Package Of Health Services Research Articles

Regarding Investment in a Healthier Future: Impact of the 2012 Institute of Medicine Finance Report.

Governments at all levels work to ensure a healthy public, yet financing, organization, and delivery of public health services differ across the United States. A 2012 Institute of Medicine Finance report provided a series of recommendations to ensure a high-performing and adequately funded public health infrastructure. This review examines the influence of the Finance report's 10 recommendations on public health policy and practice. This review utilized peer-reviewed and gray literature published since 2012. Documents that address at least one of the Finance report's 10 recommendations and contain information on either official actions taken in response to the Finance report or evidence of the report's influence on the practice community. Of 2394 unique documents found, a total of 56 documents met the eligibility criteria. Review of these 56 documents indicated that the most substantial activity related to the recommendations was focused on the "minimum package of public health services" concept and establishment of a uniform chart of accounts. Progress has been mixed on the Finance report recommendations. Improved tracking and auditing of public health activity appears to be advancing, yet financial benchmarks remain unmet. Challenges remain in determining actual investment in public health and equitable resource allocation approaches. State and local health department use of cost estimation methodology and a uniform chart of accounts tool has contributed to an increase in understanding and improvement in public health spending. The Finance report has served as a strong impetus for advocating for an increased investment in governmental public health. Efforts are bolstered by informed public health practitioners and stakeholders but often stymied by policy makers who must balance complex competing issues and priorities. Although many successes have occurred, further work is needed toward improving investment in the nation's public health.

The cost-effectiveness of using performance-based financing to deliver the basic package of health services in Afghanistan

Performance-based financing (PBF) is a mechanism to improve the quality and the utilisation of health benefit packages. There is a dearth of economic evaluations of PBF in the ‘real world’....

How to reduce the impact of cervical cancer worldwide: Gaps and priority areas identified through the essential cancer and primary care packages: An analysis of effective interventions.

Cervical cancer is a preventable cancer; therefore, countries should provide strategic, evidence-based health services to reduce its incidence and impact on their populations. Two packages of health services that group together all the services related to cervical cancer, the Essential Cancer Package (9 interventions) and the Primary Care Package (5 interventions), are defined in this article with the aim of assessing the global status of the availability of health services and their coverage in 194 countries worldwide. The study was based on the 2017 World Health Organization (WHO) Noncommunicable Disease Country Capacity Survey. Although the survey covered multiple noncommunicable diseases, this report examined only those results pertaining to cervical cancer in the 194 WHO member states divided by WHO region and World Bank income. Only 21% of the countries reported providing all 9 interventions of the Essential Cancer Package, with the highest proportions being found in Europe (45.3%) and among high-income countries (HICs; 54.3%). As for the Primary Care Package, only 19.1% of countries provided all 5 interventions, with the highest proportions being found in Europe (39.6%) and among HICs (45.5%). The complete development and appropriate coverage of each service listed in both the Essential Cancer Package and the Primary Care Package are essential to reduce the impact of cervical cancer worldwide, and they should be integrated into all cancer control planning efforts.

Introduction of birth dose of hepatitis B virus vaccine to the immunization program in Ethiopia: an economic evaluation

BackgroundHepatitis B virus (HBV) infection is an important cause of morbidity and mortality with a very high burden in Africa. The risk of developing chronic infection is marked if the infection is acquired perinatally, which is largely preventable through a birth dose of HBV vaccine. We examined the cost-effectiveness of a birth dose of HBV vaccine in a medical setting in Ethiopia.MethodsWe constructed a decision analytic model with a Markov process to estimate the costs and effects of a birth dose of HBV vaccine (the intervention), compared with current practices in Ethiopia. Current practice is pentavalent vaccination (DPT-HiB-HepB) administered at 6, 10 and 14 weeks after birth. We used disability-adjusted life years (DALYs) averted to quantify the health benefits while the costs of the intervention were expressed in 2018 USD. Analyses were based on Ethiopian epidemiological, demographic and cost data when available; otherwise we used a thorough literature review, in particular for assigning transition probabilities.ResultsIn Ethiopia, where the prevalence of HBV among pregnant women is 5%, adding a birth dose of HBV vaccine would present an incremental cost-effectiveness ratio (ICER) of USD 110 per DALY averted. The estimated ICER compares very favorably with a willingness-to-pay level of 0.31 times gross domestic product per capita (about USD 240 in 2018) in Ethiopia. Our ICER estimates were robust over a wide range of epidemiologic, vaccine effectiveness, vaccine coverage and cost parameter inputs.ConclusionsBased on our cost-effectiveness findings, introducing a birth dose of HBV vaccine in Ethiopia would likely be highly cost-effective. Such evidence could help guide policymakers in considering including HBV vaccine into Ethiopia’s essential health services package.

