Health System Performance Research Articles

Resilience dimensions in health system performance assessments, European Union.

To explore the definition and operationalization of resilience in health system performance assessments in European Union countries. We conducted multiple empirical case study analyses. We identified relevant cases through a literature review from 2014 to 2023 using Google Scholar and through a snowball technique to retrieve additional information. We included only documents that explicitly mentioned resilience in health system performance assessments. We performed a content analysis to identify common patterns in defining resilience. The final sample consisted of six countries: Belgium, Croatia, Czechia, Estonia, Ireland and Italy. Each country adopted a distinct approach to conceptualizing resilience, with countries prioritizing specific aspects based on lessons learnt from the coronavirus disease 2019 (COVID-19) pandemic. Some countries focused on maintaining essential health-care services and protecting vulnerable groups. Other countries prioritized management capacity, staff preparedness, digital health utilization and strengthening of primary health care. Content analysis revealed six resilience definitions derived from the key performance indicators: addressing unmet needs and maintaining outcomes; protecting vulnerable groups; acquiring and using resources; having trained and prepared staff in place; using digital health; and strengthening primary health care. Integration of resilience into the health profiles of European Union countries preceded its inclusion in national health system performance assessments, the latter of which became more prominent after the COVID-19 pandemic. Variations in interpretations within health system performance assessments reflect differences in indicators and policy responses.

Policy approaches to health system performance assessment.

Policy approaches to health system performance assessment.

Routine data in a primary care performance dashboard, Ethiopia.

To explore the feasibility of building a primary care performance dashboard using DHIS2 data from Ethiopia's largest urban (Addis Ababa), agrarian (Oromia) and pastoral (Somali) regions. We extracted 26 data elements reported by 12 062 health facilities to DHIS2 for the period 1July 2022 to 30June 2023. Focusing on indicators of effectiveness, safety and user experience, we built 14 indicators of primary care performance covering reproductive, maternal and child health, human immunodeficiency virus, tuberculosis, noncommunicable disease care and antibiotic prescription. We assessed data completeness by calculating the proportion of facilities reporting each month, and examined the presence of extreme outliers and assessed external validity. At the regional level, average completeness across all data elements was highest in Addis Ababa (82.9%), followed by Oromia (66.2%) and Somali (52.6%). Private clinics across regions had low completeness, ranging from 38.6% in Somali to 58.7% in Addis Ababa. We found only a few outliers (334 of 816 578 observations) and noted that external validity was high for 11 of 14 indicators of primary care performance. However, the 12-month antiretroviral treatment retention rate and proportions of patients with controlled diabetes or hypertension exhibited poor external validity. The Ethiopian DHIS2 contains information for measuring primary care performance, using simple analytical methods, at national and regional levels and by facility type. Despite remaining data quality issues, the health management information system is an important data source for generating health system performance assessment measures on a national scale.

Health system performance assessment and reforms, Oman.

To prioritize key areas of action and investment for the next strategic cycle of national development plans (2026-2031) in Oman, we needed a holistic view of the country's health system and its main deficiencies and inefficiencies. Informed by the World Health Organization framework, our team of seven national health ministry staff and two international experts conducted a rapid health system performance assessment. We used already available data to identify system bottlenecks and their potential root causes, verifying our findings with key informant interviews. Oman's 4.9 million population is relatively young (average age 28years) but ageing, with a mounting burden of chronic diseases. While health-care services are free for Omani nationals, more than 1.5 million expatriates rely on out-of-pocket payments for health-care services. Strengthening primary health care, improving the quality of care, providing financial protection, and ensuring that public and private health-care providers operate within the same legal and procedural framework are recognized as key national priorities. Our assessment highlighted the need to extend health service coverage to the whole population, strengthen private health-care sector governance, improve health education, increase financial investment, and expand the country's capacity for data collection and analysis. The assessment framework allowed us to identify areas where information is lacking and use already available data to analyse multiple health outcomes. As well as identifying issues that need to be addressed during the next policy development cycle, our findings have contributed towards the preparation of a more extensive assessment.

