Health System Approach Research Articles

Child Poverty and Health in the United States: Introduction and Executive Summary.

Child Poverty and Health in the United States: Introduction and Executive Summary.

The impact of pulse oximetry on diagnosis, management and outcomes of acute febrile illness in low-income and middle-income countries: a systematic review

BackgroundAcute fever is a common presenting symptom in low/middle-income countries (LMICs) and is strongly associated with sepsis. Hypoxaemia predicts disease severity in such patients but is poorly detected by clinical...

Opioids and obstructive sleep apnea.

Freire C, Sennes LU, Polotsky VY. Opioids and obstructive sleep apnea. J Clin Sleep Med. 2022;18(2):647-652.

1.M. Workshop: Protecting and preparing healthcare workers: what to learn from COVID-19 to strengthen resilience?

BackgroundThis workshop is dedicated to the WHO International Year of Health and Care Workers in 2021 in recognition of their commitment during the COVID-19 pandemic. During the first wave of the pandemic healthcare workers were lionised, yet societies' and health policymakers' appreciation of their new ‘heroes' was decreasing when corona fatigue was increasing. Health systems and policymakers have not fully understood the new emergent threats during the COVID-19 pandemic. Health workforce protection and pandemic preparedness are not limited to individual healthcare workers, but strongly impact in health system resilience.ObjectivesThis workshop sets the focus on the protection and preparedness of healthcare workers for global public health emergencies, like the COVID-19 pandemic. It aims to identify strengths and weaknesses of health workforce policy during COVID-19 and to highlight the need for a health system and governance approach. The following major questions will be addressed: How can the protection and pandemic preparedness of healthcare workers be improved? How can the capacities of the health workforce be used and governed more effectively during a pandemic? What policy priorities can be identified to support the health and wellbeing of healthcare workers and prevent infection and deaths, as well as post-COVID fatigue, burn-out and job leaves? How can we build back better and more equitable, including strengthening gender equality and establishing solidarity-based health workforce migration policy?ResultsThe workshop introduces novel results drawn from four European comparative studies. A number of important policy recommendations are emerging from the research, which include among others: (1) improve attention to the complex health and social needs of healthcare workers, (2) implement comprehensive surveillance and monitoring systems, (3) establish European health workforce governance to mitigate shortages and inequality between countries and globally, and (4) take action to implement gender equality policies and to better protect female healthcare workers.ConclusionsThe workshop will stimulate critical debate and improve knowledge exchange across countries and between researchers. It will contribute to creating resilience of the health workforce and health systems and to build back better after COVID-19 in a fair and equitable manner.Key messages Health systems must be accountable for the protection and preparedness of healthcare workers.Action is needed to develop a health workforce surveillance system on national and EU level.

Ayurvedic Response to COVID-19 Pandemic in Kerala, India and Its Impact on Quarantined Individuals - A Community Case Study.

The SARS-CoV-2 infection has resulted in massive loss of valuable human lives, extensive destruction of livelihoods and financial crisis of unprecedented levels across the globe. Kerala, a province in India, like the rest of the country, launched preventive and control measures to mitigate the impact of COVID-19 early in 2020. The Government of Kerala started 1206 Ayur Raksha Clinics and associated Task Forces across the state in April 2020 to improve the reach and penetration of Ayurvedic preventive, therapeutic and convalescent care strategies for the COVID-19 pandemic. The implementation framework of the strategy was properly designed, and had a decentralized, people-centered, and participatory approach. Kerala has robust public health machinery with adequate human resource and infrastructure in the conventional medicine sector. This community case study examines how the decentralized organizational framework was effectively utilized for facilitating the delivery of Ayurvedic services in the COVID-19 situation. Key observations from the study are: Ayurvedic programs implemented systematically, under an organized framework with social participation enables wider utilization of the services. Such a framework is easily replicable even in resource-poor settings. Rather than a pluralistic approach, an integrative health system approach may be more viable in the Kerala scenario in public health emergencies.

A learning health system approach to COVID-19 exposure notification system rollout.

