Beyond the Judicialization of Health: Overlapping Powers in the Case of the Cancer Pill

The 1988 Brazilian Federal Constitution institutes the promotion of “universal and equal access” to health care for Brazilian citizens. In this article, we will focus on the use and distribution of medicines as one of the national health system components. The organization responsible for standardizing and regulating the production and consumption of products and services is ANVISA – National Health Surveillance Agency, which works like the FDA (Federal Drug Administration). A unique episode took place in 2015 when a “popular uprising” began to take shape in Brazil around an issue regulated by ANVISA. Cancer patients had started to file lawsuits calling for access and permission to use a drug not authorized by this agency and which, according to the askers, supposedly would cure their disease. This drug is named phosphoethanolamine (popular name, cancer pill). Apart from the efficacy or otherwise of the drug in question, it might be interesting to organizational studies why a government organization may miss legitimation to exercise its legal role due to popular pressure, which strongly diverges from court decisions, especially involving power and legal interpretation. We approach theoretical possibilities about judicialization of health discussing triggers of institutional and social conflicts (a) by surveying studies that deal with judicialization calling for supply or release of medication (b) possible connections already established in the academy with the so-called cancer pill and, finally, (c) relating such situations to the concept of institutional void.

Inclusion of Construction Occupational Health and Safety Management System (OHSMS) Components in Building Construction Project

Building construction projects are required to have the Occupational Health and Safety Management System (Sistem Manajemen Kesehatan dan Keselamatan Kerja, OHSMS) due to its high-risk nature. For this purpose, the Ministry of Public Works and People’s Housing of the Republic of Indonesia has issued the Circular Letter Number 66/SE/M/2015 on Costs for Implementing Construction Occupational Health and Safety Management System (OHSMS) in the Field of Public Works. The purpose of this study is to present a detailed description of OHSMS implementation in several building construction projects by using the Ministry’s Circular as the reference. This study is a descriptive study on 30 building construction projects implemented in Indonesia from 2017 to 2019 as the unit of analysis. Data were collected using a questionnaire which was developed based on the content of the Circular of the Minister of Public Works and People’s Housing Number 66/SE/M/2015. This questionnaire was then distributed to respondents using the purposive sampling technic.The OHSMS implementation subcomponents that are most frequently included in the work agreement of building construction projects are work procedure manual development, OHS induction, safety net, protective helmet, worker insurance (BPJS ketenagakerjaan dan kesehatan kerja), OHS expert and/or OHS officer, first aids kit, prohibition sign, and portable fire extinguishers. The least frequently included subcomponents are the provision of worker identity cards (KIP), poster, fall restraint, life jacket, Certificate of OHS Steering Committee (Panitia Pembina Keselamatan dan Kesehatan Kerja, P2K3), medical officer, fogging solution, traffic strip light, OHS flag, and internal audit and inspection programs. A total of 30 building construction projects have implemented OHSMS by including the details of the construction OHSMS implementation, as stated in the Minister of Public Works and People’s Housing Circular Number 66/SE/M/2015 in their work contract.

Did an Intervention Programme Aimed at Strengthening the Maternal and Child Health Services in Nigeria Improve the Completeness of Routine Health Data Within the Health Management Information System?

During 2012-2015, the Federal Government of Nigeria launched the Subsidy Reinvestment and Empowerment Programme, a health system strengthening (HSS) programme with a Maternal and Child Health component (Subsidy Reinvestment and Empowerment Programme [SURE-P]/MCH), which was monitored using the Health Management Information Systems (HMIS) data reporting tools. Good quality data is essential for health policy and planning decisions yet, little is known on whether and how broad health systems strengthening programmes affect quality of data. This paper explores the effects of the SURE-P/MCH on completeness of MCH data in the National HMIS. This mixed-methods study was undertaken in Anambra state, southeast Nigeria. A standardized proforma was used to collect facility-level data from the facility registers on MCH services to assess the completeness of data from 2 interventions and one control clusters. The facility data was collected to cover before, during, and after the SURE-P intervention activities. Qualitative in-depth interviews were conducted with purposefully-identified health facility workers to identify their views and experiences of changes in data quality throughout the above 3 periods. Quantitative analysis of the facility data showed that data completeness improved substantially, starting before SURE-P and continuing during SURE-P but across all clusters (ie, including the control). Also health workers felt data completeness were improved during the SURE-P, but declined with the cessation of the programme. We also found that challenges to data completeness are dependent on many variables including a high burden on providers for data collection, many variables to be filled in the data collection tools, and lack of health worker incentives. Quantitative analysis showed improved data completeness and health workers believed the SURE-P/MCH had contributed to the improvement. The functioning of national HMIS are inevitably linked with other health systems components. While health systems strengthening programmes have a great potential for improved overall systems performance, a more granular understanding of their implications on the specific components such as the resultant quality of HMIS data, is needed.