Patients’ satisfaction with services in HIV clinic at a public tertiary health institution in Ogun State, Nigeria: Patients-providers perspectives

Objective: This study assessed HIV patients´ satisfaction, factors associated with patients´ satisfaction and gaps in the quality of health care service delivery in a virology clinic in Ogun State, Nigeria. Methodology: A cross-sectional study design using mixed methods was used for the study. Three hundred and fifty adult HIV patients on HAART for uninterrupted six months were selected by multistage sampling technique. The Chi-square test was used to assess associations between categorical variables. The p-value used was 0.05. The key informants that were interviewed were the clinic manager, the clinic consultant, the adherence counsellor and the clinic pharmacist. Thematic analysis was done on the key informant interviews. Results: The mean satisfaction scores were high for confidentiality (4.24±0.97), overall care (4.17±0.56) and accessibility of care (4.09±0.82). Waiting time (mean of 3.35±0.42 minutes) and hospital environment (mean of 3.97±0.74) had the lowest mean satisfaction scores. Factors associated with satisfaction were patients’ income (p = 0.001), occupation (p = 0.001) and gender (p = 0.007). The key informants identified long waiting times in the clinic, shortage of manpower, inadequate financial support for patients and inadequate technical support for clinic activities as aspects of care for improvement. Conclusion: In this study, patients expressed a high level of satisfaction with the quality of care and the key informants identified challenges that affect optimal care in the clinic. Healthcare quality is a core dimension of health system performance. Continuous patient satisfaction and quality of care evaluations are needed for optimal health system performance.

Data for health system comparison and assessment in the African Region: A review of 63 indicators available in international databases.

Achieving universal health coverage in the African region requires health systems strengthening. Assessing and comparing health systems contributes to this process, but requires internationally comparable data. The European Observatory on Health Systems and Policies has produced Health Systems in Transition (HiT) reviews in Europe, Asia, North America and the Caribbean with a standardised template. This study explores data availability in international databases for the quantitative health and health system indicators in the HiT template for the WHO African region. We identified ten databases which contained data for 40 of the 80 original HiT indicators and an additional 23 proxy indicators to fill some gaps. We then assessed data availability for the resulting 63 indicators by country and time, i.e. first/last year of data, years of data available overall and since 2000, and we explored for each indicator (1) against the country with the greatest availability overall and (2) against annual availability for all years since 2000. Overall data availability was greatest in South Africa (93.0% of possible total points) and least in South Sudan (59.5%). Since 2000, Uganda (60.4%) has had the highest data availability and South Sudan (37.2%) the lowest. By topic, data availability was the highest for health financing (91.4%; median start/end date 2000/2019) and background characteristics (88.5%; 1990/2020) and was considerably lower for health system performance (54.5%; 2000/2018) and physical and human resources (44.8%; 2004/2013). Data are available for different years in different countries, and at irregular intervals, complicating time series analysis. No data are available for service provision indicators. Gaps in data in international databases across time, countries, and topics undermine systematic health systems comparisons and assessments, regional health systems strengthening, and efforts to achieve universal health coverage. More efforts are needed to strengthen national data collection and management and integrate national data into international databases to support cross-country assessments, peer learning, and planning. In tandem, more research is needed to understand the specific historical, cultural, administrative, and technological determinants influencing country data availability, as well as the facilitators and barriers of data sharing between countries and international databases, and the potential of new technologies to increase timeliness of data.

'We thought supporting was strengthening': re-examining the role of external assistance for health systems strengthening in Zimbabwe post-COVID-19.