IntroductionDigital exposure notification (EN) approaches may offer considerable advantages over traditional contact tracing in speed, scale, efficacy, and confidentiality in pandemic control. We applied the science of learning health systems to test the effect of framing and digital means, email vs Short Message Service (SMS), on EN adoption among patients of an academic health center.MethodsWe tested three communication approaches of the Apple and Google EN system in a rapid learning cycle involving 15 000 patients pseudorandomly assigned to three groups. The patients in the first group received a 284‐word email that presented EN as a tool that can help slow the spread. The patients in the second group received a 32‐word SMS that described EN as a new tool to help slow the spread (SlowTheSpreadSMS). Patients in the third group received a 47‐word SMS that depicted the system as a new digital tool that can empower them to protect their family and friends (EmpowerSMS). A brief four‐question anonymous survey of adoption was included in a reminder message sent 2 days after the initial outreach.ResultsOne hundred and sixty people responded to the survey within 1 week: 2.33% from EmpowerSMS, 0.97% from SlowTheSpreadSMS, and 0.53% from emails; 29 (41.43%), 24 (41.38%), and 11 (34.38%) reported having adopted EN from each group, respectively. Patient reported barriers to adoption included iOS version incompatibility, privacy concerns, and low trust of government agencies or companies like Apple and Google. Patients recommended that healthcare systems play an active role in disseminating information about this tool. Patients also recommended advertising on social media and providing reassurance about privacy.ConclusionsThe EmpowerSMS resulted in relatively more survey responses. Both SMS groups had slightly higher, but not statistically significant EN adoption rates compared to email. Findings from the pilot not only informed operational decision‐making in our health system but also contributed to EN rollout planning in our State.

Access to Burn Care in Low- and Middle-Income Countries: An Assessment of Timeliness, Surgical Capacity, and Affordability in a Regional Referral Hospital in Tanzania.

This study investigates patients’ access to surgical care for burns in a low- and middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50% reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within 3 weeks for 74% in this group. Of contracture patients, 74% had sought healthcare after the acute burn injury. Of the same group, only 4% had been treated with skin grafts beforehand, and 70% never received surgical care or a referral. Together, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively affecting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socioeconomic factors that determine patient mortality and disability.

Challenges in pediatric post-sepsis care in resource limited settings: a narrative review.

ObjectiveThe objective of this narrative review is to outline the current epidemiology and interventional research within the context of sepsis recovery, and to provide a summary of key priorities for future work in this area.BackgroundMorbidity and mortality secondary to sepsis disproportionately affects children, especially those in low- and middle-income countries (LMICs), where over 85% of global cases and deaths occur. These regions are plagued by poorly resilient health systems, widespread socio-economic deprivation and unique vulnerabilities such as malnutrition. Reducing the overall burden of sepsis will require a multi-pronged strategy that addresses all three important periods along the sepsis care continuum - pre-facility, facility and post-facility. Of these aspects, post-facility issues have been largely neglected in research, practice and policy, and are thus the focus of this review.MethodsRelevant data for this review was identified through a literature search using PubMed, through a review of the citations of select systematic reviews and from the personal repositories of articles collected by the authors. Data is presented within three sections. The first two sections on the short and long-term outcomes among sepsis survivors each outline the epidemiology as well as review relevant interventional research done. Where clear gaps exist, these are stated. The third section focuses on priorities for future research. This section highlights the importance of data (and data systems) and of innovative interventional approaches, as key areas to improve research of post-sepsis outcomes in children.ConclusionsDuring the initial post-facility period, mortality is high with as many children dying during this period as during the acute period of hospitalization, mostly due to recurrent illness (including infections) which are associated with malnutrition and severe acute disease. Long-term outcomes, often labelled as post-sepsis syndrome (PSS), are characterized by a lag in developmental milestones and suboptimal quality of life (QoL). While long-term outcomes have not been well characterized in resource limited settings, they are well described in high-income countries (HICs), and likely are important contributors to long-term morbidity in resource limited settings. The paucity of interventional research to improve post-discharge outcomes (short- or long-term) is a clear gap in addressing its burden. A focus on the development of improved data systems for collecting routine data, standardized definitions and terminology and a health-systems approach in research need to be prioritized during any efforts to improve outcomes during the post-sepsis phase.

Improving bone health: addressing the burden through an integrated approach.

As people age, maintaining mobility becomes increasingly imperative, therefore addressing bone health is the most important way to preserve mobility. Poor bone health encompasses a broad spectrum of diseases, but it is most often quantified as the cumulative burden of osteoporosis and osteoporotic fractures. Rates of these fractures have been increasing and are expected to continue rising globally, attributed to increasing life expectancy worldwide.No single strategy will be sufficient to address this global public health issue. Co-ordination across a wide array of stakeholders is vital to decrease the health and socioeconomic burden of poor bone health. Stakeholders include an assortment of specialists ranging from health professionals (primary and secondary care clinicians, nurses, physical therapists, and social care workers), policy-makers, government bodies (including departments of health and social services), employers, civil society, as well as patients and their caregivers. We need to ensure that there is a better understanding of the socioeconomic and health consequences of poor bone health to promote better policies to address needs. Building a more resilient health system approach to bone health based on the evidence and sound decision-making will not only improve population health, but will provide cost savings to health systems by preventing poor bone health in the first place. Health systems around the world must prioritise bone health to preserve mobility and wellbeing in advance of the impending surge in demand from ageing populations.Poor bone health is not an inevitable part of ageing. Working across the lifespan, we can all benefit from improved bone health throughout our lives.