Cross-sectional analysis tracking workforce density in surgery, anesthesia, and obstetrics as an indicator of progress toward improved global surgical access

Introdution: Safe surgical care, including anesthesia, obstetrics, and trauma, is an essential component of a functional health system, yet is lacking in much of the world. One indicator of surgical access is the number of specialist surgeons, anesthesiologists, and obstetricians (SAO) per 100,000 population, but global progress reaching threshold SAO density (SAOD) is unknown. This study measured SAOD change/trajectory and highlighted components of workforce expansion. Methods: SAOD in 2019 was captured utilizing publicly available medical licensing data for a convenience sample of 21 countries. Projected 2030 SAOD were estimated by extrapolating annual changes since 2015. Ugandan medical students were surveyed regarding postgraduate plans and SAO training availability. Workforce contribution by nonphysician surgical and anesthetic providers was measured in Sierra Leone. Results: Three low-income countries (LICs), 4 lower middle-income countries (L-MICs), 7 upper middle-income countries (UMICs), and 7 high-income countries (HICs) were included. Overall SAOD increased since 2015. The average 2019 SAOD was 1.16±0.81 (LICs), 3.19±1.92 (L-MICs), 20.98±12.55 (UMICs), and 44.04±12.41 (HICs). The projected 2030 SAOD in LICs and L-MICs remains below 20. In Uganda, 144 specialist SAO training positions and practice preferences predict an inadequate future workforce. In Sierra Leone, nonphysician providers contributed a 6-fold increase in the surgical workforce, though remains inadequate. Conclusions: Despite incremental positive changes since 2015, the current SAOD trajectory is inadequate to realize 2030 access goals. Increased training and retention of specialists and nonphysician providers are necessary to address this critical deficit.

HIGHLIGHTS ACROSS MYOLOGY: O.16 Results of a preconception carrier screening trial including severe neuromuscular disorders

We report the results of a preconception carrier screening study using components of the Western Australian public health system. Non-pregnant couples were recruited through general practitioners and other healthcare professionals in metropolitan Perth or Busselton, a regional town in the South-West of Western Australia. Couples were tested for 474 genes associated with mostly severe recessive paediatric disorders using a targeted gene panel, as well as for spinal muscular atrophy and Fragile X by standard diagnostic laboratory protocols.

Availability, price, and affordability of WHO priority maternal and child health medicine in public health facilities of Dessie, north-East Ethiopia

BackgroundAccess to health care is a fundamental human right, and the provision of affordable, high-quality, and appropriate medicines for maternal and child health is a vital component of a well-functioning health system. The study assessed the availability, price, and affordability of WHO priority maternal and child medicines in public health facilities, Dessie, North-East Ethiopia.MethodsA retrospective cross-sectional study design was conducted in Dessie town from November 2018 to February 2019. A standard checklist adapted from the Logistics Indicator Assessment Tool and WHO/HAI was used to collecting data on the availability, affordability, and price of 45 priority life-saving medicines from eight public health centers and two public hospitals. Descriptive statistics (percent and median) were computed for availability and prices. Affordability was reported in terms of the daily wage of the lowest-paid unskilled government worker.ResultsTwenty-two medicines were not found at all in public health facilities. The overall availability of WHO priority maternal and child medicines was 34.02%. The mean number of stock-outs was 3.9, and the mean number was 128.9 days. The mean average point availability was 33.5%, and 7 medicines stock out on the days of assessment. From WHO priority maternal and child medicines, 4 (40%) of the products were unaffordable and 5 (55.5%) had higher prices than international prices. Ceftriaxone 1 g, ceftriaxone 500 mg, and hydralazine 20 mg injection required wages of 6.58, 8.01, and 5.02 to cover specific maternal health problems respectively. The median price ratio of priority lifesaving maternal and child medicines in public health facilities ranged from 0.65 to 3.19.ConclusionsThe average mean period and point mean availability was very low. The available products were encountered with a high number of stock-outs and unaffordable. The strict control of inventory is recommended to have a steady supply of these essential medicines and improve the quality of health services.

