Dimensions Of Health Systems Research Articles

Digital health and equitable access to care.

Research on digital health equity has developed in important ways especially since the onset of the COVID-19 pandemic, with a series of clear recommendations now established for policy and practice. However, research and policy addressing the health system dimensions of digital health equity is needed to examine the appropriate roles of digital technologies in enabling access to care. We use a highly cited framework by Levesque et al on patient-centered access to care and the World Health Organization's framework on digitally enabled health systems to generate insights into the ways that digital solutions can support access to needed health care for structurally marginalized communities. Specifically, we mapped the frameworks to identify where applications of digital health do and do not support access to care, documenting which dimensions of access are under-addressed by digital health. Our analysis suggests that digital health has disproportionately focused on downstream enablers of access to care, which are low-yield when equity is the goal. We identify important opportunities for policy makers, funders and other stakeholders to attend more to digital solutions that support upstream enablement of peoples' abilities to understand, perceive, and seek out care. These areas are an important focal point for digital interventions and have the potential to be more equity-enhancing than downstream interventions at the time that care is accessed. Overall, we highlight the importance of taking a health system perspective when considering the roles of digital technologies in enhancing or inhibiting equitable access to needed health care.

Regional variation in access to and quality of acute stroke care: results of Germany’s Health System Performance Assessment pilot, 2014–2020

BackgroundHealth System Performance Assessments (HSPA) and analyses of unwarranted regional variation in health care both aim at identifying strengths and weaknesses of health systems to improve care. Applying HSPA’s conceptual approach of interrelated health system dimensions (e.g., access, quality) to regional levels might help to better understand variation in care to reduce inequity and improve performance.MethodsWe use four indicators identified and analysed in a pilot study for a German HSPA to assess variation in access to and quality of acute stroke care between Germany’s 16 federal states and urban vs. rural regions from 2014 to 2020. Stroke unit (SU) density, share of the population reaching a SU within 30 min by car, share of inpatient stroke cases treated in a hospital with a SU, and inpatient mortality were computed based on hospital quality reports and discharge data covering all acute care hospitals. Inpatient mortality was adjusted for age, sex, stroke type, and comorbidities.ResultsAbout 500 SU were identified, i.e., 2.0 per 1,000 inpatient stroke cases. Almost 95% of Germans could reach a SU hospital within 30 min (rural: 90%; urban: 99%; > 88% in all states but one). The share of inpatient stroke cases treated in a SU hospital increased to 93% with a decreasing span between rural (92%) and urban (95%) regions and between states (74–98%). Inpatient mortality stagnated around 8.5% and increased to 9.0% in 2020 (rural: 8.7%; urban: 9.2%; states: 7.0–9.7%, one outlier of 13.3%).ConclusionsThe results especially revealed varying performance patterns in access to and quality of acute stroke care between the federal states, indicating different areas for improvement which might be addressed by more targeted policy measures in the future.

Barriers to accessibility of medicines for hyperlipidemia in low- and middle-income countries.

Despite the high burden of hyperlipidemia and the effectiveness of treatment, evidence suggests that the accessibility of hyperlipidemia medicines can be low in many low- and middle-income countries (LMICs). The aim of this study was to identify common barriers to the accessibility of medicines for hyperlipidemia in LMICs. A multimethod analysis and multiple data sources were used to assess the accessibility and barriers of medicines for hyperlipidemia in selected LMICs. The overall median availability of statins for hyperlipidemia in public facilities was 0% and 5.4%, for originators and generics, respectively. In private facilities, median availability was 13.3% and 35.9%, for originators and generics, respectively. Statin availability was lowest in Africa and South-East Asia. Private facilities generally had higher availability than public facilities. Statins are less affordable in lower-income countries, costing around 6 days' wages per month. Originator statins are less affordable than generics in countries of all income-levels. The median cost for statin medications per month ranges from a low of $1 in Kenya to a high of $62 in Mexico, with most countries having a median monthly cost between $3.6 and $17.0. The key informant interviews suggested that accessibility to hyperlipidemia medicines in LMICs faces barriers in multiple dimensions of health systems. The availability and affordability of statins are generally low in LMICs. Several steps could be implemented to improve the accessibility of hyperlipidemia medicines, including private sector engagement, physician education, investment in technology, and enhancement of health systems.