Gestational Diabetes Mellitus and Associated Health Risk Outcomes in Mothers and Neonates

Global Gestational Diabetes Mellitus (GDM) pregnancy complication is estimated at 200,000 cases annually with serious health consequences for maternal and neonates. A cohort study to establish GDM risks and associated health outcomes was conducted among 238 women attending antenatal clinic in selected health facilities in Nairobi, Kenya. Results indicated that mothers with GDM are four times more likely to have varied physical discomforts and complicated deliveries as result of high neonatal birth weight. To improve population health, there is need to advocate for inclusion of diabetes testing and management as part of Essential Health Services Package for Kenya to realize positive health outcomes among women.
 Key words: • Gestational diabetes mellitus • Maternal • Neonates
 
 Copyright © 2020 Adoyo et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Knowledge, attitudes and skills of dementia care in general practice: a cross-sectional study in primary health settings in Beijing, China

BackgroundGeneral practitioners (GPs) play a significant role in dementia care. However, the knowledge and attitudes of them towards dementia care are poorly characterized. The present study aimed to investigate GPs’ knowledge, attitudes and skills of dementia care in primary health settings in Beijing.MethodsA cross-sectional survey was conducted in 27 community health service centers (CHSCs) in Beijing. The GPs’ knowledge, attitudes and skills were assessed utilizing the Alzheimer’s Disease Knowledge Scale (ADKS), Dementia Care Attitude Scale (DCAS) and self-designed questionnaire, respectively.ResultsA total of 341 participants returned the questionnaire. The overall mean score of GPs’ dementia knowledge measured by the ADKS was 21.42 (SD = 2.73) out of 30 (71.4%), GPs’ attitudes to dementia care was 36.25 (SD = 5.12) out of 50 (72.5%), and GPs’ self-confidence on dementia care skills was 53.93 (SD = 9.57) out of 75 (71.9%). GPs’ overall knowledge towards dementia care was limited and the attitudes were generally positive. They had low level recognition of their roles towards dementia care. The majority of GPs believed that dementia care was within a specialist’s domain not that of general practice.ConclusionGPs demonstrate low levels of dementia knowledge and skills, but express generally positive attitudes towards dementia in this study. It is much needed to translate detailed dementia care handbook, and adequate dementia knowledge training for GPs into practice to improve care outcomes for people with dementia in China. In addition, dementia management should be covered in the national basic package of public health services in primary care.

The Roadside Healthcare Facility Location Problem A Managerial Network Design Challenge

The population of truck drivers plays a key role in the spread of HIV and other infectious diseases in sub‐Saharan Africa. Truck drivers thereby affect the health and lives of many, but also suffer from poor health and significantly reduced life expectancy themselves. Due to professional circumstances, their health service needs are generally not well addressed. Therefore, the non‐governmental organization North Star Alliance builds a network of healthcare facilities along the largest trucking routes in sub‐Saharan Africa. This paper studies the problem where to place additional facilities, and which health service packages to offer at each facility. The objective combines the maximization of the patient volume at these facilities and the maximization of the effectiveness of the health service delivery to the population served. The latter criterion is modeled through three novel access measures which capture the needs for effective service provisioning. The resulting optimization problem is essentially different from previously studied healthcare facility location problems because of the specific mobile nature of health service demand of truck drivers. Applying our model to the network of major transport corridors in South‐East Africa, we investigate several prominent questions managers and decision‐makers face. We show that the present network expansion strategy, which primarily focuses on patient volumes, may need to be reconsidered: substantial gains in effectiveness can be made when allowing a small reduction in patient volumes. We furthermore show that solutions are rather robust to data impreciseness and that long‐term network planning can bring substantial benefits, particularly in greenfield situations.