Zimbabwe has received substantial external assistance for health since the early 2000s, including funding earmarked for, or framed as, health systems strengthening (HSS). This study sought to examine whether external assistance has strengthened the health system (i.e. enabled comprehensive changes to health system performance drivers) or has just supported the health system (by increasing inputs and improving service coverage in the short term). Between August and October 2022, we conducted in-depth key informant interviews with 18 individuals and reviewed documents to understand: (1) whether external funding has supported or strengthened Zimbabwe's health system since the 2000s; (2) whether the experience of COVID-19 fosters a re-examination of what had been considered as HSS during the pre-pandemic era; and (3) areas to be reconsidered for HSS post COVID-19. Our findings suggest that external funders have supported Zimbabwe to control major epidemics and avert health system collapse. However, the COVID-19 pandemic showed that supporting the health system is not the same as strengthening it, as it became apparent at that time that the health sector is plagued with several system-wide bottlenecks. External funding is fragile and highly unsustainable, which reinforces the oft-ignored reality that HSS is a sovereign mandate of country-level authorities, and one that falls outside the core interests of external funders. The key positive lesson from the pandemic is that Zimbabwe is capable of raising domestic resources to fund HSS. However, there is no guarantee that such funding will be maintained. There is a need, then, to reconsider government's stewardship for HSS. External funders need to re-examine whether their funding really strengthens the national health system or just supports the country to provide basic services in their areas of interest.

Provision of oral healthcare services in WHO-EMR countries: a scoping review

Global neglect of oral healthcare services (OHCS) provision, mainly in Low- and Middle-Income Countries, exacerbates the deterioration of health systems and increases global health inequality.ObjectivesThe objective is to explore the profiles of available oral healthcare services in the WHO Eastern Mediterranean Region (EMR) countries.MethodsA systematic literature search was conducted of grey literature and databases (PubMed, Medline, Embase, and the Cochrane Library). Peer-reviewed articles that reviewed and/or evaluated OHCS in WHO-EMR countries were identified. No time or language limitations were applied. Two independent reviewers conducted the screening and data extraction. A third reviewer arbitrated disagreement. The evaluation of the OHCS provision followed the WHO framework for health system performance assessment. The extraction included socio-demographic characteristics of the studied population, OHCS profile, responsiveness, and health insurance coverage.ResultsOne hundred and thirty-seven studies were identified. The studies that met the inclusion criteria were fifteen published between 1987 and 2016. In addition, two reports were published in 2022. The included studies were conducted in Pakistan, Saudi Arabia, Iran, Libya, Egypt, Oman, Syria, Jourdan, Kuwait, and Tunisia. Generally, Ministries of Health are the main providers of OHCS. The provision for national dental care prevention programmes was highly limited. Furthermore, most of these Ministries of Health have struggled to meet their local populations’ dental needs due to limited finances and resources for OHCS.ConclusionsOral and dental diseases are highly prevalent in the WHO-EMR region and the governments of the region face many challenges to meeting the OHCS needs of the population. Therefore, further studies to assess and re-design the OHCS in these countries to adapt dental care prevention into national health programmes are crucial.

Quantifying sustained health system benefits of primary care-based integrated disease management for COPD: a 6-year interrupted time series study

BackgroundSevere exacerbation of chronic obstructive pulmonary disease (COPD) is a trajectory-changing life event for patients and a major contributor to health system costs. This study evaluates the real-world impact of...

Die Bevölkerungsperspektive in der Bewertung der Leistungsfähigkeit des deutschen Gesundheitssystems: Ergebnisse einer Querschnittsbefragung GKV-Versicherter