6.E. Workshop: Health promotion: An integrative paradigm for sustainable health, wellbeing and development

Abstract This workshop addresses the importance of health promotion for enabling all human beings to have healthy lives, to maximise their health potential and ensure that no one is left behind. Health promotion is a critical component of modern health systems and a vital strategy for sustainable health development and human flourishing. Effective health promotion strategies are essential in addressing the broader determinants of health, reducing health inequities, and tackling current and emerging health challenges to human development. Achieving the UN Sustainable Development Goals (SDGs) and universal health coverage calls for concerted action on health promotion as an integral component of modern health systems and future development. While successive global health policies have endorsed the need to invest in health promotion, political commitment to implementing health promotion is lacking and health policies and budgets remain focused on curative approaches. Health promotion is often poorly understood, both within the health sector and society more widely, and there is a limited appreciation of what is required to translate health promotion into effective action. Transformative health promotion actions are needed to deliver on improved population health and wellbeing and the creation of a healthy society where human wellbeing can flourish. Objectives This workshop will engage participants in an interactive discussion on how health promotion policy, research and practice can be strengthened in order to advance human health and wellbeing. Critical insights will be exchanged on how to bring a renewed focus on health promotion as a key transformative and disruptive strategy for advancing human wellbeing development. The workshop will critically consider what mechanisms are needed for strengthening health promoting policies, implementation processes and structures, capacities and research, to advance population health and wellbeing and a healthier future for all. Key messages Health promotion actions are critical to the delivery of improved population health and health equity, transforming health systems and enhancing human wellbeing and sustainable development. Strengthening health promoting polices, practices and research is essential to achieve the UN Sustainable Development Goals and enable the conditions for a healthier world.

A critical refection on the enablers of transformative health promotion action

Abstract The goal of ensuring that all human beings can have healthy lives and can maximise their health potential calls for concerted action on health promotion as an integral component of modern health systems and public policy. In addressing current health and global challenges, there is an urgent need to move beyond the rhetoric of health promotion towards concrete action and strengthening the capacity of countries to implement health promotion at a political, policy and service delivery level. This presentation reviews progress to date and critically considers the enabling mechanisms and system requirements for transformative health promotion actions that can improve the capacity of health and social systems to improve population health and wellbeing, reduce health inequities, and realise the ambitions of the SDGs and the right to health for all. Drawing on a recent report prepared for the European Commission, this presentation discusses what actions are needed to strengthen health promoting policies, research and practices that support a whole-of-government and whole-of-society approach. This presentation makes the case for investing in transformative actions for improved health and wellbeing. Health promotion needs to be placed at the centre of the health policy and sustainable development agenda in order to enhance the resilience of health systems, improve health equity, and make health promotion practices and actions integral to the global health and wellbeing agenda.

Extended HSPA framework for UHC

Abstract Based on the work presented earlier, this presentation shows the entire extended HSPA framework for UHC. The framework consists of the functions and their subfunctions, linked to performance assessment areas and leading, ultimately, to the achievement of health system goals (population health, responsiveness, financial protection; as well as equity and efficiency as distribution of outcomes and ratio of inputs respectively). This approach shows that it is possible to have a common denominator between the existing HSPA frameworks and tools, that can be allied in various income settings globally. The added value of this approach is that country reports generated through the use of the existing health system assessment tools can be used not just to describe health system structures and functioning, but also to assess performance of individual health system components down to sub-function level. While not intended to provide a deep-dive into smaller, specific parts within health systems, the HSPA framework for UHC can help in identifying potential areas of strengths and weaknesses, which can then be related to actions or responsibilities of specific actors within a health system, or linkages to other sectors.

Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis.

Background: Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the ‘social value of health systems.’ Methods: We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between ‘health systems’ and ‘social values.’ We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory. Results: We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen’s understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups. Conclusion: We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.

Una mirada al sistema de salud mental en Paraguay

The objective of this paper is to analyze three components of the mental health system in Paraguay, specifically the National Mental Health Policy, the Mobile Mental Health Unit and the Foster Homes. It can be seen that progress was made at specific periods through deinstitutionalization initiatives that need to be continued. However, there are still many weaknesses to be addressed within the system.

Supply-and-demand projections for the health workforce at a provincial level from 2015 to 2025 in Ilam, Iran

Background: Human resources are the key component of health systems. It is critical to have the right number of human resources at anytime and anywhere in the health system. This article aims to help local health decision makers to identify potential gaps between the future supply and demand of human resources and to make necessary changes in medical training processes to fill the gap. Methods: An eight-stage process was applied to project the supply and demand of health workers in Ilam province in 2025 for the following fields: public health, environmental health, general medicine, dentistry, pharmacy, nursing and midwifery. To estimate the demand for human resources, a mainly population-based model (manpower-to-population ratio) was applied. A modified version of the Australian dynamic stock and flow model was used to predict the supply of new recruits in 2025. The potential surplus or shortfall in the health workforce was calculated by comparing the supply and demand in 2025. Results: The demand and supply projections for the chosen fields were estimated respectively as: general medicine 457, 709; pharmacy 131, 86; dentistry 86, 251; nursing 949, 1657; midwifery 24, 247; public health 182, 211; and environmental health 92, 225. Conclusions: The current trend of medical graduates will meet the need for human resources in 2025, and there is no need to increase medical student admission. The Education Deputy of Ilam Medical University should take into account the health needs of its catchment area in medical educational processes and training new health-care staff.

Making the health system work for the delivery of nutrition interventions

Addressing malnutrition requires strategies that are comprehensive and multi‐sectoral. Within a multi‐sectoral approach, the health system is essential to deliver 10 nutrition‐specific interventions, which, if scaled up, could substantially reduce under‐5 deaths in high‐burden countries through improving maternal and child undernutrition. This study identifies the health system components required for the effective delivery of these interventions, highlighting opportunities and challenges for nutrition programmes and policies. We reviewed implementation guidance for each nutrition‐specific intervention, mapping the delivery process for each intervention and determining the health system components required for their delivery. We integrated the components into a single health systems framework for nutrition, illustrating the pathways by which health system components influence household‐level determinants of nutrition and individual‐level health outcomes. Nutrition‐specific interventions are typically delivered in one of four ways: (i) when nutrition interventions are intentionally sought out, (ii) when care is sought for other, unrelated interventions, (iii) at a health facility after active community case finding and referral, and (iv) in the community after active community case finding. A health system enables these processes by providing health services and facilitating care seeking for services, which together require a skilled and motivated health workforce, an effective supply chain, demand for services and access to services. The nutrition community should consider the processes by which nutrition‐specific interventions are delivered and the health system components required for their success. Programmes should encourage the delivery of nutrition interventions at every client–provider interaction and should actively generate demand for services—in general, and for nutrition services specifically.

A critical interpretive synthesis of the roles of midwives in health systems

BackgroundMidwives’ roles in sexual and reproductive health and rights continues to evolve. Understanding the profession’s role and how midwives can be integrated into health systems is essential in creating evidence-informed policies. Our objective was to develop a theoretical framework of how political system factors and health systems arrangements influence the roles of midwives within the health system.MethodsA critical interpretive synthesis was used to develop the theoretical framework. A range of electronic bibliographic databases (CINAHL, EMBASE, Global Health database, HealthSTAR, Health Systems Evidence, MEDLINE and Web of Science) was searched through to 14 May 2020 as were policy and health systems-related and midwifery organisation websites. A coding structure was created to guide the data extraction.ResultsA total of 4533 unique documents were retrieved through electronic searches, of which 4132 were excluded using explicit criteria, leaving 401 potentially relevant records, in addition to the 29 records that were purposively sampled through grey literature. A total of 100 documents were included in the critical interpretive synthesis. The resulting theoretical framework identified the range of political and health system components that can work together to facilitate the integration of midwifery into health systems or act as barriers that restrict the roles of the profession.ConclusionsAny changes to the roles of midwives in health systems need to take into account the political system where decisions about their integration will be made as well as the nature of the health system in which they are being integrated. The theoretical framework, which can be thought of as a heuristic, identifies the core contextual factors that governments can use to best leverage their position when working to improve sexual and reproductive health and rights.