Performance-Based Financing, Basic Packages of Health Services and User-Fee Exemption Mechanisms: An Analysis of Health-Financing Policy Integration in Three Fragile and Conflict-Affected Settings.

BackgroundAs performance-based financing (PBF) is increasingly implemented across sub-Saharan Africa, some authors have suggested that it could be a ‘stepping stone’ for health-system strengthening and broad health-financing reforms. However, so far, few studies have looked at whether and how PBF is aligned to and integrated with national health-financing strategies, particularly in fragile and conflict-affected settings.ObjectiveThis study attempts to address the existing research gap by exploring the role of PBF with reference to: (1) user fees/exemption policies and (2) basic packages of health services and benefit packages in the Central African Republic, Democratic Republic of Congo and Nigeria.MethodsThe comparative case study is based on document review, key informant interviews and focus-group discussions with stakeholders at national and subnational levels.ResultsThe findings highlight different experiences in terms of PBF’s integration. Although (formal or informal) fee exemption or reduction practices exist in all settings, their implementation is not uniform and they are often introduced by external programmes, including PBF, in an uncoordinated and vertical fashion. Additionally, the degree to which PBF indicators lists are aligned to the national basic packages of health services varies across cases, and is influenced by factors such as funders’ priorities and budgetary concerns.ConclusionsOverall, we find that where national leadership is stronger, PBF is better integrated and more in line with the health-financing regulations and, during phases of acute crisis, can provide structure and organisation to the system. Where governmental stewardship is weaker, PBF may result in another parallel programme, potentially increasing fragmentation in health financing and inequalities between areas supported by different donors.Electronic supplementary materialThe online version of this article (10.1007/s40258-020-00567-8) contains supplementary material, which is available to authorized users.

Are people most in need utilising health facilities in post-conflict settings? A cross-sectional study from South Kivu, eastern DR Congo

ABSTRACT Background: The disruptive effect of protracted socio-political instability and conflict on the health systems is likely to exacerbate inequities in health service utilisation in conflict-recovering contexts. Objective: To examine whether the level of healthcare need is associated with health facility utilisation in post-conflict settings. Methods: We conducted a cross-sectional study among adults with diabetes, hypertension, mothers of infants with acute malnutrition, informal caregivers (of participants with diabetes and hypertension) and helpers of mothers of children acutely malnourished, and randomly selected neighbours in South Kivu province, eastern DR Congo. Healthcare need levels were derived from a combination, summary and categorisation of the World Health Organisation Disability Assessment Schedule 2.0. Health facility utilisation was defined as having utilised in the first resort a health post, a health centre or a hospital as opposed to self-medication, traditional herbs or prayer homes during illness in the past 30 days. We used mixed-effects Poisson regression models with robust variance to identify the factors associated with health facility utilisation. Results: Overall, 82% (n = 413) of the participants (N = 504) utilised modern health facilities. Health facility utilisation likelihood was higher by 27% [adjusted prevalence ratio (aPR): 1.27; 95% CI: 1.13–1.43; p < 0.001] and 18% (aPR: 1.18; 95% CI: 1.06–1.30; p = 0.002) among participants with middle and higher health needs, respectively, compared to those with low healthcare needs. Using the lowest health need cluster as a reference, participants in the middle healthcare need cluster tended to have a higher hospital utilisation level. Conclusion: Greater reported healthcare need was significantly associated with health facility utilisation. Primary healthcare facilities were the first resort for a vast majority of respondents. Improving the availability and quality of health service packages at the primary healthcare level is necessary to ensure the universal health coverage goal advocating quality health for all can be achieved in post-conflict settings.