IntroductionSince the World Health Report in 2000, Health System Performance Assessment (HSPA) has been established as a tool for the evaluation and evidence-informed governance of health systems. So far, the population perspective has not been integrated into HSPA in a systematic manner, although people's experiences and expectations are of great importance to improve health systems and especially to strengthen patient-centered care. Therefore, this study aims to conduct an HSPA of Germany's health system from the population's perspective covering all eight goals of WHO’s Health Systems Framework, and to identify strengths and needs for improvement. MethodsIn 2018, 32,000 people insured with the German sickness fund ‘AOK Nordost’ were invited by mail to participate in the survey. The questionnaire contained a total of 43 items covering the eight goals of WHO's Health Systems Framework (e.g., access, quality, safety) plus socioeconomics and other characteristics of the insured persons. The data on the health system goals were analyzed descriptively and by subgroups (age, sex, income, chronic conditions, health literacy). ResultsThe sample (n=1,481; response rate 4.6%) was 54.8% female and had a mean age of 59.1 years (±18.5). Altogether, the participants saw several needs for improvement within the German health system. For instance, 60.0% found quality differences between hospitals to be big, and between 3.9% and 8.5% reported mistakes related to their treatment or prescription medication in the previous two years. A big need for reform was especially seen regarding out-of-pocket payments (51.5%) and the coordination of ambulatory care physicians among each other (44.2%) and with hospitals (41.9%). In addition, big subgroup differences were seen, especially for income and health literacy. Of the participants in the lower income group, 37.2% reported a (very) strong financial burden due to out-of-pocket payments (vs. 20.7%). People with limited health literacy (52.1%) assessed the access to care generally as not being good, and they perceived greater quality differences and needs for reform, compared to their counterparts. For instance, 36.6% had experienced discrimination in the previous year (vs. 19.9%). DiscussionThe survey results provide a comprehensive picture of Germany's health system from the population perspective. In some areas, previous findings were confirmed (e.g., a lack of coordination between providers). Other results expand existing knowledge (e.g., the role of health literacy in health care provision) or raise new questions (e.g., the difference between the subjectively assessed burden from out-of-pocket payments and the objective measures currently used). The great differences between subgroups are a call to action on the level of both politics and practice to better consider the individual's needs in order to make health better for everyone. Further research could provide deeper insights in this regard. ConclusionStrengthening the population perspective in HSPA allows for a better understanding and evaluation of health systems and, in particular, helps to identify areas for improvement in patient-centered care.

Revised OECD Health System Performance Assessment Framework: Towards a Resilient and People-Centered Performance Assessment

Revised OECD Health System Performance Assessment Framework: Towards a Resilient and People-Centered Performance Assessment

Decentralization of the health system - experiences from Pakistan, Portugal and Brazil.

Decentralization of a health system is a complex and multidimensional phenomenon that demands thorough investigation of its process logistics, predisposing factors and implementation mechanisms, within the broader socio-political environment of each nation. Despite its wide adoption across both high-income countries (HICs) and low-and-middle-income countries (LMICs), empirical evidence of whether decentralization actually translates into improved health system performance remains inconclusive and controversial. This paper aims to provide a comprehensive description of the decentralization processes in three countries at different stages of their decentralization strategies - Pakistan, Brazil and Portugal. This study employed a systematic analysis of peer-reviewed academic journals, official government reports, policy documents and publications from international organizations related to health system decentralization. A comprehensive search was conducted using reputable databases such as PubMed, Google Scholar, the WHO repository and other relevant databases, covering the period up to the knowledge cutoff date in June 2023. Information was systematically extracted and organized into the determinants, process mechanics and challenges encountered during the planning, implementation and post-decentralization phases. Although decentralization reforms have achieved some success, challenges persist in their implementation. Comparing all three countries, it was evident that all three have prioritized health in their decentralization reforms and aimed to enhance local decision-making power. Brazil has made significant progress in implementing decentralization reforms, while Portugal and Pakistan are still in the process. Pakistan has faced significant implementation challenges, including capacity-building, resource allocation, resistance to change and inequity in access to care. Brazil and Portugal have also faced challenges, but to a lesser extent. The extent, progress and challenges in the decentralization processes vary among the three countries, each requiring ongoing evaluation and improvement to achieve the desired outcomes. Notable differences exist in the extent of decentralization, the challenges faced during implementation and inequality in access to care between the three countries. It is important for Portugal, Brazil and Pakistan to address these through reinforcing implementation strategies, tackling inequalities in access to care and enhancing monitoring and evaluation mechanism. Additionally, fostering knowledge sharing among these different countries will be instrumental in facilitating mutual learning.