Health system strengthening in fragile and conflict-affected states: A review of systematic reviews.

Globally, there is growing attention towards health system strengthening, and the importance of quality in health systems. However, fragile and conflict-affected states present particular challenges. The aim of this study was to explore health system strengthening in fragile and conflict-affected states by synthesising the evidence from published literature. We conducted a review of systematic reviews (Prospero Registration Number: CRD42022371955) by searching Ovid (Medline, Embase, and Global Health), Scopus, Web of Science, and the Cochrane Library databases. Only English-language publications were considered. The Joanna Briggs Institute (JBI) Critical Appraisal Tool was employed to assess methodological quality of the included studies. The findings were narratively synthesised and presented in line with the Lancet's 'high-quality health system framework'. Twenty-seven systematic reviews, out of 2,704 identified records, considered key dimensions of health systems in fragile and conflict-affected states, with the 'foundations' domain having most evidence. Significant challenges to health system strengthening, including the flight of human capital due to safety concerns and difficult working conditions, as well as limited training capacities and resources, were identified. Facilitators included community involvement, support systems and innovative financing mechanisms. The importance of coordinated and integrated responses tailored to the context and stage of the crisis situation was emphasised in order to strengthen fragile health systems. Overall, health system strengthening initiatives included policies encouraging the return and integration of displaced healthcare workers, building local healthcare workers capacity, strengthening education and training, integrating healthcare services, trust-building, supportive supervision, and e-Health utilisation. The emerging body of evidence on health system strengthening in fragile and conflict-affected states highlights its complexity. The findings underscore the significance of adopting a comprehensive approach and engaging various stakeholders in a coordinated manner considering the stage and context of the situation.

Results of Germany's health system performance assessment (HSPA) pilot: the example of stroke care

Abstract Background HSPA is a tool to monitor, evaluate, and improve health systems based on their achievements within different dimensions, e.g., access to care, quality, and population health. Next to the overall system, HSPA also allows to analyze its performance for specific groups across dimensions. In a pilot for a German HSPA, a conceptual framework was developed, and indicators for every dimension were selected and analyzed. This presentation illustrates the results of the German HSPA pilot using the example of access to and quality of care for ischemic stroke. Methods Selected indicators include stroke unit (SU) density, availability of a SU within 30 minutes by car, share of inpatient cases treated in a hospital with a SU, and inpatient mortality from 2014 to 2020, respectively. Indicators were analyzed based on nation-wide hospital discharge data. Travel time was computed and provided by the Federal Institute for Research on Building, Urban Affairs and Spatial Development. Results About 475 SU were identified in hospital data (2014: 463), compared to 350 certified SU in Germany. In 75% of Germany's 11,000 municipalities, 100% of the population could reach a SU within 30 minutes by car. Number of inpatient ischemic stroke cases was about 250,000 per year. Of the 215,000 cases without transfer from another hospital, 93% were treated in a hospital with a SU in 2020 (2014: 88%). Inpatient mortality was about 6,4% for all ischemic stroke cases and 6,1% for cases without transfer, varying only slightly over time. SU treatment showed large, and inpatient mortality minor regional variation. Conclusions Access to and quality of inpatient stroke care seems comparatively good in Germany, as SU density is high and mortality low in the European context. However, regional variation should be further tackled. The example shows how HSPA can be used to assess different strands of care by connecting health system dimensions, to produce actionable evidence for policy. Key messages • Health system performance assessment (HSPA) is a tool for the evaluation and improvement of the overall system but also of the care for specific groups or diseases across health system dimensions. • The results of the German HSPA pilot show a good access and quality for the case of inpatient stroke care. Regional variations might be further reduced via improvements in hospital planning.

Health policy under the microscope: a micro policy design perspective.

The comparative study of health policy has focused mainly on the macro-structural dimensions of health systems and reforms that have sought to change these organizational arrangements. Thus, a great deal of attention has been paid to the multiple models of insurance against sickness risks and various modes of organizing and financing healthcare providers. However, little attention has been paid to policy tools and policy design in the health policy domain. This research gap largely impedes a focus on the micro (granular) dimension of health policy, although this is the level at which health policies impact reality and thus deliver progress toward the expected goals. Such a focus on the micro dimension could not only allow a finer-grained comparison of how health systems work but also shed light on how capable health policies are of achieving the expected outcomes. This paper fills this gap by presenting an analytical framework capable of illuminating the granular dimension of policy design (the instrumental delivery package) and shows the analytical relevance of the framework by applying it to the designs of maximum waiting time guarantee and vaccination mandate policies.

