Health Systems Framework Research Articles

Impact of health systems interventions in primary health settings on type 2 diabetes care and health outcomes among adults in West Africa: A systematic review protocol

Type 2 diabetes is a major global public health challenge, particularly in the African region. Though evidence exists on pharmacological agents and non-pharmacological interventions in maintaining blood glucose concentration, the healthcare systems’ ability to meet patients’ needs may be inadequate. The management of non-communicable diseases, particularly diabetes, has been postulated to depend on functioning health systems. This systematic review will, therefore, summarize the current evidence on existing health systems interventions in primary health settings for type 2 diabetes care and health outcomes in West Africa and will explore the impact of these system-level interventions on service availability, accessibility and quality, as well as individualized outcomes such as glycemic control, disease awareness and treatment adherence. The review will be conducted according to the reporting guidance in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). The health system framework by Witter et al., 2019 will guide the system-level interventions and the search strategy to be explored in this review. This framework was designed to integrate the six building blocks of the World Health Organization (WHO) health systems framework and it delineates how they work synergistically to improve specific health outcomes. We will search the following databases PubMed, Google Scholar and Cumulated Index to Nursing and Allied Health Literature (CINAHL) between January 2000 to January 2024. We will also search Cairn.info for articles published between January 2005 to January 2024. The Cochrane Collaboration tool for assessing Risk of Bias will be implemented in each included study. We will conduct a narrative synthesis and make comparisons across findings using Excel-generated tables. In Conclusion, this systematic review will outline the existing system-level interventions that aim to or already improve type 2 diabetes services in primary health settings in West Africa and will offer suggestions for the strengthening and co-production of successful interventions that can be generalized to the entire sub-region.

Protocol for a qualiquantitative study of accessibility of sexual and reproductive health services among women with motor disabilities in Morocco

Introduction Approximately 1.3 billion people worldwide live with a disability, underlining the need for equitable health care for this group is important. Inclusive health systems are consistent with global health priorities, respond to United Nations sustainable development goals and economically viable. Despite advancements in Morocco’s health system and legal framework, significant disparities remains inaccessing sexual and reproductive health (SRH) services for women with disabilities. This study explores barriers and facilitators affecting access to SRH services for these women, aiming to provide recommendations for more inclusive services and improved health outcomes. Methods Using a mixed approach, this study assessSRH access for women with motor disabilities in two cities in Morocco, selected for their socio-demographic, cultural and and healthcare diversity. Quantitative data will be generated through questionnaires administrered to 400 participants, while qualitative information will come from 20 to 30 interviews. Recruitment involves working with health professionals, NGOs and social media campaigns to ensure a diverse sample. Data analysis includes NVivo for qualitative data and descriptive/inferential statistics for quantitative data. Conclusion The study aims to explore the perspectives of women with disabilities and health professionals regarding SRH services. It will provide recommendations for making SRH services more equitable and inclusive, ultimately improving health out comes and uphold health rights for women with disabilities.

From fragmentation to functionality: Enhancing coherence of digital health integration in health systems.

Digital health programs continue to be implemented within Canadian health systems at a steady pace. The effectiveness of digital health initiatives has been rigorously analyzed, with both benefits and drawbacks extensively commented on. While the discussion about digital health continues, both positive and negative perspectives of it are approaching saturation in their themes. Accepting that digital health is here to stay post-pandemic, the focus should shift to strategies and supports needed to avoid the fragmentation of care through digital health implementation. This short article poses three questions which policy-makers and decision-makers should explore as part of a level-setting exercise with involved stakeholders at the outset of a digital health program's consideration. An implementation team should design the digital health program to have equity as its foundational focus, conduct value-based evaluations, and position the program in a learning health system framework to guard against the fragmentation of care.