International cross-cultural development and field testing of the primary care practice questionnaire for the PaRIS survey (PaRIS-PCPQ)

BackgroundThe PaRIS survey, an initiative of the Organisation for Economic Co-operation and Development (OECD), aims to assess health systems performance in delivering primary care by measuring the care experiences and outcomes of people over 45 who used primary care services in the past six months. In addition, linked data from primary care practices are collected to analyse how the organisation of primary care practices and their care processes impact care experiences and outcomes. This article describes the development and validation of the primary care practice questionnaire for the PaRIS survey, the PaRIS-PCPQ.MethodThe PaRIS-PCPQ was developed based on domains of primary care practice and professional characteristics included in the PaRIS conceptual framework. Questionnaire development was conducted in four phases: (1) a multi-step consensus-based development of the source questionnaire, (2) translation of the English source questionnaire into 17 languages, (3) cross-national cognitive testing with primary care professionals in participating countries, and (4) cross-national field-testing.Results70 items were selected from 7 existing questionnaires on primary care characteristics, of which 49 were included in a first draft. Feedback from stakeholders resulted in a modified 34-item version (practice profile, care coordination, chronic care management, patient follow-up, and respondent characteristics) designed to be completed online by medical or non-medical staff working in a primary care practice. Cognitive testing led to changes in the source questionnaire as well as to country specific localisations. The resulting 32-item questionnaire was piloted in an online survey and field test. Data from 540 primary care practices from 17 countries were collected and analysed. Final revision resulted in a 34-item questionnaire.ConclusionsThe cross-national development of a primary care practice questionnaire is challenging due to the differences in care delivery systems. Rigorous translation and cognitive testing as well as stakeholder engagement helped to overcome most challenges. The PaRIS-PCPQ will be used to assess how key characteristics of primary care practices relate to the care experiences and outcomes of people living with chronic conditions. As such, policymakers and care providers will be informed about the performance of primary care from the patient’s perspective.

Strengthening district health management and planning: an evaluation of a multi-country initiative in Eastern and Southern Africa

Background District health management and leadership capacity is increasingly recognised as critical to health system performance. District health managers play a central role in effective implementation and tailoring of national health policies, and they need adequate skills and support. The District Health System Strengthening Initiative (DHSSi) was implemented over 2019-22 in Malawi, Kenya, Tanzania and Uganda to strengthen sub-national capacity for evidence-based planning and a broader set of management competencies needed to operationalize district plans. To support learning and adaptation, a three-year evaluation was conducted to assess progress against outcomes and to inform ongoing implementation and future investment. Methods The evaluation used a mixed-methods theory-based approach. Evaluation questions were structured using criteria of relevance, coherence, efficiency, effectiveness, sustainability and impact, and corresponded to outputs, outcomes and impacts in the DHSSi Theory of Change. The evaluation was conducted over three annual rounds, and combined data from document review, observation, interviews and group discussions with cross-country, national and district stakeholders, and analysis of secondary quantitative data. Results Experience of DHSSi implementation indicated the relevance of supporting district management and planning, with gaps in current capacity, government interest, and indications of the potential to improve district practice. DHSSi experience also highlighted challenges to effective achievement of stronger capacity, and to translation of skills to improved management practice and, ultimately, to improved service delivery. A range of factors beyond skills affected district capacities, motivation and opportunities for effective planning and management, including areas such as funding, planning templates, health information systems, staff turnover, partner alignment and political structures. Conclusions Strengthening sub-national health management is an important agenda in efforts to expand high-quality primary health care. Future initiatives should prioritize detailed understanding of the range of influences on district management, and work to strengthen the enabling environment for effective district practice.

A shifting terrain: Understanding the perspectives of walk-in physicians on their roles amid worsening primary care access in Ontario, Canada.

High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022. Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how.

Impact of early death recording on international comparison of acute myocardial infarction mortality – administrative hospital data study using the example of Germany and the United States