Improving health system readiness to address violence against women and girls: a conceptual framework

BackgroundThere is an increasing focus on readiness of health systems to respond to survivors of violence against women (VAW), a global human rights violation damaging women’s health. Health system readiness focuses on how prepared healthcare systems and institutions, including providers and potential users, are to adopt changes brought about by the integration of VAW care into services. In VAW research, such assessment is often limited to individual provider readiness or facility-level factors that need to be strengthened, with less attention to health system dimensions. The paper presents a framework for health system readiness assessment to improve quality of care for intimate partner violence (IPV), which was tested in Brazil and Palestinian territories (oPT).MethodsData synthesis of primary data from 43 qualitative interviews with healthcare providers and health managers in Brazil and oPT to explore readiness in health systems.ResultsThe application of the framework showed that it had significant added value in capturing system capabilities - beyond the availability of material and technical capacity - to encompass stakeholder values, confidence, motivation and connection with clients and communities. Our analysis highlighted two missing elements within the initial framework: client and community engagement and gender equality issues. Subsequently, the framework was finalised and organised around three levels of analysis: macro, meso and micro. The micro level highlighted the need to also consider how the system can sustainably involve and interact with clients (women) and communities to ensure and promote readiness for integrating (and participating in) change. Addressing cultural and gender norms around IPV and enhancing support and commitment from health managers was also shown to be necessary for a health system environment that enables the integration of IPV care.ConclusionThe proposed framework helps identify a) system capabilities and pre-conditions for system readiness; b) system changes required for delivering quality care for IPV; and c) connections between and across system levels and capabilities.

Improving population health in Germany – lessons of a pilot study to assess health system performance

Abstract Background Improving the population health, both its level and equity, is a major goal of health systems. Health System Performance Assessment (HSPA) is a tool to evaluate the performance of different health system dimensions, e.g., population health, access, efficiency. For the first time, a systematic HSPA was piloted for Germany including the dimension population health. Methods The conceptual framework for the German HSPA pilot has been developed in a previous feasibility study. The selection of indicators was based on established indicators used in other HSPA initiatives. Another inclusion criterium was data availability. The ten indicators to measure population health cover e.g., maternal and neonatal health, amenable mortality, infectious diseases, and cancer screening. The indicators are evaluated in terms of their trend over time (2000-2020), in international comparison (e.g., Austria, Denmark, France), and by various equity criteria (e.g., age, gender, region). Results Overall, Germany's health system performs moderately regarding population health, especially when compared to selected European countries. While Germany performs very well in terms of incidence rates of infectious diseases, amenable mortality is an area with need for improvements. However, trends over time show improvements of the population health in Germany. Conclusions Measuring population health in Germany using ten predefined indicators reveals areas for improvement. Furthermore, subgroup analyses indicate inequities. These results should be considered in further efforts aiming at the improvement of population health in Germany. Key messages

Health System Inquiry: Is Health Sector Reforms in Bangladesh Imperative?

In Bangladesh, Government is trying to find a perfect health system that best serves its population. Here, we present the results of our study with aim to assess the opinion of various stakeholders about: what are the 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. We conducted a cross-sectional, exploratory and anonymous population-based e-survey from February to June, 2021 among individuals aged above 26 years. A semi-structured questionnaire was designed and incorporated into the Google survey tool (Google Forms) and a shareable link was generated and disseminated to physicians, Academicians/ Clinicians of Medical Colleges/ Universities, Health System administrators etc. Respondents were also given space to comment on each topic. Comments & reactions of all respondents were categorized into three main headings. These were 1) high-priority areas, 2) moderate priority areas, and 3) low-priority areas to reform the health sectors for Bangladesh. Out of 483 respondents, 476 respondents (80.5% males and 19.5% female) completed the entire survey. The mean age of respondents is 44.70 SD± 10.07 with age range 26-86 years. About 27% of the respondents were from faculties from medical colleges /medical universities and 1.7% were health system administrators. The high prioritized areas where the majority (>60%) of our respondents strongly agreed upon, for instance, good governance, structural referral system should be establishment, and reformation of existing health care procurement & purchasing policy. The moderate prioritized areas where 50 - 60% of our respondents strongly agreed upon, such as securing sustainable financing for health care, further development of existing health infrastructure, and establishment of Health Academy of planning and development (HAPD). The low prioritized areas where less than 50% of our respondents strongly agreed upon, such as decentralization and autonomous health system, public health-oriented infection prevention and control (IPC) program, and implement the national health insurance system (NHIS) under a separate authority etc. Good governance in health departments & health care provider organizations are essential elements for health sector reform. Health sector reform should be sustained, purposeful, planned and evidence-based and fundamental change addressing significant, strategic dimensions of health systems. J Bangladesh Coll Phys Surg 2022; 40: 84-94