Empiric segmentation of high-risk patients: a structured literature review.

Empiric segmentation is a rapidly growing, learning health system approach that uses large health care system data sets to identify groups of high-risk patients who may benefit from similar interventions. We aimed to review studies that used data-driven approaches to segment high-risk patient populations and describe how their designs and findings can inform health care leaders who are interested in applying similar techniques to their patient populations. Structured literature review. We searched for original research articles published since 2000 that identified high-risk adult patient populations and applied data-driven analyses to segment the population. Two reviewers independently extracted study population source and criteria for high-risk designation, segmentation method, data types included, model selection criteria, and model results from the identified studies. Our search identified 224 articles, 12 of which met criteria for full review. Of these, 8 segmented high-risk patients and 4 segmented diagnoses without assigning patients to unique groups. Studies segmenting patients more often had clinically interpretable results. Common groups were defined by high prevalence of diabetes, cardiovascular disease, psychiatric conditions including substance use disorders, and neurologic disease (eg, stroke). Few studies incorporated patients' functional or social factors. Resulting patient and diagnosis clusters varied in ways closely linked to the model inputs, patient population inclusion criteria, and health care system context. Empiric segmentation can yield clinically relevant groups of patients with complex medical needs. Segmentation results are context dependent, suggesting the need for careful design and interpretation of segmentation models to ensure that results can inform clinical care and program design in the target setting.

Changing the Narrative: Structural Barriers and Racial and Ethnic Inequities in COVID-19 Vaccination.

The COVID-19 pandemic has disproportionately affected racial and ethnic minority groups in the United States. Although a promising solution of the COVID-19 vaccination offers hope, disparities in access again threaten the health of these communities. Various explanations have arisen for the cause of disparate vaccination rates among racial and ethnic minorities, including discussion of vaccine hesitancy. Conversely, the role of vaccine accessibility rooted in structural racism as a driver in these disparities should be further explored. This paper discusses the impact of structural barriers on racial and ethnic disparities in COVID-19 vaccine uptake. We also recommend public health, health system, and community-engaged approaches to reduce racial disparities in COVID-19 disease and mortality.

A Learning Health Systems Approach to Frailty Prediction Using EHR Data

Research ObjectiveTo predict occurrence of preventable patient safety events using only data elements that are almost universally supported in EHR systems.Study DesignWe drew a random sample was drawn from the EHR records of adult patients not restricted to any particular age range or diagnosis and therefore representative of a real‐world health system population. This sample was subdivided into a developmental and a test subset. We used the Rockwood Deficit Accumulation method to construct a frailty index from ICD10 codes, lab value‐flags, and vital signs on a per‐visit basis with a rolling two‐year time‐window (EFI, electronic frailty index). The Cox proportional hazard model was used to model days elapsed from a randomly selected visit to the first occurrence of the selected outcomes (which are also based on routinely available EHR data elements). In contrast to previous studies, we treated EFI as a time‐varying predictor with multiple follow‐ups per patient, which is more realistic than relying on one static time‐point. We used a representative sample of the adult patient population rather than limiting it to older individuals and found EFI to be a useful metric even at relatively young ages.Population StudiedWe accessed EHR data for 14,844 patients randomly sampled from our academic health center's data warehouse which supports our ACT/SHRINE node and is regularly updated from our institution's EHR system.Principal FindingsWe found that this electronic frailty index was robustly predictive of ED utilization, hospitalization, discharge from hospital to SNF/ICF, hospital readmission, all‐cause mortality, and complications including in‐hospital trauma and infections.ConclusionsThough currently frailty indexes are most used in geriatrics and gerontology, we find evidence that age‐related declines follow a lifelong trajectory that is observable in patient charts even in younger patients (18–45).Implications for Policy or PracticeFrailty predicts poor patient outcomes and healthcare services utilization. Accurate assessment of frailty can inform clinical management decisions and assist with anticipating healthcare resource utilization. Deficit accumulation indexes have a much simpler algorithm than most other frailty scores (e.g. HCC‐RAF). Because they capture a large number of conditions, they are robust against missing data and variations between disparate data sources. To further reduce barriers to implementation and accelerate the evolution of this tool, we are making the source code freely available under and open source license. Our next goal will be a side‐by‐side comparison of HCC‐RAF and EFI for predicting the outcomes presented here as well as cost of care. If EFI can be shown to out‐perform CMS risk scores, the implications for value‐based care will be significant.Primary Funding SourceNational Institutes of Health.