BackgroundIn-hospital mortality from acute myocardial infarction (AMI) is widely used in international comparisons as an indicator of health system performance. Because of the high risk of early death after AMI, international comparisons may be biased by differences in the recording of early death cases in hospital inpatient data. This study examined whether differences in the recording of early deaths affect international comparisons of AMI in-hospital mortality by using the example of Germany and the United States, and explored approaches to address this issue.MethodsThe German Diagnosis-Related Groups Statistics (DRG Statistics), the U.S. National Inpatient Sample (NIS) and the U.S. Nationwide Emergency Department Sample (NEDS) were analysed from 2014 to 2019. Cases with treatment for AMI were identified in German and U.S. inpatient data. AMI deaths occurring in the emergency department (ED) without inpatient admission were extracted from NEDS data. 30-day in-hospital mortality figures were calculated according to the OECD indicator definition (unlinked data) and modified by including ED deaths, or excluding all same-day cases.ResultsGerman age-and-sex standardized 30-day in-hospital mortality was substantially higher compared to the U.S. (in 2019, 7.3% vs. 4.6%). The ratio of German vs. U.S. mortality was 1.6. After inclusion of ED deaths in U.S. data this ratio declined to 1.4. Exclusion of same-day cases in German and U.S. data led to a similar ratio.ConclusionsWhile short-duration treatments due to early death are generally recorded in German inpatient data, in U.S. inpatient data those cases are partially missing. Excluding cases with short-duration treatment from the calculation of mortality indicators could be a feasible approach to account for differences in the recording of early deaths, that might be existent in other countries as well.

Health system inequities in Lao People's Democratic Republic: Evidence from a nationally representative phone survey.

Despite substantial economic growth in Lao People's Democratic Republic (PDR) over the past 20 years, high levels of income inequality and poverty persist and have likely been exacerbated by the COVID-19 pandemic. In this article, we use novel survey data to assess the extent to which socioeconomic status is associated with access to quality care in Lao PDR. We utilised data from the Lao People's Voice Survey (PVS), which was designed to measure health system performance from the perspective of the population. The survey was conducted between May and August 2022. Primary outcomes of interest were having a usual source of healthcare, using a government health centre (rather than a hospital or private clinic) as the usual source for care, receiving preventive health services, experiencing unmet healthcare needs, the quality of recent healthcare visit, and confidence in accessing and affording healthcare when needed. Poverty was measured using household asset ownership. We used logit models to assess the associations between poverty and health system performance measures, and additionally assessed differences between these associations in urban vs. rural areas by interacting urban residence with poverty. Poverty was negatively associated with having a regular provider for care (adjusted odds ratio (aOR) 0.45, 95% CI 0.26-0.78), receiving preventive health services (aOR 0.54, 95% CI 0.37-0.80), and confidence in the ability to receive care (aOR 0.50, 95% CI 0.34-0.72) and afford care (aOR 0.50, 95% CI 0.34-0.73) when needed. Poverty was positively associated with using government managed health centres as a usual source or for care (aOR 2.16, 95% CI 1.35-3.48). Poverty was not significantly associated with user experience or perceived quality of care in the last visit to the health facility. No differences in the associations between poverty and access to quality care were found between rural and urban settings. The results presented in this article suggest socioeconomic disparities in health care access in Lao PDR despite major national efforts to provide universal access to care. Universal health care policies may not be reaching the poor and additional targeted efforts may be needed to meet their healthcare needs.

Effective coverage of antenatal care services in Ethiopia: a population-based cross-sectional study

BackgroundAntenatal care (ANC) is a principal component of safe motherhood and reproductive health strategies across the continuum of care. Although the coverage of antenatal care visits has increased in Ethiopia, there needs to be more evidence of effective coverage of antenatal care. The 'effective coverage' concept can pinpoint where action is required to improve high-quality coverage in Ethiopia. Effective coverage indicates a health system's performance by incorporating need, utilization, and quality into a single measurement. The concept includes the number of contacts, facility readiness, interventions received, and components of services received. This study aimed to measure effective antenatal care coverage in Ethiopia.MethodsA two-stage cluster sampling method was used and included 2714 women aged 15–49 years and 462 health facilities from six Ethiopian regions from October 2019 to January 2020. The effective coverage cascade was analyzed among the targeted women by computing the proportion who received four or more antenatal care visits where the necessary inputs were available, received iron-folate supplementation and two doses of tetanus vaccination according to process quality components of antenatal care services.ResultsOf all women, 40% (95%CI; 38, 43) had four or more visits, ranging from 3% in Afar to 74% in Addis Ababa. The overall mean health facility readiness score of the facilities serving these women was 70%, the vaccination and iron-folate supplementation coverage was 26%, and the ANC process quality was 64%. As reported by women, the least score was given to the quality component of discussing birth preparedness and complication readiness with providers. In the effective coverage cascade, the input-adjusted, intervention-adjusted, and quality-adjusted antenatal coverage estimates were 28%, 18%, and 12%, respectively.ConclusionThe overall effective ANC coverage was low, primarily due to a considerable drop in the proportion of women who completed four or more ANC visits. Improving quality of services is crucial to increase ANC up take and completion of the recommended visits along with interventions increasing women’s awareness.