In search of healthcare system ideal types — Changeable classifications and dimensions

This article aims to classify the healthcare systems of 43 developed economies into different healthcare system types, and to examine whether the dimensions of health system characteristics produce coherent health system classification when the dimensions are observed separately. We group health systems into different types based on their institutional structures and performance using healthcare financing, healthcare provision and health outcomes as dimensions of the health system characteristics. Unlike previous classifications, we classify each dimension separately using hierarchical cluster analysis. In particular dimensions, our results resemble those found in previous classifications. However, no coherent clustering of healthcare systems was found across the three dimensions. The results show that healthcare system dimensions differ from each other and each of them form their unique system types. Separating the dimensions helps detecting connections between the healthcare system types and phenomena being studied. It is relevant to note the differences of health system dimensions while discussing healthcare system classifications.

A Comparative Study of the Rehabilitation Services Systems for People With Disabilities

Objective: Providing desirable rehabilitation services to people with disabilities has always been one of the most critical concerns of the health system in all countries. Today, it is crucial for policymakers and health care providers to recognize the different systems for providing rehabilitation services to people with disabilities. In this regard, it is beneficial to conduct comparative studies and use successful countries’ experiences in this subject. This comparison-analytical study aimed to compare the systems for providing rehabilitation services to people with disabilities. Materials & Methods: This comparative study was conducted in nine countries in 2020. To determine the comparison framework in this research, four dimensions of health systems’ functions were used based on the 2000 report of the World Health Organization. The countries were compared in dimensions of stewardship, resource production, financing, and service provision. Findings obtained from each country were presented separately in the comparative tables. The model used in this comparative study was based on the Beredy Model that contains four stages of description, interpretation, proximity, and comparison. In the present study, the purposive sampling method was used. The statistical population included rehabilitation systems globally, and the research examples were Iran, China, Turkey, India, the USA, Mexico, Germany, England, and South Africa. Criteria for entering the research according to the functional model of the World Health Organization were the availability of data and selecting at least one country from each continent of America, Europe, Asia, and Africa. Results: The findings showed that in Iran, the Welfare Organization was responsible for providing rehabilitation services for people with disabilities, while in other countries, it was the Ministry of Health. Also, to compare resource production, two staff training indicators and access to comprehensive national data were used. In all countries studied, the training of specialized human resources is done through the university system. Iran, India, and Mexico did not have full access to comprehensive national data, but the United States, Germany, China, South Africa, and Turkey provided the platform for planning and policy-making. Moreover, funding in Germany, the United States, China, and Turkey is mainly provided through the insurance system. In the United Kingdom, it is mainly provided through tax, but in Iran, it is provided through subsidies from the public revenues and taxes. Finally, besides the private sector, rehabilitation services in Iran’s public sector were provided incoherently by various organizations. Some of these organizations are the Ministry of Health and Medical Education, the Exceptional Education Organization, the Red Crescent, the State Welfare Organization, and the Martyrs and Veterans Affairs Foundation, while in other countries, these services are often provided through hospitals and the private sectors. Conclusion: Despite the numerous strengths in the system of providing rehabilitation services to the disabled in Iran, the integration of the rehabilitation sectors of various organizations within the Ministry of Health not only increases the inter-sectoral and intra-sectoral coordination, the coherence of management, and unified policy, but also leads to reduced costs, proper allocation of resources and increased financial resources in this sector. Besides, it leads to a reduction in overlapping tasks and responsibilities and prevention of duplication of work, training of specialized personnel based on the needs, and finally providing more desirable services. Therefore, policymakers and planners must review and reform the laws and processes to form a system for providing rehabilitation services to the disabled in Iran.

