Health System Coverage Research Articles

Crowdfunding and global health disparities: an exploratory conceptual and empirical analysis

BackgroundThe use of crowdfunding platforms to cover the costs of healthcare is growing rapidly within low-, middle-, and high-income countries as a new funding modality in global health. The popularity of such “medical crowdfunding” is fueled by health disparities and gaps in health coverage and social safety-net systems. Crowdfunding in its current manifestations can be seen as an antithesis to universal health coverage. But research on medical crowdfunding, particularly in global health contexts, has been sparse, and accessing robust data is difficult. To map and document how medical crowdfunding is shaped by, and shapes, health disparities, this article offers an exploratory conceptual and empirical analysis of medical crowdfunding platforms and practices around the world. Data are drawn from a mixed-methods analysis of medical crowdfunding campaigns, as well as an ongoing ethnographic study of crowdfunding platforms and the people who use them.ResultsDrawing on empirical data and case examples, this article describes three main ways that crowdfunding is impacting health equity and health politics around the world: 1) as a technological determinant of health, wherein data ownership, algorithms and platform politics influence health inequities; 2) as a commercial determinant of health, wherein corporate influence reshapes healthcare markets and health data; 3) and as a determinant of health politics, affecting how citizens view health rights and the future of health coverage.ConclusionsRather than viewing crowdfunding as a social media fad or a purely beneficial technology, researchers and publics must recognize it as a complex innovation that is reshaping health systems, influencing health disparities, and shifting political norms, even as it introduces new ways of connecting and caring for those in the midst of health crises. More analysis, and better access to data, is needed to inform policy and address crowdfunding as a source of health disparities.

Embedding implementation research to enhance health policy and systems: a multi-country analysis from ten settings in Latin America and the Caribbean

BackgroundProgress towards universal health coverage requires health policies and systems that are informed by contextualised and actionable research. Many challenges impede the uptake of evidence to enhance health policy implementation and the coverage, quality, efficiency and equity of health systems. To address this need, we developed an innovative model of implementation research embedded in real-world policy and programme cycles and led directly by policy-makers and health systems decision-makers. The approach was tested in ten settings in Latin America and the Caribbean, supported under a common funding and capacity strengthening initiative. The present study aims to analyse ten embedded implementation research projects in order to identify barriers and facilitators to embedding research into policy and practice as well as to assess the programme, policy and systems improvements and the cross-cutting lessons in conducting research embedded in real-world policy and systems decision-making.MethodsThe multi-country analysis is based on the triangulation of data collected via three methods, namely (1) document review, (2) an electronic questionnaire and (3) in-depth interviews with decision-makers. Data from the document review was charted and narratively synthesised. Data from the questionnaire was used to assess three characteristics of the decision-maker’s participation in embedded research, namely (1) level of engagement in different stages of research; (2) extent to which their capacities to conduct and use research were developed; and (3) the level of confidence in undertaking implementation research activities. Interview data was analysed using a thematic approach.ResultsThe main barriers to effective delivery or scale-up of health interventions identified in the research projects were inadequate financing, fragmentation of healthcare services and information systems, limited capacity of health system stakeholders, insufficient time, cultural factors, and a lack of information. Decision-makers’ experience in embedded research showed strong engagement in protocol development, moderate engagement in data collection and low engagement in data analysis. The in-depth interviews identified 17 facilitators and 8 barriers to embedding research into policy and systems. The principal facilitating factors were actionability of findings, relevance of research and engagement of decision-makers, whereas the main barriers were time and political processes. In Argentina, the research led to the development of new monitoring indicators to improve the implementation of the perinatal health policy, while in Chile, empirical findings supported the establishment of a training programme on reproductive rights, targeted to municipal health facilities.ConclusionsThis multi-country analysis contributes to the evidence base for the embedded research approach to support health policy and systems decisions-making. Embedding research into policy and practice stimulates the relevance and applicability of research, while promoting decision-makers’ engagement and likelihood to use research evidence in policy-making and health systems strengthening.