Evaluation of the effectiveness of a quality improvement intervention to support integration of maternal, child and HIV care in primary health care facilities in South Africa

BackgroundDespite policies and guidelines recommending integration of health services in South Africa, provision of maternal and child health services remains fragmented. This study evaluated a rapid, scaleable, quality improvement (QI) intervention to improve integration of maternal and child health and HIV services at a primary health level, in KwaZulu-Natal, South Africa.MethodsA three-month intervention comprised of six QI mentoring visits, learning sessions with clinic staff to share learnings, and a self-administered checklist aimed to assist health workers monitor and implement an integrated package of health services for mothers and children. The study evaluated 27 clinics in four sub-districts using a stepped-wedge design. Each sub-district received the intervention sequentially in a randomly selected order. Five waves of data collection were conducted in all participating clinics between December 2016–February 2017. A multi-level, mixed effects logistic regression was used to account for random cluster fixed time and group effects using Stata V13.1.ResultsImprovements in some growth monitoring indicators were achieved in intervention clinics compared to control clinics, including measuring the length of the baby (77% vs 63%; p = 0.001) and health workers asking mothers about the child’s feeding (74% vs 67%; p = 0.003), but the proportion of mothers who received feeding advice remained unchanged (38% vs 35%; p = 0.48). Significantly more mothers in the intervention group were asked about their baby’s health (44% vs 36%; p = 0.001), and completeness of record keeping improved (40% vs 26%; I = < 0.0001). Discussions with the mother about some maternal health services improved: significantly more mothers in the intervention group were asked about HIV (26.5% vs 19.5%; p = 0.009) and family planning (33.5% vs 19.5%; p < 0.001), but this did not result in additional services being provided to mothers at the clinic visit.ConclusionThis robust evaluation shows significant improvements in coverage of some services, but the QI intervention was unable to achieve the substantial changes required to provide a comprehensive package of services to all mothers and children. We suggest the QI process be adapted to complex under-resourced health systems, building on the strengths of this approach, to provide workable health systems strengthening solutions for scalable implementation.Trial registrationClinicalTrials.gov NCT04278612. Date of Registration: February 19, 2020. Retrospectively registered.

The Utilization of Health Service Packages Among Mothers of Children Less Than 1Year of Age in the Somali Region of Ethiopia.

Health Service Package is the package of services that the government is providing or is aspiring to provide to its citizens in an equitable manner. The Ethiopia Family Health Service Package is part of the health extension program consisting of antenatal care, delivery service, postnatal care, immunization, and family planning. This package facilitates the utilization of maternal, neonatal and child health services and contributes to the reduction of maternal and child mortality. However, there is no data on the utilization of this package in pastoralist societies. This study aimed to assess the utilization of the Family Health Service Package and associated factors among mothers of children less than 1-year-old. From February 18-March 6, 2017 we conducted a community-based cross-sectional study with 421 mothers who gave birth in the last year in the Afdem district of the Somali region in Ethiopia. Mothers who gave birth between January 1/2016 to January 1/2017 in the district were selected by systematic random sampling. The study analysis included descriptive and bivariate statistics and multivariate logistic regression model. The overall utilization of the package was 25.1% (95% CI of 21.1-29.5%). Factors associated significantly with family health service utilization were urban place of residence [(AOR 95% CI) = 3.8 (1.5-9.9)], mother visited by health extension workers [(AOR (95% CI) = 3.1 (1.6-6.3)] and mothers participation in health extension program activities [(AOR (95% CI) = 2.8 (1.5-5.4)]. The utilization of the Family Health Service Package was low. Mothers visited by health extension workers and participated in the health extension program were more likely to utilize family health services. It needs to expand services beyond urban areas and involve rural mothers in health extension program activities.