Development and validation of a prediction model for opioid use disorder among youth

BackgroundYouth are vulnerable to opioid use initiation and its complications. With growing rates of opioid overdose, strategies to identify youth at risk of opioid use disorder (OUD) to efficiently focus prevention interventions are needed. This study developed and validated a prediction model of OUD in youth aged 14−18 years. MethodsThe model was developed in a Colorado healthcare system (derivation site) using Cox proportional hazards regression analysis. Model predictors and outcomes were identified using electronic health record data. The model was externally validated in a separate Denver safety net health system (validation site). Youth were followed for up to 3.5 years. We evaluated internal and external validity using discrimination and calibration. ResultsThe derivation cohort included 76,603 youth, of whom 108 developed an OUD diagnosis. The model contained 3 predictors (smoking status, mental health diagnosis, and non-opioid substance use or disorder) and demonstrated good calibration (p = 0.90) and discrimination (bootstrap-corrected C-statistic = 0.76: 95 % CI = 0.70, 0.82). Sensitivity and specificity were 57 % and 84 % respectively with a positive predictive value (PPV) of 0.49 %. The validation cohort included 45,790 youth of whom, 74 developed an OUD diagnoses. The model demonstrated poorer calibration (p < 0.001) but good discrimination (C-statistic = 0.89; 95 % CI = 0.84, 0.95), sensitivity of 87.8 % specificity of 68.6 %, and PPV of 0.45 %. ConclusionsIn two Colorado healthcare systems, the prediction model identified 57–88 % of subsequent OUD diagnoses in youth. However, PPV < 1% suggests universal prevention strategies for opioid use in youth may be the best health system approach.

Curing or causing? HIV/AIDS in health care system of Punjab, Pakistan.

BackgroundPakistan’s National AIDS Control Program has registered 44,000 HIV/AIDS patients to date, but the actual number of cases have been estimated to be as high as 150,000–170,000. The health care system has a very important role to play in this equation and must be reformed to improve the health care services in Pakistan, with regards to HIV/AIDS.MethodsIt was a qualitative research employing a phenomenological approach. The principal researcher visited nine public and private health care facilities and conducted 19 key informant interviews with people working for providing preventive and curative services, in addition to the observations made on the site.ResultsPakistan’s health system has a limited capacity to address the HIV spread in the country, with its current resources. There is an obvious scarcity of resources at the preventive, diagnostic and curative level. However, menace can be curtailed through measures taken at the service delivery level by checking the unsafe needles practices, unclean surgical procedures and an unregulated and untrained private health workforce which are dangerous potentials routes of transmission of the virus to the general population. Healthcare establishments carry the chances of nosocomial infections including HIV/AIDS. Poverty, illiteracy and stigma associated with the disease is compounding the overall situation.ConclusionImproved accessibility to service delivery with a greater focus on prevention would be imperative to address the threat of HIV/AIDS in Pakistan. A health systems approach would help in identifying gaps at both strategic and operational levels, and concurrently find and implement solutions.

Management of Rheumatic Diseases During the COVID-19 Pandemic: A National Veterans Affairs Survey of Rheumatologists.

To assess the experience, views, and opinions of rheumatology providers at Veterans Affairs (VA) facilities about rheumatic disease health care issues during the COVID-19 pandemic. We performed an anonymized cross-sectional survey, conducted from April 16 to May 18, 2020, of VA rheumatology providers. We assessed provider perspectives on COVID-19 issues and resilience. Of the 153 eligible VA rheumatologists, 103 (67%) completed the survey. A significant proportion of providers reported a ≥50% increase related to COVID-19 in visits by telephone (53%), video-based VA video connect (VVC; 44%), and clinical video telehealth with a facilitator (29%). A majority of the responders were somewhat or very comfortable with technology for providing health care to established patients during the COVID-19 pandemic using telephone (87%), VVC (64%), and in-person visits (54%). A smaller proportion were comfortable with technology providing health care to new patients. At least 65% of rheumatologists considered telephone visits appropriate for established patients with gout, osteoporosis, polymyalgia rheumatica, stable rheumatoid arthritis, stable spondyloarthritis, or osteoarthritis; 32% reported a rheumatology medication shortage. Adjusted for age, sex, and ethnicity, high provider resilience was associated with significantly higher odds ratios (ORs) of comfort with technology for telephone (OR 3.1 [95% confidence interval (95% CI) 1.1-9.7]) and VVC visits for new patients (OR 4.7 [95% CI 1.4-15.7]). A better understanding of COVID-19 rheumatic disease health care issues using a health-system approach can better inform providers, improve provider satisfaction, and have positive effects on the care of veterans with rheumatic disease.