The case for a universal hepatitis C vaccine to achieve hepatitis C elimination

BackgroundThe introduction of highly effective direct-acting antiviral (DAA) therapy for hepatitis C has led to calls to eliminate it as a public health threat through treatment-as-prevention. Recent studies suggest it is possible to develop a vaccine to prevent hepatitis C. Using a mathematical model, we examined the potential impact of a hepatitis C vaccine on the feasibility and cost of achieving the global WHO elimination target of an 80% reduction in incidence by 2030 in the era of DAA treatment.MethodsThe model was calibrated to 167 countries and included two population groups (people who inject drugs (PWID) and the general community), features of the care cascade, and the coverage of health systems to deliver services. Projections were made for 2018–2030.ResultsThe optimal incidence reduction strategy was to implement test and treat programmes among PWID, and in settings with high levels of community transmission undertake screening and treatment of the general population. With a vaccine available, the optimal strategy was to include vaccination within test and treat programmes, in addition to vaccinating adolescents in settings with high levels of community transmission. Of the 167 countries modelled, between 0 and 48 could achieve an 80% reduction in incidence without a vaccine. This increased to 15–113 countries if a 75% efficacious vaccine with a 10-year duration of protection were available. If a vaccination course cost US$200, vaccine use reduced the cost of elimination for 66 countries (40%) by an aggregate of US$7.4 (US$6.6–8.2) billion. For a US$50 per course vaccine, this increased to a US$9.8 (US$8.7–10.8) billion cost reduction across 78 countries (47%).ConclusionsThese findings strongly support the case for hepatitis C vaccine development as an urgent public health need, to ensure hepatitis C elimination is achievable and at substantially reduced costs for a majority of countries.

Primary health care performance: a scoping review of the current state of measurement in Africa.

IntroductionCountries with strong primary healthcare (PHC) report better health outcomes, fewer hospital admissions and lower expenditure. People-centred care that delivers essential elements of primary care (PC) leads to improved health outcomes and reduced costs and disparities. Such outcomes underscore the need for validated instruments that measure the extent to which essential, evidence-based features of PC are available and applied to users; and to ensure quality care and provider accountability.MethodsA systematic scoping review method was used to identify peer-reviewed African studies and grey literature on PC performance measurement. The service delivery dimension in the Primary Healthcare Performance Initiative conceptual framework was used to identify key measurable components of PC.ResultsThe review identified 19 African studies and reports that address measuring elements of PC performance. 13 studies included eight nationally validated performance measuring instruments. Of the eight, the South African and Malawian versions of Primary Care Assessment Tool measured service delivery comprehensively and involved PC user, provider and manager stakeholders.Conclusion40 years after Alma Ata and despite strong evidence for people-centred care, significant gaps remain regarding use of validated instruments to measure PC performance in Africa; few validated instruments have been used. Agreement on indicators, fit-for-purpose validated instruments and harmonising existing instruments is needed. Rigorous performance-based research is necessary to inform policy, resource allocation, practice and health worker training; and to ensure access to high quality care in a universal health coverage (UHC) system—research with potential to promote socially responsive, accountable PHC in the true spirit of the Alma Ata and Astana Declarations.

Reinhardt’s Final Work

Reinhardt’s Final Work

Indonesia Hospital Cost Analysis: a Micro-Costing Approach

Efforts to develop the financing methods is needed to strengthen the Indonesia’s recently implemented universal health coverage system. Hospital cost data is urgently needed to calculate the unit cost of medical services that is important to evaluate the reimbursement rate setting. The most recent approach to calculate unit cost of medical services in hospital is micro-costing approach. This study aimed to perform a unit cost calculation using micro-costing approach in Indonesia’s district hospital in June-Dec 2016 from the provider perspective. The costing study followed the standard costing method and financial data were obtained through the hospital financial reports. Some financial data were directly measured since this study used bottom-up approach. This study showed that the unit cost was not relevant with the reference price set up by the government. It could be caused by different cost items and cost objects that had been employed in the study since the government tariff’s did not have clear and detailed information about the source of cost calculation. Micro-costing approach was useful as a precise method to calculate unit cost, even though rigorous efforts were needed to complete the data.