Maternity waiting homes in Liberia: Results of a countrywide multi-sector scale-up.

ObjectiveDescriptions of maternity waiting homes (MWHs) as an intervention to increase facility delivery for women living in remote geographic areas dates back to the 1950s, yet there is limited information on the scale-up and sustainability of MWHs. The objective of this study was to describe the evolutionary scale-up of MWHs as a component of health system strengthening efforts and document the successes, challenges, and barriers to sustainability in Liberia.MethodsData were collected from a national sample of 119 MWHs in Liberia established between 2010–2018. The study used a mixed method design that included focus group discussions, individual interviews, logbook reviews, and geographic information systems. Qualitative data were grouped into themes using Glaser’s constant comparative method. Quantitative data were analyzed using negative binomial regression to measure the differences in the counts of monthly stays at facilities with different funding sources and presence of advisory committee. Additionally, each MWH was geo-located for purposes of geo-visualization.ResultsIn the years since the original construction of five MWHs, an additional 114 MWHs were constructed in 14 of the 15 counties in Liberia. Monthly stays at facilities funded by community were 2·5 times those funded by NGOs (IRR, 2·46, 95% CI 1·33–4·54). Attributes of sustainability included strong local leadership/active community engagement and community ownership and governance.ConclusionSuccess factors for scale-up and sustainability included strong government support through development of public policy, local and county leadership, early and sustained engagement with communities, and self-governance. A multi-pronged approach with strong community engagement is key to the scale-up and sustainability of MWHs as an intervention to increase facility delivery for women living the farthest from a healthcare facility.

Person-centred and efficient care delivery for high-need, high-cost patients: primary care professionals\u2019 experiences

BackgroundHigh-need, high-cost (HNHC) patients, who typically have complex and long-term care demands, contribute considerably to the high work pressure of primary care professionals (PCPs). To improve patient as well as provider experiences, it is crucial to take into account the PCPs’ perspective in designing health care strategies for HNHC patients. Therefore, this study aimed to create insight into PCPs’ experienced barriers and possible solutions with regards to person-centred, efficient care delivery to HNHC patients.MethodsWe conducted a qualitative study using focus group interviews with PCPs at a Dutch primary care group. A semi-structured interview guide was developed for the interviews. Qualitative content analysis was employed deductively by means of a categorisation matrix. The matrix was based on the components retrieved from the SELFIE framework for integrated care for multi-morbidity.ResultsForty-two PCPs participated in five focus group interviews. Discussed barriers and solutions were related to the core of the SELFIE framework (i.e. the individual and environment), and particularly four of the six health system components in the framework: service delivery, leadership & governance, workforce, and technologies & medical products. Many discussed barriers revolved around the complex biopsychosocial needs of HNHC patients: PCPs reported a lack of time (service delivery), insufficiently skilled PCPs (workforce), and inefficient patient information retrieval and sharing (technologies & medical products) as barriers to adequately meet the biopsychosocial needs of HNHC patients.ConclusionsThis qualitative study suggests that primary care is currently insufficiently equipped to accommodate the complex biopsychosocial needs of HNHC patients. Therefore, it is firstly important to strengthen primary care internally, taking into account the experienced lack of time, the insufficient number of equipped PCPs and lack of inter-professional information retrieval and sharing. Secondly, PCPs should be supported in cooperating and communicating more efficiently with health services outside primary care to adequately deliver person-centred, efficient care. As a prerequisite, it is crucial to direct policy efforts at the design of a strong system of social and community services. In terms of future research, it is important to assess the feasibility and effects of re-designing primary care based on the provided recommendations.

Strengthening mental health services in Sierra Leone: perspectives from within the health system.