Everyday challenges facing high-risk older people living in the community: a community-based participatory study

BackgroundConsidering the real-world experiences of those with cognitive impairments is important in building a positive community for older people. Community-based participatory research is an important methodology for investigators focused on improving community health. The aim of this study was to 1) investigate factors associated with the continuation of community dwelling among high-risk older people and 2) to create a model of an inclusive community space for older people in the largest housing complex district in Tokyo.MethodsFrom 198 residents who completed all three steps (mail, face-to-face, and home-visit) of a previous large-scale epidemiological survey, we identified 66 residents who were at high-risk of moving out of the community. These participants underwent 6 months of regular assessments by experienced researchers to identify the factors associated with continuing to live in the community.We also employed a community action approach to develop a community space for residents in the study district where more than two researchers who were medical professionals served as staff. The services offered by the space were continuously improved according to user feedback. The function of this center was evaluated during interdisciplinary research meetings.ResultsAfter 6 months, among the 66 high-risk residents, 49 people were living in the community and 12 people had moved out of the community. Those who could not continue to live in the community had greater unmet needs in terms of social support, especially daily living support and housing support. In addition, their families perceived a heavier burden of care. Interestingly, dementia diagnosis via the DSM-5, clinical dementia rating, physical health, mental health, and long-term care usage did not predict the outcome.Through discussions with guests, we equipped the space with various services such as coordination of community care and networking with existing organizations.ConclusionsMerely providing healthcare and long-term care might not be sufficient to support community living in people with cognitive impairments. Daily living support and housing support should be provided in the context of a broad health services package. For this purpose, creating a comfortable community space for residents and community workers is essential.

The role of husband support in 3-month injection birth control visits at the Cibeber Cimahi Community Health Center in 2018

Background:Family planning services are one in the package of essential reproductive health services that need serious attention, because with the quality family planning services, it will improve the welfare, health of infants and children and reproductive health. The husband is a wife's life partner so the husband's role is considered very important in supporting the successful use of contraception. At the Cibeber Health Center the highest use of contraception is 3-month injection contraception, where women who use it must re-visit according to the allotted time every 3 months. Based on data obtained at the public health, there are many old-age pregnancies, pregnancies with close range and even multi-parity and even grande that occur, one of which is due to the re-visit of contraception that is not on time. The purpose of this study was to determine the number of husband support for wives who use contraception, the number of return visits for 3 months injectable contraception acceptors and the relationship of husband support for 3 months injection visit. The research method used in this research is analytic descriptive using chi square test as a bivariate analysis and questionnaire as a research instrument. The results of this study were 51% of husbands who did not support and 49% of husbands who supported the use of 3 months injection contraception. The result of bivariate analysis is that there is a significant relationship between the role of husband support with 3 months injection contraception visit where the results of the chi square analysis show the p value = 0,000. Discussion in this research women who use contraception must have the support of their husbands so that the continuation of 3-month injection contraception can run well and make repeat visits on time.Keywords: Contraception, Support

Perception of basic package of health services’ impact on health service delivery and mortality among residents of Wulu County, South Sudan

A populations’ perception of health service delivery is critical to the understanding of the relationship between quality of care and utilization of health services and has been increasingly treated as an outcome of health care delivery. This study aimed to assess the perceived impact of a basic package of health services on health service delivery and mortality in Wulu County, South Sudan. A cross-sectional survey of 396 eligible adults aged 18 years and above who had benefitted from the services of health facilities within communities of Wulu County and equally resided in the community during the years 2014 to 2016 was conducted. A structured questionnaire was used to determine respondents’ perceived mortality and health service delivery ratings. Most respondents expressed moderate overall perceptions of health service delivery (62.4%) and mortality (84.1%) during 2014–2016. In 2016 significantly lower (p < 0.05) mortality perception scores and significantly higher perceived scores of health service delivery were recorded than in 2014 and 2015. In 2015, however, significantly lower mortality perception scores were recorded than in 2014. Respondents from the most urban area, Wulu Payam, expressed significantly higher health service satisfaction scores than those from other payams. The perception of a basic package of health services provided by health care agencies in South Sudan as expressed by the residents of Wulu County was satisfactory and considered to have achieved a significant reduction in the population’s mortality rate. However, the rural payams appeared to be lagging behind.