The power of accessibility

As pharmacists, we are the nation's most accessible health care professionals. This accessibility has long given us an open door to answer patients' questions in the midst of their busy routines and lend a hand to family members and loved ones involved in their care. While these are essential benefits, our accessibility gives us so much more than simply access. It also provides an opportunity for us to facilitate change and the power to create better conditions of care in our patients' lives, as well as collaborating with other members of the health care team and community.This is especially important in the context of structural racism, the topic of this month's Pharmacy Today cover story (page 24). We are increasingly recognizing that racial health inequities are rooted in the structure of our society, policies, laws, rules, and practices. This recognition, in turn, brings opportunities for change. APhA President Sandra Leal, PharmD, MPH, FAPhA, CDE, asks pharmacists the question, “How do we use the power of our accessibility and trust to create better conditions for patients?” This means, among other things, looking at our patients through a lens of compassion and care. It also means continually examining our attitudes, behaviors, and speech—the structure of our interactions—for subconscious preconceptions, assumptions, or other patterns that may reinforce racial bias.In this issue of Today, you will also learn more about barriers to care for American Indian and Alaska Native youth (page 41), one health system's approach to pharmacist burnout during COVID (page 40), and the latest on new drugs (pages 14–16), ashwagandha for stress and anxiety (page 17), and use of cannabis for neurological disorders (page 19). Get strategies for addressing bias in patient communication to prevent systemic racism in this month's CPE article (page 61).For many of us, approaching our patient interactions from the perspective of structural racism adds a new layer to our mindset of accessibility and patient communication. But it is a layer that is essential if we are to move toward abolishing racism and health inequities. Reach out to your patients today. Ask hard questions. Advocate for your patients. Be an agent for change.Have a great Today! As pharmacists, we are the nation's most accessible health care professionals. This accessibility has long given us an open door to answer patients' questions in the midst of their busy routines and lend a hand to family members and loved ones involved in their care. While these are essential benefits, our accessibility gives us so much more than simply access. It also provides an opportunity for us to facilitate change and the power to create better conditions of care in our patients' lives, as well as collaborating with other members of the health care team and community. This is especially important in the context of structural racism, the topic of this month's Pharmacy Today cover story (page 24). We are increasingly recognizing that racial health inequities are rooted in the structure of our society, policies, laws, rules, and practices. This recognition, in turn, brings opportunities for change. APhA President Sandra Leal, PharmD, MPH, FAPhA, CDE, asks pharmacists the question, “How do we use the power of our accessibility and trust to create better conditions for patients?” This means, among other things, looking at our patients through a lens of compassion and care. It also means continually examining our attitudes, behaviors, and speech—the structure of our interactions—for subconscious preconceptions, assumptions, or other patterns that may reinforce racial bias. In this issue of Today, you will also learn more about barriers to care for American Indian and Alaska Native youth (page 41), one health system's approach to pharmacist burnout during COVID (page 40), and the latest on new drugs (pages 14–16), ashwagandha for stress and anxiety (page 17), and use of cannabis for neurological disorders (page 19). Get strategies for addressing bias in patient communication to prevent systemic racism in this month's CPE article (page 61). For many of us, approaching our patient interactions from the perspective of structural racism adds a new layer to our mindset of accessibility and patient communication. But it is a layer that is essential if we are to move toward abolishing racism and health inequities. Reach out to your patients today. Ask hard questions. Advocate for your patients. Be an agent for change. Have a great Today!

Japanese WHO Collaborating Centres (WHO CCs) fight against COVID-19.