Though mental and substance use disorders are a leading cause of disability worldwide, mental health systems are vastly under-resourced in most low- and middle-income countries and the majority of people with serious mental health needs receives no formal treatment. Despite international calls for the integration of mental health into routine care, availability of outpatient mental health services and integration of mental health into the broader healthcare system remain weak in many countries. Efforts to strengthen mental healthcare systems must be informed by the local context, with attention to key health system components. The current study is a qualitative analysis of stakeholder perspectives on mental health system strengthening in one low-income country, Sierra Leone. It utilizes locally grounded knowledge from frontline healthcare providers to identify constraints and opportunities for strengthening mental health care within each component of the health system. In-depth semi-structured interviews were conducted with 43 participants including doctors, nurses, community health workers, mental health advocates, mental health specialists, and traditional healers recruited from the Bo, Moyamba and Western Area Urban Districts. Interview transcripts were content-coded in NVivo using both a priori and emergent codes and aggregated into broader themes, utilizing the World Health Organization Health Systems Framework. Participants described an extremely limited system of mental health care, with constraints and obstacles within each health system component. Participants identified potential strategies to help overcome these constraints. Findings reinforce the importance of factors outside of the healthcare system that shape the implementation of mental health initiatives, including pervasive stigma towards mental illness, local conceptualizations of mental illness and an emphasis on traditional treatment approaches. Implications for mental health initiatives in Sierra Leone and other low-income countries include a need for investment in primary care clinics to support integrated mental health services and the importance of engaging communities to promote the utilization of mental health services.

The importance of faith-based mental healthcare in African urbanized sites.

This review highlights what current research says about how local beliefs and norms can facilitate expansion of mental healthcare to meet the large unmet need for services in Africa. In contemporary Africa, religious beliefs exert important influences on mental health as well as the way people with mental illnesses are viewed and cared for. Mental healthcare practices based on traditional and other religious beliefs, and offered by complementary and alternative health providers (CAPs), reflect the people's culture and are often preferentially sought by a majority of the population. Despite important differences in the worldviews of CAPs and biomedical mental healthcare practitioners in regard to causal explanations, there are nevertheless overlaps in the approaches of both sectors to the management of mental health conditions. These overlaps may provide a platform for collaboration and facilitate the scaling-up of evidence-based mental health services to underserved African populations, especially those residing in ever-expanding urban centres. Faith-based mental healthcare is an important but informal component of the mental health system in much of Africa. Collaboration between its practitioners and biomedical practice may help to bridge the large treatment gap for mental health conditions on the continent.

A comparative carbon footprint analysis of disposable and reusable vaginal specula

Healthcare systems in the United States have increasingly turned toward the use of disposable medical equipment in an attempt to save time, lower costs, and reduce the transmission of infections. However, the use of disposable instruments is associated with increased solid waste production and may have negative impacts on the environment, such as increased greenhouse gas emissions. The purpose of this study was to inform this discussion; we applied life cycle assessment methods to evaluate the carbon footprints of 3 vaginal specula: a single-use acrylic model and 2 reusable stainless steel models. The functional unit of the study was defined as the completion of 20 gynecologic examinations by either type of speculum. The greenhouse gas emissions (eg, carbon dioxide, methane, nitrous oxide) across all life cycle stages, which includes material production and manufacturing, transportation, use and reprocessing, and end-of-life, were analyzed with the use of SimaPro life cycle assessment software and converted into carbon dioxide equivalents. The reusable stainless steel grade 304 speculum was found to have a lesser carbon footprint over multiple model scenarios (different reprocessing techniques, autoclave loading/efficiency, and number of uses) than either the reusable stainless steel grade 316 or the disposable acrylic specula. The material production and manufacturing phase contributed most heavily to the total life cycle carbon footprint of the acrylic speculum, whereas the use and reprocessing phase contributed most to the carbon footprints of both stainless steel specula. The use of disposable vaginal specula is associated with increased greenhouse gas equivalents compared with reusable alternatives with no significant difference in clinical utility. These findings can be used to inform decision-making by healthcare systems, because they weigh a wide range of considerations in making final purchase decisions; similar analytic methods can and should be applied to other components of health systems' waste streams.