A process study of early achievements and challenges in countries engaged with the WHO Special Initiative for Mental Health

BackgroundThere is increasing awareness of the importance of the transformation of mental health systems. Launched in 2019, the WHO Special Initiative for Mental Health seeks to accelerate access to quality and affordable care for mental health conditions as an integral component of Universal Health Coverage. Nine countries are currently engaged with the initiative.MethodsThis study reviewed processes of implementation—and progress achieved—across all settings by late 2022. It involved review of 158 documents provided by WHO relating to Special Initiative activities and 42 interviews with country-level stakeholders, WHO Regional and HQ personnel engaged with the initiative, and core donors. Documents were thematically coded using a template based upon the WHO framework of health system building blocks. Responses to structured interviews were coded based on an emergent thematic framework.ResultsDocumentation reported similar achievements across all domains; however challenges were reported most frequently in relation to service delivery, leadership and governance, and workforce. Issues of financing were notable in being twice as likely to be reported as a challenge than a success. Interviews indicated four major areas of perceived achievement: establishing a platform and profile to address mental health issues; convening a multi-stakeholder, participatory engagement process; new, appropriate services being developed; and key developments in law, policy, or governance around mental health. The planning process followed for the initiative, senior country-level buy-in and the quality of key personnel were the factors considered most influential in driving progress. Ambivalent political commitment and competing priorities were the most frequently cited challenges across all interviewees.ConclusionsThe role of the Special Initiative in raising the profile of mental health on national agendas through a participatory and inclusive process has been widely valued, and there are indications of the beginnings of transformational shifts in mental health services. To secure these benefits, findings suggest three strategic priorities: increasing political prioritisation and funding for systems-level change; clearly articulating sustainable, transformed models of care; and promoting feasible and contextualised measures to support accountability and course correction. All are of potential relevance in informing global strategies for mental health systems transformation in other settings.

Examining the roles and relationships of actors in community health systems in Nigeria through the lens of the expanded health systems framework

BackgroundCommunity health system (CHS) exists through the actions and activities of different actors within and outside communities. However, these actors, their roles and their relationships with one another have not...

Accelerating a learning public health system: Opportunities, obstacles, and a call to action.

Public health systems worldwide face increasing challenges in addressing complex health issues and improving population health outcomes. This experience report introduces the concept of a Learning Public Health System (LPHS) as a potential solution to transform public health practice. Building upon the framework of a Learning Health System (LHS) in healthcare, the LPHS aims to create a dynamic, data-driven ecosystem that continuously improves public health interventions and policies. This report explores the definition, benefits, challenges, and implementation strategies of an LPHS, highlighting its potential to revolutionize public health practice. This report employs a comparative analysis approach, examining the similarities and differences between an LPHS and an LHS. It also identifies and elaborates on the potential benefits, challenges, and barriers to implementing an LPHS. Additionally, the study investigates promising national initiatives that exemplify elements of an LPHS in action. An LPHS integrates data from diverse sources to inform knowledge generation, policy development, and operational improvements. Key benefits of implementing an LPHS include improved disease prevention, evidence-informed policy-making, and enhanced health outcomes. However, several challenges were identified, such as interoperability issues, governance concerns, funding limitations, and cultural factors that may impede the widespread adoption of an LPHS. Implementation of an LPHS has the potential to significantly transform public health practice. To realize this potential, a call to action is issued for stakeholders across the public health ecosystem. Recommendations include investing in informatics infrastructure, prioritizing workforce development, establishing robust data governance frameworks, and creating incentives to support the development and implementation of a LPHS. By addressing these key areas, public health systems can evolve to become more responsive, efficient, and effective in improving population health outcomes.

Audit of Geriatric Emergency Medicine-Unit staff compliance in providing care in line with the Age Friendly Health Systems Conceptual Framework