COVID-19: The impact of social distancing policies, cross-country analysis.

At the onset of the COVID-19 pandemic a large number of countries introduced a range of non-pharmaceutical interventions. Whereas the policies are similar across countries, country characteristics vary substantially. We examine the effectiveness of such policies using a cross-country variation in socio-economic, environmental and geographic, and health system dimensions. The effectiveness of policies that prescribe closures of schools and workplaces is declining with population density, country surface area, employment rate and proportion of elderly in the population; and increasing with GDP per capita and health expenditure. Cross-country human mobility data reinforce some of these results. We argue that the findings can be explained by behavioural response to risk perceptions and resource constraints. Voluntary practice of social distancing might be less prevalent in communities with lower perceived risk, associated with better access to health care and smaller proportion of elderly population. Higher population density, larger geographical area, and higher employment rate may require more resources to ensure compliance with lockdown policies.

Integrating the Population Perspective into Health System Performance Assessment (IPHA): Study Protocol for a Cross-Sectional Study in Germany Linking Survey and Claims Data of Statutorily and Privately Insured.

Background:Health system performance assessment (HSPA) is a major tool for evidence-based governance in health systems and patient/population-orientation is increasingly considered as an important aspect. The IPHA study aims (1) to undertake a comprehensive performance assessment of the German health system from a population perspective based on the intermediate and final dimensions defined by the World Health Organization (WHO) and (2) to identify differences in HSPA between (a) common user characteristics and (b) user types, which differ in their interactions and patterns of action within the health system.Methods and Analysis: A cross-sectional survey was conducted between October and December 2018 with statutorily and privately health insured to assess the German health system from a population perspective related to the past 12 months. The random sample consists of 32 000 persons insured by AOK Nordost and 20 000 persons insured by Debeka. Data from the survey will subsequently be linked with health insurance claims data at the individual level for each respondent who has given consent for data linkage. Claims data covers the time period January 1, 2017 to June 30, 2018. The combination of the 2 data sources allows to identify associations between insured patient characteristics and differences in the assessment of health system performance. The survey consists of 71 items measuring all final and intermediate health system goals defined by the WHO and user characteristics like health literacy, self-efficacy, the attention an individual pays to his or her health or disease, the personal network, autonomy, compliance and sociodemographics. The claims data contains information on morbidity, care delivery, service utilization, (co)payments and sociodemography. Discussion: The study represents a promising attempt to perform a holistic HSPA using a population perspective. For this purpose, a questionnaire was designed that contains both validated and new items in order to collect data on all relevant health system dimensions. In particular, linking survey data on HSPA with claims data is of high potential for assessing and analysing determinants of health system performance from the population perspective.

Whose Elimination? Frontline Workers' Perspectives on the Elimination of the Human African Trypanosomiasis and Its Anticipated Consequences.

While academic literature has paid careful attention to the technological efforts―drugs, tests, and tools for vector control―deployed to eliminate Gambiense Human African Trypanosomiasis (HAT), the human resources and health systems dimensions of elimination are less documented. This paper analyses the perspectives and experiences of frontline nurses, technicians, and coordinators who work for the HAT programme in the former province of Bandundu in the Democratic Republic of the Congo, at the epidemic’s very heart. The research is based on 21 semi-structured interviews conducted with frontline workers in February 2018. The results highlight distinctive HAT careers as well as social elevation through specialised work. Frontline workers are concerned about changes in active screening strategies and the continued existence of the vector, which lead them to question the possibility of imminent elimination. Managers seem to anticipate a post-HAT situation and prepare for the employment of their staff; most workers see their future relatively confidently, as re-allocated to non-vertical units. The findings suggest concrete pathways for improving the effectiveness of elimination efforts: improving active screening through renewed engagements with local leaders, conceptualising horizontal integration in terms of human resources mobility, and investing more in detection and treatment activities (besides innovation).