Using rapid reviews to strengthen health policy and systems and progress towards universal health coverage

### Summary box As many countries are developing policies addressing universal health coverage (UHC) and the Sustainable Development Goals, there is increasing demand for relevant and contextualised evidence to inform...

Challenges to achieving universal health coverage through community-based health planning and services delivery approach: a qualitative study in Ghana

ObjectiveCommunity-based initiatives have enormous potential to facilitate the attainment of universal health coverage (UHC) and health system development. Yet key gaps exist and threaten its sustainability in many low-income and...

Patient satisfaction with pharmaceutical care services provided at primary-level and secondary-level health facilities in Indonesia’s health coverage system

Purpose The purpose of this paper is to determine patient expectation and perception of pharmaceutical care services in order to measure the level of patient satisfaction provided by Indonesia’s health coverage (IHC) system. Design/methodology/approach A patient satisfaction survey was conducted at primary-level and secondary-level health facilities operating under IHC system. The assessment was performed using a closed-ended questionnaire that had been tested for validity and reliability. The patients’ point of view was evaluated based on their expectation and perception of six dimensions of the pharmaceutical care services they had received. Patient satisfaction was calculated based on the gap between their expectation and their perception. Findings A total of 602 patients participated in this research. The levels of the patients’ expectation of the pharmaceutical care services provided at primary-level health facilities range from high (3.39) to very high (3.54), whereas at secondary-level health facilities, the range was from low (2.04) to very high (3.75). This indicates that patients have a higher expectation of the provided pharmaceutical care services compared to the actual experience of the healthcare services that they received, resulting in a low value in the measurement of patient satisfaction levels. Originality/value The high level of patient expectation is an opportunity for pharmacists at both primary-level and secondary-level health facilities to continue developing pharmaceutical care services. Improving drug information service, patient counseling and reducing patient waiting time can be good ways to increase patient satisfaction within pharmaceutical care services.

Malaysia’s Rural Health Development: Foundation of Universal Health Coverage (UHC)

From 101 records relating to health kept in the National Archives of Malaysia for the period 1946–1981, 30 records were chosen using purposive criterion-based sampling on dimensions of universal health coverage (UHC) and health system governance. From those 30, document review was performed on 13 records that were selected based on relevance to analysis of the evolution of private and public health institutions and their roles in achieving UHC from 1946 to 1981. UHC relates to the ability of patients to access good quality service with high population coverage of health care at low financial risk. Malaya was a former Western Pacific nation ruled by the British colonial government. Initially, the government bore the cost of medicines and passages between the United Kingdom and Malaya for Red Cross and St. John’s ambulance teams to serve in rural areas in Malaya. This was later replaced by home grown Rural Health Teams trained in purpose built Rural Health Centres beginning with the first such training school in Jitra under the Rural Health Scheme. The Rural Health Scheme was implemented from 1953 to 1956 and marked an ambitious period of utilising limited resources to expand human resource and establish District Health Centres, Sub-District Health Centres, Midwives’ Houses and Maternal and Child Health Centres across the rural landscape of Malaya. After analysis, it was found that the British colonial government’s efforts in improving public health through the Rural Health Scheme had provided the foundation for achieving UHC in Malaysia today. DOI : http://dx.doi.org./10.17576/JSKM-2019-1701-05

The Essential Public Health Services and How They Correspond to the 12 Principles of the Ethical Practice of Public Health in Competing Tuberculosis in South Africa