Abstract Background The Geriatric Emergency Medicine Unit (GEMU) in University Hospital Limerick (UHL) is in the Emergency Department for the assessment of those over the age of 75. The unit is staffed by a multi-disciplinary team with specialist skills in older person’s care. The aim of this audit was to determine assessment and documentation compliance with the Age Friendly Health Systems conceptual framework for older persons who present to GEMU. Methods A retrospective documentation review took place from patients who attended GEMU between January-March 2023. Medical record numbers were selected at random from the Health and Social Care Professionals (HSCP) team data management system with individual patient records subsequently retrieved from the Therefore Emergency Medicine (EM) patient management system. Patient records were reviewed by SW, which included Nursing, EM Doctors documentation and HSCP documentation. Results 15 charts were reviewed. Compliance varied across all areas from 0-100%. Compliance was greatest in the domains of the EWS score, mobility assessments, falls history and 4AT. Hydration and the documentation of ‘What Matters’/patient care preference were both 0%. Otherwise, compliance broadly was >50%. The first re-audit of 15 charts took place from December 2023-January 2024. Improvements were noted across all assessments, with 100% compliance additionally achieved in CFS, cognitive status, co-morbidities and nutritional intake. A second re-audit of 15 charts took place from March-April 2024, with further improvements seen in terms of lying and standing blood pressures and polypharmacy assessments. Conclusion Results demonstrate the continued improvements made amongst the team in adhering to the Age Friendly Health Systems Framework. Efforts are ongoing to focus specifically on the care preference component, with structured QIPs in place and a view to re-auditing in Q4 2024.

Improving possible serious bacterial infection (PSBI) management in young infants when referral is not feasible: lessons from embedded implementation research in Ethiopia and Kenya

BackgroundSepsis is a leading cause of neonatal mortality, despite the availability of effective treatment of possible serious bacterial illness (PSBI), including when referral to a hospital is not feasible. Gaps in access and delivery worsened during COVID-19. We conducted embedded implementation research in Ethiopia and Kenya aimed at mitigating the impact of COVID-19 and addressing various implementation challenges to improve PSBI management.MethodsThe implementation research projects were implemented at the subnational level in Ethiopia and Kenya between November 2020-June 2022 (Ethiopia) and December 2020-August 2022 (Kenya). Guided by the implementation research frameworks, both projects conducted mixed formative quantitative and exploratory research from April to May 2021, followed by summative evaluations conducted between June and July 2022. Frameworks encompassed Consolidated Framework for Implementation Research (CFIR), Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM), as well as health systems framework that incorporates cascades of care and World Health Organization Health Systems Building Blocks. Results were synthesized across the projects through document review and sharing cross-project measures and strategies through a project community of practice.ResultsDespite differences in settings across the projects, cross-cutting facilitators included community health worker program and support, and existence of guidelines for PSBI management at primary care levels. Barriers included community attitudes towards seeking care for sick newborns, COVID-19 risks and fear, and lack of health care worker competence. Country-specific contextual barriers included supply chain issues, civil conflict (Ethiopia), and labor strikes (Kenya). Strategies chosen to mitigate barriers and support implementation and sustainability in both settings included leveraging community health workers to address resistance to care-seeking, health workers’ training, COVID-19 infection prevention measures, stakeholder engagement, and advocacy to integrate PSBI management into existing programs, policies, and training. Other strategies addressing emerging project-specific barriers, included improving follow-up through a community health desk and PSBI mobile app (Kenya) and supply chain strengthening (Ethiopia). Both projects improved PSBI management coverage, increased adoption and uptake, and informed national policy changes supporting potential for sustainability.ConclusionsPragmatic embedded implementation research effectively supports the identification of barriers and mapping to strategies designed to increase effective coverage of PSBI management when referral is not feasible during the COVID-19 pandemic. Despite differences in context, cross-cutting strategies identified could inform broader scale-up in the region, including during future health system shocks.

Suggested solutions to barriers in accessing healthcare by persons with disability in Uganda: a qualitative study