Exploring health system readiness for adopting interventions to address intimate partner violence: a case study from the occupied Palestinian Territory.

Domestic violence (DV) against women is a widespread violation of human rights. Adoption of effective interventions to address DV by health systems may fail if there is no readiness among organizations, institutions, providers and communities. There is, however, a research gap in our understanding of health systems’ readiness to respond to DV. This article describes the use of a health system’s readiness assessment to identify system obstacles to enable successful implementation of a primary health-care (PHC) intervention to address DV in the occupied Palestinian Territory (oPT). This article describes a case study where qualitative methods were used, namely 23 interviews with PHC providers and key informants, one stakeholder meeting with 19 stakeholders, two health facility observations and a document review of legal and policy materials on DV in oPT. We present data on seven dimensions of health systems. Our findings highlight the partial readiness of health systems and services to adopt a new DV intervention. Gaps were identified in: governance (no DV legislation), financial resources (no public funding and limited staff and infrastructure) and information systems (no uniform system), co-ordination (disjointed referral network) and to some extent around the values system (tension between patriarchal views on DV and more gender equal norms). Additional service-level barriers included unclear leadership structure at district level, uncertain roles for front-line staff, limited staff protection and the lack of a private space for identification and counselling. Findings also pointed to concrete actions in each system dimension that were important for effective delivery. This is the first study to use an adapted framework to assess health system readiness (HSR) for implementing an intervention to address DV in low- and middle-income countries. More research is needed on HSR to inform effective implementation and scale up of health-care-based DV interventions.

The politics of the basic benefit package health reforms in Tajikistan

BackgroundHealth reform is a fundamentally political process. Yet, evidence on the interplay between domestic politics, international aid and the technical dimensions of health systems, particularly in the former Soviet Union and Central Asia, remains limited. Little regard has been given to the political dimensions of Tajikistan’s Basic Benefit Package (BBP) reforms that regulate entitlements to a guaranteed set of healthcare services while introducing co-payments. The objective of this paper is therefore to explore the governance constraints to the introduction and implementation of the BBP and associated health management changes.MethodsThis qualitative study draws on literature review and key informant interviews. Data analysis was guided by a political economy framework exploring the interplay between structural and institutional features on the one hand and agency dynamics on the other. Building on that the article presents the main themes that emerged on structure-agency dynamics, forming the key governance constraints to the BBP reform and implementation.ResultsPolicy incoherence, parallel and competing central government mandates, and regulatory fragmentation, have emerged as dominant drivers of most other constraints to effective design and implementation of the BBP and associated health reforms in Tajikistan: overcharging and informal payments, a weak link between budgeting and policymaking, a practice of non-transparent budget bargaining instead of a rationalisation of health expenditure, little donor harmonisation, and weak accountability to citizens.ConclusionThis study suggests that policy incoherence and regulatory fragmentation can be linked to the neo-patrimonial character of the regime and donor behaviour, with detrimental consequences for the health system.. These findings raise questions on the unintended effects of non-harmonised piloting of health reforms, and the interaction of health financing and management interventions with entrenched power relations. Ultimately these insights serve to underline the relevance of contextualising health programmes and addressing policy incoherence with long horizon planning as a priority.

Waiting and hoping: a phenomenographic study of the experiences of boarded patients in the emergency department.

To understand the experiences and concerns of patients in the emergency department during inpatient boarding. Boarding in the emergency department is an increasingly common phenomenon worldwide. Emergency department staff, patients and their families become more stressed as the duration of boarding in the emergency department increases. Yet, there is limited knowledge of the experiences and concerns of boarded patients. The qualitative approach of phenomenography was used in the study. The phenomenographic study was conducted in one emergency department that treats approximately 15,000 patients each month. Twenty emergency department boarding patients were recruited between July-September 2014. Semi-structured interviews were used for data collection. The seven steps of qualitative data analysis for a phenomenographic study - familiarisation, articulation, condensation, grouping, comparison, labelling and contrasting - were employed to develop an understanding of participants' experiences and concerns during their inpatient boarding in the emergency department. The perceptions that emerged from the data were collected into four categories of description of the phenomenon of emergency department boarding patients: a helpless choice; loyalty to specific hospitals and doctors; an inevitable challenge of life; and distrust of the healthcare system. The outcome space for the emergency department boarding patients was waiting and hoping for a cure. The experiences and concerns of emergency department boarding patients include physical, psychological, spiritual and health system dimensions. It is necessary to develop an integrated model of care for these patients. Understanding the experiences and concerns of patients who are placed on boarding status in the ED will help emergency healthcare professionals to improve the quality of emergency care. There is a need to develop a care model and associated intervention measures for emergency department patients during the boarding process. The results of this study will help health regulatory authorities to develop an appropriate emergency department boarding system so that patients receive better emergency care.