Although the Essential Public Health Services are noble, there is a growing demand from WHO regional offices and Member States to deliver better conceptual clarity on EPHS in Public health advocacy and strengthened health System planning, discussions on the resilient health system and universal health coverage. This paper critically analyzes the Essential Public Health Services (EPHS) and describes how these correspond to the 12 Principles of the Ethical Practice of Public Health (PEPPH). The 12 PEPPH are discussed along with the 10 Essential Public Health Services which are categories into categories: Assessment which includes, Monitor health status and Diagnoses and investigates health problems, Policy development for Inform and educates, Mobilize communities to address health problems and Develop policies and plans and Assurance which includes the Enforce laws and regulations, Link people to needed health services, Assure a competent health services workforce, Evaluate health services and Conduct research for new innovations and how they correspond to the in 12 PEPPH. Tuberculosis is used as an example to critically analyze the EPHS and their relation to the 12 PEPPH to identify the gap between research and policy in South Africa. Although there are obvious benefits and strengths in aiming for the achievement of the EPHS there is a general consensus about the basic conceptual features of public health its practical boundaries in government, the private sector and throughout society have proven much more challenging. There is a gap in the manner in which these essential services related to the SDGs and universal health coverage. With regard to regional perspectives on EPHS, although there were numerous overlaps of different initiatives from PAHO and CDC, it was clear that there was no unified WHO approach. The WHO regions that have developed their own list of EPHS have done so individually, through regional programmers, at different times over the past there is no representation or adaptation from countries within the African continent and other continents which face systemic public health challenges. There is a limitation to the assessment in developing and implementing of these services on evidence-based public health reorganizations, included an overt relations to a reform process, broad-based collaborative and ownership of national stakeholders, and the availability of technical assistance for both the evaluation and the subsequent prioritization process needed to make specific recommendations. The gap between research and policy is wide in South Africa and continentally. Challenges of this gap are not dealt with in the Essential Public health Services and without addressing such issues the attainment of these essential services is highly handicapped.

Transforming the Gendered Regime Through Reproductive Politics: Neoliberal Health Restructuring, The Debt Economy and Reproductive Rights in Turkey

The “Health Transformation Program,” started by the AKP (Justice and Development Party) in 2003 in Turkey, is part of the global neoliberal “Health Sector Reforms-HSRs” which have been undertaken since the late 1980s and early 1990s with the support of World Bank advisers and reports, in various ‘developing’ countries such as Brazil, Mexico, South Korea, Taiwan, always with the rationale of a “health crisis” (increasing costs of health care), a need to prevent public corruption and bring “efficiency.” Similar to these other contexts, the Turkish health reform or health restructuring as we call it, comprised changes to finance mechanisms and provision of care and introduced a premium-based compulsory health coverage system. Alongside the neoliberal policies, there has also been a rise in the New Right under the AKP regime, which had at its center anti-women discourses, policies and implementations, including a pronatalist discourse and implementations and statements equating abortion with murder. To contribute to the existing feminist literature that analyzes the intricate links between capitalism, neoliberalism and gender, especially on connecting the latest stage of neoliberalism–the debt economy- to reproductive rights, we designed a multisite feminist research to investigate the effects of neoliberal health-structuring on reproductive rights in Turkey, France and the U.S. Our theoretical groundings are in transnational feminist theory and writings on the state of neoliberalism and the debt economy, especially those of Lazaratto and Berardi. In this paper, we discuss our findings in Turkey, especially the focus-group interviews with healthcare providers working in family health centers, in order to reveal how the gender regime in Turkey is being transformed via reproductive and body politics. Analyzing our existent data on Turkey in light of the writings on the debt economy, we observed the neoliberal mechanisms of the dismantling of the public/privatization and the creation of individual debt and quantification of care (as related to mathematization of life and language). We witnessed how these neoliberal mechanisms interact with the conservative discourse leading to the erosion of women’s rights to access contraceptive and abortion care in Turkey and a transformation of the gender regime through the alteration of its reproductive politics.