BackgroundThere are 1.3 billion people with disabilities globally, and they frequently face barriers to accessing healthcare, contributing to their worse health and higher mortality. However, little research has explored patient-reported approaches to improve healthcare for persons with disabilities. Consequently, this study aimed to explore possible solutions and recommendations to address the existing barriers to access to healthcare for persons with disabilities in rural Uganda.MethodsWe conducted 27 semi-structured interviews with individuals with various disabilities in rural Luuka district, Eastern Uganda, between September and November 2022. The participants included individuals with visual impairment (n = 5), physical impairment (n = 5), hearing impairment (n = 6), multiple impairments (n = 5), intellectual/cognitive impairment (n = 5), and albinism (n = 1). Interviews were recorded, transcribed verbatim, and thematically analysed. We categorized the solutions using the Missing Billion disability-inclusive health systems framework.ResultsOur findings, framed within the health systems framework, revealed several critical themes. On the demand side, suggested solutions emphasized advocacy and sensitization for persons with disabilities, their communities, and caregivers about healthcare needs. Socio-economic empowerment and community-based health services were also highlighted as essential. On the supply side, participants stressed the importance of training healthcare workers on disability, facilitating dialogue and experience-sharing sessions, and employing health workers with disabilities. Additional recommendations included improving accessibility and reasonable accommodation, organizing inclusive services like special clinic days and outreaches, ensuring representation in health facility management, and establishing comprehensive rehabilitation services with affordable assistive devices.ConclusionThe multifaceted solutions proposed by persons with disabilities highlight the complex challenges they face in accessing healthcare services and highlight the necessity for comprehensive, sustainable interventions. The call to action for policymakers and healthcare providers is to prioritise the incorporation of disability-inclusive practices and explore multi-dimensional approaches that foster a more inclusive healthcare environment that adequately meets the needs of persons with disabilities.

Equity in practice: Integrating cross cultural health brokers for culturally safe primary care for immigrants and refugees in British Columbia.

Umbrella Multicultural Health Co-op is a community health centre serving cultural communities of immigrants/refugees in British Columbia. It uses Cross Cultural Health Brokers (CCHBs), multicultural workers bridging patients and the healthcare system, to better meet the primary care needs of immigrant/refugee populations. Through the Team Primary Care initiative, Umbrella Co-op: (1) added new CCHBs alongside allied health practitioners; and (2) implemented team workshops and evaluation for quality improvement. The learning health system framework guided project activities. Comprehensive, culturally responsive primary care for immigrants and refugees benefits from a team-based approach that includes the integration of CCHBs. Team development activities improved team function. Co-developing evaluation with the interprofessional team enabled meaningful participation. Health system design for equity-oriented team-based primary care for immigrants and refugees should include resources for CCHBs and team development infrastructure.

Sustainability in Participatory Health: Applying WHO's Operational Framework.

The World Health Organization's Operational Framework for Climate Resilient and Low Carbon Health Systems outlines 10 broad components for the development and maintenance of health systems that respond effectively to climate-related challenges. This work analyses the WHO framework from a participatory health informatics perspective and identifies specific initiatives involving non-professionals that align with the framework. Citizen and patient participation in the development of climate-resilient health systems is not only possible but also necessary to maximize climate resiliency at the community and global levels.

US public health surveillance, reimagined.

This study presents two novel concepts for standardizing electronic health records (EHR)-based public health surveillance through utilization of existing informatics methods and data platforms. Drawing from the collective experience in applied epidemiology, health services research and health informatics, the author presents a vision for an alternative path to public health surveillance by repurposing existing tools and resources, such as (1) computable phenotypes which have already been created and validated for a variety of chronic diseases of interest to public health and (2) large data platforms/collaboratives, such as All of Us Research Program and National COVID Cohort Collaborative. Opportunities and challenges are discussed regarding EHR-based chronic disease surveillance, as well as the concept of phenotype definitions and large data platforms reuse for public health needs. Reusing of computable phenotypes for EHR-based public health surveillance would require secure data platforms and nationally representative data. Standardization metrics for reuse of previously developed and validated computable phenotypes are also necessary and are currently being developed by the author. This study presents a reimagined Learning Health System framework by incorporating Public Health and two novel concept sets of solutions into the healthcare ecosystem. Alternative approaches to limited resources and current infrastructure of the US Public Health System, especially as applied to disease surveillance, are needed and may be possible when repurposing the resources and methodologies across the Learning Health System.

A model of academic-practice collaboration for facilitating informatics capacity and building a learning health system framework in public health.