WHO Regional Office for the Western Pacific (WPRO) organized an online meeting connecting WHO Collaborating Centres (WHO CCs) in the region on 25 August 2020, to share experiences and promote networking on COVID-19 response. The meeting shared regional update on situation and responses, and COVID-19 related experiences of selected WHO CCs, followed by discussions on opportunities for enhancing collaboration between WPRO and WHO CCs. Priorities of WPROs support to countries included a health systems approach rather than single intervention. On behalf of WHO CCs in Japan, the National Center for Global Health and Medicine (NCGM) delivered a presentation on the results of a survey about COVID-19 related activities of these WHO CCs. These activities were categorized into collaboration with WHO, research and development, public health responses, and clinical services. Collaboration with WHO included sending consultants through the scheme of GOARN, strengthening of COVID-19 testing, and contribution to development of WPRO guidelines. Research and development involved establishment of a nationwide registry of COVID-19 clinical data. Following the meeting, NCGM further enhanced its activities as WHO CC. Since WHO CCs in the country have a wide range of expertise that could contribute to health system strengthening, it is worthwhile for the WHO CCs to consider amending existing work plans for supporting countries in the region to incorporate a health systems approach as part of COVID-19 response strategies.

Guideline-Driven Management of Hypertension: An Evidence-Based Update.

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Strengthening the community health program in Liberia: Lessons learned from a health system approach to inform program design and better prepare for future shocks.

BackgroundArising from the Ebola virus disease (EVD) outbreak, the 2015-2021 Investment Plan aimed to improve the health status of the Liberian population through building a resilient health system that contributes to achieving equitable health outcomes. Recognizing the significance of community participation in overcoming the EVD outbreak, strengthening community systems emerged as one of the most important strategies for bridging the gap in accessing primary health care (PHC) services. This study reviewed the community health policy development process in order to draw lessons from the health system strengthening efforts in Liberia post-EVD crisis.MethodsA government-led health system analysis approach was applied to assess, review and revise the community health program in Liberia. The mixed method approach combines the use of an adapted tool to assess bottlenecks and solutions during workshops, a qualitative survey (key informant interviews and focus group discussions) to assess perceptions of challenges and perspectives from different stakeholders, and an inter-agency framework – a benchmarks matrix – to jointly review program implementation gaps using the evidence compiled, and identify priorities to scale up of the community program.ResultsStakeholders identified key health system challenges and proposed policy and programmatic shifts to institutionalize a standardized community health program with fit for purpose and incentivized community health assistants to provide PHC services to the targeted populations. The community health program in Liberia is currently at the phase of implementation and requires strengthened leadership, local capacities, and resources for sustainability. Lessons learned from this review included the importance of: establishing a coordination mechanism and leveraging partnership support; using a systems approach to better inform policy shifts; strengthening community engagement; and conducting evidence-based planning to inform policy-makers.ConclusionsThis article contributes toward the existing body of knowledge about policy development processes and reforms on community health in Liberia, and most likely other African settings with weak health systems. Community-based systems will play an even bigger role as we move toward building resilience for future shocks and strengthening PHC, which will require that communities be viewed as actors in the health system rather than just clients of health services.

Maternal and perinatal death surveillance and response in low- and middle-income countries: a scoping review of implementation factors.

Maternal and perinatal death surveillance and response (MPDSR), or any form of maternal and/or perinatal death review or audit, aims to improve health services and pre-empt future maternal and perinatal deaths. With expansion of MPDSR across low- and middle-income countries (LMIC), we conducted a scoping review to identify and describe implementation factors and their interactions. The review adapted an implementation framework with four domains (intervention, individual, inner and outer settings) and three cross-cutting health systems lenses (service delivery, societal and systems). Literature was sourced from six electronic databases, online searches and key experts. Selection criteria included studies from LMIC published in English from 2004 to July 2018 detailing factors influencing implementation of MPDSR, or any related form of MPDSR. After a systematic screening process, data for identified records were extracted and analysed through content and thematic analysis. Of 1027 studies screened, the review focuses on 58 studies from 24 countries, primarily in Africa, that are mainly qualitative or mixed methods. The literature mostly examines implementation factors related to MPDSR as an intervention, and to its inner and outer setting, with less attention to the individuals involved. From a health systems perspective, almost half the literature focuses on the tangible inputs addressed by the service delivery lens, though these are often measured inadequately or through incomparable ways. Though less studied, the societal and health system factors show that people and their relationships, motivations, implementation climate and ability to communicate influence implementation processes; yet their subjective experiences and relationships are inadequately explored. MPDSR implementation contributes to accountability and benefits from a culture of learning, continuous improvement and accountability, but few have studied the complex interplay and change dynamics involved. Better understanding MPDSR will require more research using health policy and systems approaches, including the use of implementation frameworks.