Access to Medications for Cardiovascular Diseases in Low- and Middle-Income Countries.

Cardiovascular diseases (CVD) represent the highest burden of disease globally. Medicines are a critical intervention used to prevent and treat CVD. This review describes access to medication for CVD from a health system perspective and strategies that have been used to promote access, including providing medicines at lower cost, improving medication supply, ensuring medicine quality, promoting appropriate use, and managing intellectual property issues. Using key evidence in published and gray literature and systematic reviews, we summarize advances in access to cardiovascular medicines using the 5 health system dimensions of access: availability, affordability, accessibility, acceptability, and quality of medicines. There are multiple barriers to access of CVD medicines, particularly in low- and middle-income countries. Low availability of CVD medicines has been reported in public and private healthcare facilities. When patients lack insurance and pay out of pocket to purchase medicines, medicines can be unaffordable. Accessibility and acceptability are low for medicines used in secondary prevention; increasing use is positively related to country income. Fixed-dose combinations have shown a positive effect on adherence and intermediate outcome measures such as blood pressure and cholesterol. We have a new opportunity to improve access to CVD medicines by using strategies such as efficient procurement of low-cost, quality-assured generic medicines, development of fixed-dose combination medicines, and promotion of adherence through insurance schemes that waive copayment for long-term medications. Monitoring progress at all levels, institutional, regional, national, and international, is vital to identifying gaps in access and implementing adequate policies.

Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials

Existing accountability efforts in Nigeria primarily serve as retrospective policing. To enable accountability to guide change prospectively and preemptively, we drew from a literature review to develop a framework that highlights mutually reinforcing dimensions of accountability in health systems along three counterbalancing axes. The axis of power sparks change by wielding 'sticks' that curb the potential abuse of power, but also by offering 'carrots' that motivate constructive agency. The axis of ability supports change by enabling service delivery actors with formal rules that appropriately expand their authority to act, but also the informal norms and inputs for improved performance. Last, the axis of justice orients the strategic direction of change, balancing political representation, community ownership and social equity, so that accountability measures are progressive, rather than being captured by self-interests. We consulted Nigerian government officials to understand their viewpoints on accountability and mapped their responses to our evolving framework. All government officials (n = 36) participating in three zonal workshops on routine immunization filled out questionnaires that listed the top three opportunities and challenges to strengthening accountability. Thematically coded responses highlighted dimensions of accountability within the axes of ability and power: clarifying formal roles and responsibilities; transparency, data and monitoring systems; availability of skilled health personnel that are motivated and supervised; addressing informal norms and behaviours; and availability of inputs regarding funding and supplies. Other dimensions of accountability were mentioned but were not as critical from their viewpoints: managerial discretion; sanctions and enforcements; political influence and community engagement. Strikingly, almost no respondents mentioned social equity as being an important aspect of accountability, although a few mentioned broad development concerns that reflected community perspectives. Reframing accountability as a means of sparking, supporting and steering change can highlight different dimensions of health systems that need reform, particularly depending on the positionality of the viewpoints consulted.

Cultural aspects of mental health and mental health service delivery with a focus on Nigeria within a global community

ABSTRACTWith an endless range of subgroups and individual variations, culture bears upon what all people bring to the clinical setting. Culture could account for health-seeking behaviour, type of services and support system and variations in how people communicate their health concerns. Culture may underlie presentation of sets of symptoms that are peculiar to certain societies – culture-bound syndromes. Culture also influences the meanings that people impart to their illness and also stigma associated with such illnesses. Culture must be viewed from the patients, clinicians and health system dimensions. Changes in mental health service delivery in last few decades have yielded culturally competent mental health services. The aim of this paper was to discuss culture and mental health with a focus on Nigeria and from a global perspective.