The data modernization initiative (DMI) is a multi-year, multi-billion-dollar endeavor toward a robust public health information infrastructure. The various DMI projects (interoperability, analytics, workforce, governance) present an opportunity for a learning health system (LHS) framework in public health. The objective is to share an academic-practice partnership model between the University of Minnesota (UMN) and the Minnesota Department of Health (MDH) in advancing public health informatics (PHI) and its relationship to an LHS model. The UMN-MDH partnership was conceptualized in 2018 as a 1-year pilot with annual renewals through a time/cost-sharing faculty position with PHI expertise. The partnership focus was decided based on MDH's needs and mutual interests, with the core collaborating faculty (SR) being an embedded researcher at MDH. Responsibilities included supporting electronic case reporting (eCR), interoperability projects, and assisting MDH staff with PHI presentations/publications. The partnership has expanded to PHI workforce development through a national grant and now includes an interest in applying the LHS framework to MDH-DMI work. The MDH-DMI team has embarked upon 13 projects for assessment through an LHS approach: systems interoperability projects between MDH and healthcare/local public health (n = 6); systems modernization for MDH programs (n = 5); informatics workforce development (n = 1); and program governance (n = 1). Each project has been evaluated and/or has current/future assessment plans to synthesize learnings and create a feedback loop for iterative improvement. The partnership has been mutually beneficial as it met agreed upon metrics across both institutions. The program's productivity is showcased with shared authorship in 10 peer-reviewed proceedings/publications, 22 presentations and 16 posters across local/national conferences. The current case report of the UMN-MDH partnership is a relatively recent exemplar to support tangible LHS demonstration in public health. Building LHS momentum at MDH and other public health entities will require LHS champion(s) and continued academic collaboration.

Resolving disparities in access to cancer care in LMIC-positive learning using a 10-year-old model.

156 Background: Despite significant advances in cancer diagnosis and treatment, there are wide disparities in access to cancer care, more so in low- and middle-income countries. The problem is multifactorial, such as patient-related, health system-related, socio-cultural-related to language and literacy, and socio-cultural-related to beliefs and stigma. These disparities extend across the cancer continuum, from diagnosis to end-of-life care. It is imperative to address these disparities. Here we report 10-year experience from an innovative access delivery model in one go, comprehensively addressing many of these challenges. Methods: Learning from the WHO framework of health system strengthening, a model that affects the major contributors to health system strengthening was developed. These include government-owned health departments, district hospitals, and physicians. Various regulations strengthened each of these components. The regulations were issued to create systems in district hospitals, train an alternative oncology workforce, and make oncology drugs available in the periphery. This measure allowed cancer-care-related services to be feasible in the existing peripheral health system. Results: In 2014, one of the states in India decided to initiate cancer care services in government-run district hospitals. One physician and two nurses from every district hospital were trained to offer cancer-related services locally from diagnosis to end-of-life, including cancer chemotherapy, under the 24 x7 mentorship of a senior oncologist. To date, more than 250 physicians and 500 nurses have been trained in this field. The program has been extended to eight states and 198 districts, covering an area of over a million square kilometers and a population of over 380 million. Data from only one district alone showed that nearly 7000 new patients availed of services (average 700 per year) with more than 17000 sessions of chemotherapy (Table). Conclusions: The majority of the world, including LMICs, is dependent on the services provided by government-run health institutions. The empowerment of government health systems appears to be the single most important factor in improving access to cancer care. This model of cancer cere delivery has consistently proven its robustness, replicability, and scalability. This finding deserves consideration for further research and expansion to other countries. [Table: see text]

Care models for individuals with chronic multimorbidity: lessons for low- and middle-income countries