Operationalising effective coverage measurement in Ethiopia: a qualitative study

Background Efforts to improve the quality of maternal, neonatal and child health services have intensified in Ethiopia. Consistent with global recommendations, measuring only coverage of these health services is no longer sufficient to assess their impact on population health. As a result, interest has grown in effective coverage measures that combine service access and service quality into one metric. However, operationalising effective coverage measurement in settings like Ethiopia requires understanding the context and feasibility with available data and resources. Thus, this study aimed to explore the demand for effective coverage measurement among Ethiopian key stakeholders and identify the actions needed to enhance its implementation in Ethiopia’s healthcare system. Methods An explorative, qualitative study design was employed, and data was collected through semi-structured interviews. Nineteen key informants from national level, three regions (Amhara, Oromia and Gambela), and one administrative city (Addis Ababa) in Ethiopia, participated in the study from March to April 2023. Key informants were identified using a snowballing approach. This study received ethical approval from the London School of Hygiene and Tropical Medicine and the Ethiopian Public Health Institute ethical review boards. Results There is a strong demand for effective coverage measurement for decision making on health care quality in the Ethiopian health sector. The demand is characterised either for individual patient care or for tracking health system performance; currently, there is limited clarity on the distinction between these two needs. A strong sentiment exists for the use of routine health information system data for this purpose, although stakeholders acknowledge the limitations of this data source. To advance the effective coverage measurement agenda in Ethiopia, respondents recommend building confidence in the quality of data sources, the need for more guidance on how to generate effective coverage measures, and the need for government leadership to coordinate these efforts. Conclusions The strong demand for effective coverage measures and the positive policy environment encourages further testing of effective coverage measurement in Ethiopia.

Concept analysis of health system resilience

BackgroundThere are several definitions of resilience in health systems, many of which share some characteristics, but no agreed-upon framework is universally accepted. Here, we review the concept of resilience, identifying its definitions, attributes, antecedents and consequences, and present the findings of a concept analysis of health system resilience.MethodsWe follow Schwarz-Barcott and Kim’s hybrid model, which consists of three phases: theoretical, fieldwork and final analysis. We identified the concept definitions, attributes, antecedents and consequences of health system resilience and constructed an evidence-informed framework on the basis of the findings of this review. We searched PubMed, PsycINFO, CINAHL Complete, EBSCOhost-Academic Search and Premier databases and downloaded identified titles and abstracts on Covidence. We screened 3357 titles and removed duplicate and ineligible records; two reviewers then screened each title, and disagreements were resolved by discussion with the third reviewer. From the 130 eligible manuscripts, we identified the definitions, attributes, antecedents and consequences using a pre-defined data extraction form.ResultsResilience antecedents are decentralization, available funds, investments and resources, staff environment and motivation, integration and networking and finally, diversification of staff. The attributes are the availability of resources and funds, adaptive capacity, transformative capacity, learning and advocacy and progressive leadership. The consequences of health system resilience are improved health system performance, a balanced governance structure, improved expenditure and financial management of health and maintenance of health services that support universal health coverage (UHC) throughout crises.ConclusionA resilient health system maintains quality healthcare through times of crisis. During the coronavirus disease 2019 (COVID-19) epidemic, several seemingly robust health systems were strained under the increased demand, and services were disrupted. As such, elements of resilience should be integrated into the functions of a health system to ensure standardized and consistent service quality and delivery. We offer a systematic, evidence-informed method for identifying the attributes of health system resilience, intending to eventually be used to develop a measuring tool to evaluate a country’s health system resilience performance.