Health and disease concepts: an approach to health development

Purpose Health for all is an ideal goal that all governments aspire to reach. The purpose of this paper is to assess the definitions of the key terms used to better appreciate the role of the WHO member states in their efforts to achieve improved healthcare systems that suit each nation’s particular needs. Design/methodology/approach Definitions of the terms disease, illness and health are discussed against health concepts as a means of assessing the most effective approach toward achieving an effective universal healthcare system. Findings Universal health and treatment of sickness and disease have improved globally, but the target of achieving total wellness still remains as a goal for the future and may be impeded by diseases that have not yet evolved. The implementation of a universal health coverage system is a positive step toward achieving the goals of health and wellness for the present times. Originality/value This is a commentary piece.

Patients\u2019 perspectives regarding hospital visits in the universal health coverage system of Thailand: a qualitative study

BackgroundA universal health coverage policy was implemented in Thailand in 2002 and led to an increase in accessibility to, and equity of, healthcare services. The Thai government and academics have focused on the large-scale aspects, including effectiveness and impacts, of universal health coverage over one decade. Here, we aimed to identify patients’ perspectives on hospital visits under universal health coverage.MethodsA qualitative study was carried out in four public hospitals in rural Thailand. We collected data through focus group discussions (FGDs) and in-depth interviews (IDIs). The semi-structured interview guide was designed to elicit perspectives on hospital visits among participants covered by the Universal Coverage Scheme, Social Security Scheme or Civil Servant Medical Benefit Scheme. Data were transcribed and analysed using a thematic approach.ResultsTwenty-nine participants (mean age, 56.76 ± 16.65 years) participated in five FGDs and one IDI. The emerging themes and sub-themes were identified. Factors influencing decisions to visit hospitals were free healthcare services, perception of serious illness, the need for special tests, and continuity of care. Long waiting times were barriers to hospital visits. Employees, who could not leave their work during office hours, could not access some services such as health check-ups. From the viewpoint of participants, public hospitals provided quality and equitable healthcare services. Nevertheless, shared decision making for treatment plans was not common.ConclusionsThe factors and barriers to utilisation of healthcare services provide exploratory data to understand the healthcare-seeking behaviours of patients. Perceptions towards free services under universal health coverage are positive, but participation in decision making is rare. Future studies should focus on finding ways to balance the needs and barriers to hospital visits and to introduce the concept of shared decision making to both doctors and patients.

Which is the cost for having a live born with in vitro fertilization in women older than 40 years of age?