BackgroundPatients with multiple long-term conditions requires understanding the existing care models to address their complex and multifaceted health needs. However, current literature lacks a comprehensive overview of the essential components, impacts, challenges, and facilitators of these care models, prompting this scoping review.MethodsA scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for Scoping Reviews guideline. Our search encompassed articles from PubMed, Web of Science, EMBASE, SCOPUS, and Google Scholar. The World Health Organization’s health system framework was utilized to synthesis the findings. This framework comprises six building blocks (service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance) and eight key characteristics of good service delivery models (access, coverage, quality, safety, improved health, responsiveness, social and financial risk protection, and improved efficiency). Findings were synthesized qualitatively to identify components, impacts, barriers, and facilitators of care models.ResultsA care model represents various collective interventions in the healthcare delivery aimed at achieving desired outcomes. The names of these care models are derived from core activities or major responsibilities, involved healthcare teams, diseases conditions, eligible clients, purposes, and care settings. Notable care models include the Integrated, Collaborative, Integrated-Collaborative, Guided, Nurse-led, Geriatric, and Chronic care models, as well as All-inclusive Care Model for the Elderly, IMPACT clinic, and Geriatric Patient-Aligned Care Teams (GeriPACT). Other care models (include Care Management Plus, Value Stream Mapping, Preventive Home Visits, Transition Care, Self-Management, and Care Coordination) have supplemented the main ones. Care models improved quality of care (such as access, patient-centeredness, timeliness, safety, efficiency), cost of care, and quality of life for patients that were facilitated by presence of shared mission, system and function integration, availability of resources, and supportive tools.ConclusionsCare models were implemented for the purpose of enhancing quality of care, health outcomes, cost efficiency, and patient satisfaction by considering careful recruitment of eligible clients, appropriate selection of service delivery settings, and robust organizational arrangements involving leadership roles, healthcare teams, financial support, and health information systems. The distinct team compositions and their roles in service provision processes differentiate care models.

Custo-Efetividade da Oxigenação por Membrana Extracorpórea Venoarterial no Choque Cardiogênico Refratário: Um Estudo na Perspectiva Brasileira

Abstract Background Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. Methods We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. Results In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. Conclusions Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Loneliness and its correlation with self-care and activities of daily living among older adults: a partial least squares model

BackgroundThe growing elderly population worldwide is accompanied by an increased disrupting daily activities and self-care. Neglecting the multifaceted needs of the elderly can lead to detrimental effects such as loneliness or social isolation, threatening healthy aging. Self-care is a key strategy to enhance daily functioning and mitigate feelings of loneliness among the elderly. This study was conducted with the aim of investigating the feelings of loneliness and its relationship with self-care and Activities of Daily Living (ADL) among the older adults of Tabriz city.MethodsIn this observational cross-sectional study, we engaged 315 older adults using a simple random sampling. Participants were selected randomly from Iran’s Integrated Health System (IIHS) framework. Three questionnaires including de Jong Gierveld Loneliness Scale, Persian version of self-care scale, and ADL-Katz were used for data collection. The Partial Least Squares and Spearman’s correlation were used to investigate the relationships between demographic characteristics, loneliness, self-care, and ADL.ResultsThe sample comprised 315 respondents 51.1% were female, 49.5% had a middle school literacy and 86% were married. A significant negative relationship was observed between loneliness and self-care (P < 0.001 and r =-0.311). Demographic characteristics, including age and marital status, were found to negatively moderate the relationship between self-care (path coefficient − 0.07, P = 0.044) and positively moderate the relationship with loneliness (path coefficient 0.29, p < 0.001). ADL was positively associated with self-care (path coefficient 0.41, p = 0.046) and also a direct and significant relationship was observed between ADL and daily self-care (P < 0.001 and r = 0.335).ConclusionThis study underscores the complex interplay between loneliness, self-care, and ADL. It highlights the need for interventions that address emotional health and daily living skills as part of comprehensive self-care strategies. Further research is needed to explore these relationships in more detail and to develop targeted interventions for different demographic groups.

Effect of the data-informed platform for health intervention on the culture of data use for decision-making among district health office staff in North Shewa Zone, Ethiopia: a cluster-randomised controlled trial