A cross-sectional study on socio-demographic profile and problems of Anganwadi workers in the urban municipality area of Raichur city

Background: ICDS is the World`s largest community based outreach program running all over the country, which offers a package of health, nutrition and education services to children below the age of 6 years, pregnant and nursing mothers. The focal point for delivery of these services is Anganwadi Centre (AWC). As anganwadi workers (AWWs) are the backbone of ICDS program, its successful functioning depends upon the effectiveness of anganwadi workers which in turn depends upon their knowledge, attitude and practices. Objectives: 1) To study the socio-demographic and work profile of anganwadi workers. 2) To assess the problems perceived by anganwadi workers in executing the above services. Methods: A descriptive cross-sectional study conducted at the anganwadi centres in the urban area of Raichur municipality. After taking verbal consent, Anganwadi worker were interviewed using questionnaire. Duration of the study was one year. 210 anganwadi centres were included in the study. Results: Majority of anganwadi workers (71%) were aged less than 40 years, 44.3% were matriculate and 60% had working experience of

Why do many basic packages of health services stay on the shelf? A look at potential reasons in the WHO South-East Asia Region.

Basic packages of health services (BPHSs) are often envisaged primarily as political statements of intent to provide access to care, in an era of commitment to universal health coverage. They are often produced with little attention paid to health systems' capacity to deliver these benefit packages or other implementation challenges. Many countries of the World Health Organization (WHO) South-East Asia Region have invested in developing BPHSs. This perspective paper reflects on the issues that do not receive enough attention when packages are developed, which can often jeopardize their implementation. Countries of the region refer to burden-of-disease assessments and consider the cost-effectiveness of the listed interventions during their BPHS design processes. Some also conduct a costing study to generate "price tags" that are used for resource mobilization. However, important implementation challenges such as weak supply-side readiness, limited scope for reallocation of existing resources and management not geared for accountability are too often ignored. Implementation and its monitoring is further hampered by the limitations of existing health information systems, which are often not ready to collect and analyse data on emerging interventions such as noncommunicable disease management. Among the countries of the WHO South-East Asia Region, those with better chances of executing their BPHSs have adapted their packages to their implementation, financing and monitoring capacities, and have considered the need for a modified service delivery model able to provide the agreed services.

Myanmar health professionals' educational needs: a pilot study.

Background and aim of the work:The main factor hindering the development of the Myanmar health system lies in the scarcity of financial and human resources attributed to the health system. This paper presents the preliminary results of a pilot study on the educational needs of Myanmar health professionals, addressing the empowerment of human resources as a strategic pillar for delivering the essential packages of health services.Methods:An explorative study following a qualitative approach has been conducted through semi-structured interviews to a convenience sample of 15 persons, selected as authoritative key-informants.Results:In addition to the lack of infrastructures, medicines, ambulances and health instruments, and the health disparities between the urban and rural areas, some widespread problems are reported as requiring health professionals’ training empowerment: traumas due to road accidents, management of childbirth, non-communicable diseases’ management and poor health education of the population.Discussion:Some areas can be evidenced for an improvement of professionals, training: maternal, neonatal and child health; communication between professionals and laypeople; Myanmar population’s health education; inter-professional training between doctors and nurses, but also between health personnel and non-health personnel.Conclusions:The educational needs of Myanmar health professionals emerge as closely related to the social and health needs of the Myanmar population, to the available resources and missing resources of the country’s health system and to the role of professionals within professionals/patients’ relationship. (www.actabiomedica.it)