The aim of this study is to evaluate the reproductive results in women older than 40 years that realized an in vitro fertilization after the implementation of the National Law of Coverage for Assisted Reproductive. We analyzed, the cost that represent to our National Health System. Descriptive retrospective study. We analyzed 1102 IVF cycles carried out at our center from 2016 to 2017 in patients older than 40 years. Cycles with egg donation were excluded. Result variables analyzed were: cancellation rate (CR), pregnancy rate by oocyte retrieval (PROR), pregnancy rate per embryo transfer (PRET), miscarriage rate (MR) and take home baby rate (THBR). We calculated a cost/effectiveness relationship associated with these treatments in this particular group of patients that ended in a live born considering the impact in our national health system. The statistical analysis was performed using the Fischer’s exact test and ANOVA test with a significant p value <0.05. During this period we performed 3496 IVF cycles, from which 93.2% (3258) corresponded to cycles financed by the health system coverage and 33.8% of which were IVF cycles in women over 40 years of age. In the same period we compared THBH in women <35 years and 35-40 years with health coverage (48.9% and 42.3 % respectively), which were significantly higher than those in women > 40 (p<0.05). In our country for every completed IVF treatment, social and private health coverage system destine about USD 5000 (including assisted reproduction techniques and medication). Therefore, the cost for a healthy live born in women over 40 years is approximately USD 70.641 (1102 cycles x USD 5000/N° of live born: 78), 35-40: USD 11820 and <35: USD 10231. Maternal age directly influences THBR, with significant higher rates in women < 35 or 35-40 when compared to >40. There is no statistical difference (p= 0.18) in THBR within patients <40. The monetary cost estimated for having a healthy live born in women over 40 year of age is nearly 6 times higher when compared with women under 40. In women older than 40, our cost per healthy live born is higher than reported in the literature for the same age group. This might be a useful information in order to reevaluate the public health politics particularly in countries, like Argentina, that provides free assisted reproductive treatments in women over 40 year.Tabled 1ResultsAGEIVF CYCLESCR (%)PROR (%)PRET (%)MR (%)THBR (%)4028117.7 (50/281)16.0 (45/281)19.4 (45/231)42.2 (19/45)11.2 (26/231)4119723.8 (46/197)16.7 (33/197)21.8 (33/151)42.4 (14/33)12.6 (19/151)4221925.5 (56/219)12.7 (28/219)17.1 (28/163)32.1 (9/28)11.6 (19/163)4319827.3 (54/198)11.6 (23/198)14.3 (23/160)56.5 (13/23)6.2 (10/160)449725.7 (25/97)7.2 (7/97)11.2 (7/62)57.1 (4/7)4.8 (3/62)456839.7 (27/68)4.4 (3/68)7.3 (3/41)66.6 (2/3)2.4 (1/41)463151.6 (16/31)0 (0/31)0 (0/21)47616.6 (4/6)0 (0/6)0 (0/2)48250.0 (1/2)0 (0/2)0 (0/1)502100 (2/2)0 (0/2)521100 (1/1)0 (0/1) Open table in a new tab

An ethnographic study of enrollment obstacles in Rhode Island, USA: struggling to get covered on an Affordable Care Act insurance marketplace

ABSTRACTThe Affordable Care Act (ACA) of 2010 expanded access to health insurance coverage in the United States through online marketplaces that provided subsidized insurance coverage. Nonetheless, many obstacles made it difficult to enroll in and maintain ACA insurance coverage. In this article, we analyze obstacles to enrollment and continuous coverage based on an ethnography of ACA insurance enrollment in Rhode Island. We foreground consumers’ experiences and highlight the time and effort that people invested into getting covered. Unlike studies that focus on individual choices and employ a deficit perspective to understand gaps in coverage, this article argues that structural problems related to the organization of the American health insurance system, economic instability and bureaucratic eligibility criteria shaped the experiences of individuals and families seeking coverage. We found that people actively and intensely struggled to enroll and were met with multiple obstacles, most of which were beyond their control. In some cases, these obstacles resulted in gaps in coverage. In almost all cases, they created additional stress, were time consuming and frustrating. The most significant obstacles to enrolling in coverage were bureaucratic barriers, affordability, changes in personal or family status, and knowledge about health insurance and ACA program rules. We end by questioning the ethical basis of a health coverage system structured on ‘churn’ and offer policy recommendations to design programs that respect people’s time, avoid verification redundancies and are motivated by a mission to expand coverage.

Universal health system and universal health coverage: assumptions and strategies.

In recent years the international debate about universality in health has been marked by a polarization between ideas based on a universal system, and notions proposing universal health coverage. The concept of universal coverage has been disseminated by international organizations and has been incorporated into health system reforms in several developing countries, including some in Latin America. This article explores the assumptions and strategies related to the proposal of universal health coverage. Firstly, a comparison is provided of the models of universal health coverage and universal health systems. This is followed by a contextualization of the international debate, including examples of different health systems. Finally, the implications of the proposal of universal coverage for the right to health in Brazil are discussed. The analysis of different concepts of universality and the experiences of different countries shows that health insurance-based models, either social or private, are not as satisfactory as public, universal health systems. Greater understanding about ongoing international projects is essential in order to identify the possibilities represented by the consolidation of the Unified Health System (SUS) in Brazil, as well as the risks of dismantling the SUS.