BackgroundSimilar to other low and middle-income countries, Ethiopia faces limitations in using local health data for decision-making.We aimed to assess the effect of an intervention, namely the data-informed platform for health, on the culture of data-based decision making as perceived by district health office staff in Ethiopia’s North Shewa Zone.MethodsBy designating district health offices as ‘clusters’, a cluster-randomised controlled trial was implemented. Out of a total of 24 districts in the zone, 12 districts were allocated to intervention arm and the other 12 in the control group arms. In the intervention arm district health office teams were supported in four-monthly cycles of data-driven decision-making over 20 months. This support included: (a) defining problems using a health system framework; (b) reviewing data; (c) considering possible solutions; (d) value-based prioritizing; and (e) a consultative process to develop, commit to, and follow up on action plans. To measure the culture of data use for decision-making in both intervention and control arms, we interviewed 120 health management staff (5 per district office). Using a Likert scale based standard Performance of Routine Information System Management tool, the information is categorized into six domains:- evidence-based decision making, emphasis on data quality, use of information, problem solving, responsibility and motivation. After converting the Likert scale responses into percentiles, difference-in-difference methods were applied to estimate the net effect of the intervention. In intervention districts, analysis of variance was used to summarize variation by staff designation.ResultsThe overall decision-making culture in health management staff showed a net improvement of 13% points (95% C.I:9, 18) in intervention districts. The net effect of each of the six domains in turn was an 11% point increase (95% C.I:7, 15) on culture of evidence based decision making, a 16% point increase (95% C.I:8, 24) on emphasis on data quality, a 20% point increase (95% C.I:12, 28) on use of information, a 21% point increase (95% C.I:13, 29) on problem solving, and a 10% point increase (95% C.I:4, 16) on responsibility and motivation. In terms of variation by staff designation within intervention districts, statistically significant differences were observed only for problem solving and responsibility.ConclusionThe data-informed platform for health strategy resulted in a measurable improvement in data use and structured decision-making culture by using existing systems, namely the Performance Monitoring Team meetings. The intervention supported district health offices in identifying and solving problems through a structured process. After further research, DIPH intervention could also be applied to other health administration and facility levels.Trial registrationClinicalTrials.gov ID: NCT05310682, Dated 25/03/ 2022.

Cost-Utility of Venoarterial Extracorporeal Membrane Oxygenation in Refractory Cardiogenic Shock: A Brazilian Perspective Study.

Refractory cardiogenic shock (CS) is associated with high mortality rates, and the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a therapeutic option has generated discussions. Therefore, its cost-effectiveness, especially in low- and middle-income countries like Brazil, remains uncertain.Objectives: To conduct a cost-utility analysis from the Brazilian Unified Health System perspective to assess the cost-effectiveness of VA-ECMO combined with standard care compared to standard care alone in adult refractory CS patients. We followed a cohort of refractory CS patients treated with VA-ECMO in tertiary care centers located in Southern Brazilian. We collected data on hospital outcomes and costs. We conducted a systematic review to supplement our data and utilized a Markov model to estimate incremental cost-effectiveness ratios (ICERs) per quality-adjusted life year (QALY) and per life-year gained. In the base-case analysis, VA-ECMO yielded an ICER of Int$ 37,491 per QALY. Sensitivity analyses identified hospitalization cost, relative risk of survival, and VA-ECMO group survival as key drivers of results. Probabilistic sensitivity analysis favored VA-ECMO, with a 78% probability of cost-effectiveness at the recommended willingness-to-pay threshold. Our study suggests that, within the Brazilian Health System framework, VA-ECMO may be a cost-effective therapy for refractory CS. However, limited efficacy data and recent trials questioning its benefit in specific patient subsets highlight the need for further research. Rigorous clinical trials, encompassing diverse patient profiles, are essential to confirm cost-effectiveness and ensure equitable access to advanced medical interventions within healthcare systems, particularly in socio-economically diverse countries like Brazil.

Implementation of Quality Improvement System in a National Health System.

There is a continued need to improve the quality of health care services and the health outcomes associated with that care. Quality improvement model and the Learning Health System framework have emerged as potential methods to achieve the goals of better care and enhanced outcomes. Few practical tools and approaches have been developed to assist with the initiation of quality improvement and development of a Learning Health System. The Department of Veterans Affairs developed and deployed a national system to assist and organize improvement projects and serve as a database for learning. During its first 5 years of use, 7397 quality improvement projects were completed using the electronic tool. National implementation of a structured tool for quality improvement is possible.