FINANCIAL AND ECONOMIC ASPECTS OF THE FUNCTIONING AND DEVELOPMENT OF THE HEALTH CARE SECTOR IN UKRAINE

With Ukraine taking a course to implement systemic sectoral reforms to improve the quality of services provided to the population, decentralize resources and powers, and form an effective system of public governance, health care reform, among others, plays an important role. Their effective implementation requires scientific discussion and analysis of causal relationships. The purpose of the article is to identify and analyze the financial and economic problems of the health care system in Ukraine. The article identifies and analyzes the negative aspects of the functioning and development of the health care sector. Among the key ones are: Ukraine lags behind European countries in terms of life expectancy, mortality and health; low level of financial support for the healthcare sector; high level of attraction of private funds of patients with unsatisfactory quality of received services; excessive centralization of health care management, which has led to a lack of a transparent state-guaranteed package of health services and an increase in corruption in the procurement, education, certification and employment of health workers. Emphasis is placed on the shortcomings of the mechanism of financing disease prevention, primary health care, provision of outpatient and inpatient medical services. Among them are: duplication of services and inefficient use of financial resources at the subnational level; low efficiency of use of medical subvention funds; constant change in the mechanism of providing transfers in the field of health care, etc. Possible areas for improving health care funding are outlined. Emphasis is placed on the expediency of reforming the health care sector in terms of income mobilization in the context of coverage of the population with basic medical guarantees and the effectiveness of the organization of the process of such funding.

Realigning the provider payment system for primary health care: a pilot study in a rural county of Zhejiang Province, China.

This work aimed to evaluate a pre/post-reform pilot study from 2015 to 2018 in a rural county of Zhejiang Province, China to realign the provider payment system for primary health care (PHC). Data were extracted from the National Health Financial Annual Reports for the 21 township health centers (THCs) in Shengzhou County. An information system was designed for the reform. Differences among independent groups were assessed using Kruskal-Wallis H-test. Dunn's posthoc test was used for multiple comparisons. Differences between paired groups were tested by Wilcoxon signed-rank test. Two-tailed P < 0.05 indicated statistical significance. Data were processed and analyzed using R 3.6.1 for Windows. First, payments to THCs shifted from a "soft budget" to a mixed system of line-item input-based and categorized output-based payments, accounting for 17.54% and 82.46%, respectively, of total revenue in 2017. Second, providers were more motivated to deliver services after the reform; total volumes increased by 27.80%, 19.22%, and 30.31% for inpatient visits, outpatient visits, and the National Essential Public Health Services Package (NEPHSP), respectively. Third, NEPHSP payments were shifted from capitation to resource-based relative value scale (RBRVS) payments, resulting in a change in the NEPHSP subsidy from 36.41 to 67.35 per capita among the 21 THCs in 2017. Fourth, incentive merit pay to primary health physicians accounted for 38.40% of total salary, and the average salary increased by 32.74%, with a 32.45% increase in working intensity. A small proportion of penalties for unqualified products and pay-for-performance rewards were blended with the payments. The reform should be modified to motivate providers in remote areas. In the context of a profit-driven, hospital-centered system, add-on payments - including categorized output-based payments to THCs and incentive merit pay to primary care physicians (PCPs) - are probably worth pursuing to achieve more active and output/outcome-based PHC in China.

Needs assessment of the public health curriculum based on the first-level health services package in Isfahan University of Medical Sciences.

INTRODUCTION:After graduation, public health students should be able to work as health care givers providing first-level health care services. Therefore, the educational objectives of public health bachelor's programs should ensure that they acquire the capabilities necessary for this purpose. This study identified the educational objectives that are essential for these students and compared them with the current curriculum in Isfahan, Iran.METHODS:This needs assessment study was conducted in two phases. In the first phase, the essential educational objectives were identified using a qualitative approach, which involved eight focus group discussions held by a group consisting of experts of the public health headquarters and public health network administration offices of Isfahan province and the public health graduates working in the province's comprehensive health service centers, who were chosen using the purposive sampling method (n = 59). In the second phase, a comparative study was performed by turning the list of essential educational objectives into a checklist and using it to compare these objectives with the objectives in the current course plan in the examined curriculum. In the end, a list of educational objectives not included in the current curriculum of the public health bachelor's program was created.RESULTS:The focus group discussions produced 433 educational objectives in the cognitive domain, 79 objectives in the affective domain, and 179 objectives in the psychomotor domain, which were arranged in eight competency categories. Comparison of the essential educational objectives with the current curriculum showed that the current curriculum does not cover any of the essential objectives regarding care for the age groups of 18–29 and 30–59 and the first aid and only partially covers essential objectives in other competency categories.CONCLUSION:This study found that considering the requirements of first-level health services and the tasks expected from public health graduates to be providing these services, the current curriculum does not cover all essential learning objectives and should be revised to meet additional essential educational objectives.