Inquérito de saúde em comunidades ribeirinhas do Amazonas, Brasil

Population-based health surveys are important tools for identifying disease determinants, especially in regions with widely dispersed populations and low health system coverage. The aim of this study was to describe the principal methodological aspects and to describe the socioeconomic, demographic, and health characteristics of the riverine populations of Coari, Amazonas State, Brazil. This was a population-based cross-sectional study in river-dwelling communities in the rural area of Coari, from April to July 2015. The probabilistic cluster sample consisted of 492 individuals. The results showed that the majority of the river-dwellers were females (53%), had up to 9 years of schooling (68.5%), and earned a monthly family income equivalent to one-third the minimum wage. The health problems reported in the previous 30 days featured conditions involving pain (45.2%). The main healthcare resources were allopathic medicines (70.3%), exceeding herbal remedies (44.3%). The river-dwellers travel an average of 60.4km and take some 4.2 hours to reach the urban area of Coari. The riverine population generally presents low economic status and limited access to the urban area. Health problems are mostly solved with allopathic medicines. Geographic characteristics, as barriers to access to health services and to improvements in living conditions for the riverine population, can limit the collection of epidemiological data on these populations.

Using case management in a universal health coverage system to improve quality of life of frequent Emergency Department users: a randomized controlled trial

PurposeFrequent Emergency Department users are likely to experience poor quality of life (QOL). Case management interventions are efficient in responding to the complex needs of this population, but their effects on QOL have not been tested yet. Therefore, the aim of our study was to examine to what extent a case management intervention improved frequent Emergency Department users’ QOL in a universal health coverage system.MethodsData were part of a randomized controlled trial designed to improve frequent Emergency Department users’ QOL at the Lausanne University Hospital, Switzerland. A total of 250 frequent Emergency Department users (≥ 5 attendances during the previous 12 months) were randomly assigned to the control (n = 125) or the intervention group (n = 125). The latter benefited from case management intervention. QOL was evaluated using the WHOQOL-BREF at baseline, two, five and a half, nine, and twelve months later. It included four dimensions: physical health, psychological health, social relationship, and environment. Linear mixed-effects models were used to analyze the change in the patients’ QOL over time.ResultsPatients’ QOL improved significantly (p < 0.001) in both groups for all dimensions after two months. However, environment QOL dimension improved significantly more in the intervention group after 12 months.ConclusionsEnvironment QOL dimension was the most responsive dimension for short-term interventions. This may have been due to case management’s assistance in obtaining income entitlements, health insurance coverage, stable housing, or finding general health care practitioners. Case management in general should be developed to enhance frequent users’ QOL.Trial registration: http://www.clinicaltrials.gov, Unique identifier: NCT01934322

Scaling up newborn care in Afghanistan: opportunities and challenges for the health sector.

Newborn health in Afghanistan is receiving increased attention, but reduction in newborn deaths there has not kept pace with declines in maternal and child mortality. Using the continuum of care and health systems building block frameworks, this article identifies, organizes and provides a synthesis of the available evidence on and gaps in coverage of care and health systems, programmes, policies and practices related to newborn health in Afghanistan. Newborn mortality in Afghanistan is related to the nation's weak health system, itself associated with decades of conflict, low and uneven coverage of essential interventions, demand-side and cultural specificities, and compromised quality. A majority of deliveries still take place at home. Birth asphyxia, low birth weight, perinatal infections and poor post-natal care are responsible for many preventable newborn deaths. Though the situation has improved, there remain many opportunities to accelerate progress. Analyses conducted using the Lives Saved Tools suggest that an additional 10 405 newborn lives could be saved in Afghanistan in 5 years (2015-20), through reasonable increases in coverage of these high-impact interventions. A long-term vision and strong leadership are essential for the Ministry of Public Health to play an effective stewardship role in formulating related policy and strategy, setting standards and monitoring maternal and newborn services. Promotion of equitable access to health services, including health workforce planning, development and management, and the coordination of much-needed donor support are also imperative.