Robust Health Systems Research Articles

Surgery, obstetrics and anaesthesia: a Cambrian explosion for global health.

Our current global health structure has not yet evolved to do what the world needs of it. Despite significant advances in some areas of public health over the past few decades, disparities in health have worsened in many areas. The historical approach of global health governance to health issues has been overwhelmingly led by vertical, single disease efforts. Yet, this structure cannot effectively implement broad-reaching international development goals set forth by the United Nations. The solution requires a rapid evolution of the present health system conceptualisation. As the Cambrian period brought skeletal infrastructure to life on our planet with vertebrates, allowing life to take on new capabilities never before witnessed on earth, so will surgery, obstetrics and anaesthesia provide the much needed healthcare delivery infrastructure that will allow health system strengthening to take global healthcare along a new path. Surgery, anaesthesia and obstetrics form the core foundation upon which the whole of global health is built and serve as the skeletal structure and indicator of robust health systems. Integrating these domains as the backbone of health system strengthening will finally allow global health to stand and support all sectors of healthcare delivery as an equal partner in health.

A Secure Robust and Privacy Enhanced Mobile Healthcare Framework

This article describes how the exponential growth of mobile applications has changed the way healthcare services function, and mobile healthcare using the Cloud is the most promising technology for healthcare industry. The mobile healthcare industry is in a continuous transition phase that requires continual innovation. There has been identified some of the challenges in the area of security protocols for mobile health systems which still need to be addressed in the future to enable cost-effective, secure and robust mobile health systems. This article addresses these challenges by proposing a secure robust and privacy-enhanced mobile healthcare framework (SRPF) by adopting a Community Cloud (CC), WPKI cryptosystems, Universal Integrated Circuit Cards (UICCs) and a Trusted Platform Module (TPM). All the security properties are provided within this framework. SRPF overcomes replay attacks, Man in the Middle (MITM) Attacks, Impersonation attacks and Multi-Protocol attacks as SRPF was successfully verified using a scyther tool and by BAN logic.

Health systems flattening – the failed promises of decentralisation in Mozambique

ABSTRACTOver the past decade, health systems strengthening (HSS) has become a global health imperative. As an answer to the influence of large-scale initiatives and NGOs, HSS represents a backlash against disease-specific projects and funding. Depicted as a positive evolution, HSS advertises local autonomy, and a turn away from donor-driven agendas. Central to this shift was the hope that ‘vertical’ funding, especially for HIV/AIDS, could be better used to build up the ‘crumbling core’ of health infrastructure in sub-Saharan Africa. As part of the change in Mozambique, HIV specialty clinics known as ‘day hospitals’ were decentralised (closed down) nationwide. Done in the name of efficiency and increased treatment coverage, the full impacts of this remain uncharted. In this article, I critique the ethical adequacy of HSS as a reorganising principle, pointing out the pursuit not of robust health systems, but of easily monitored ones instead. Occurring alongside performance-based financing, HSS invites the removal of specialty services, exposing health systems to additional shaping by outside forces. Based on ethnography with HIV support groups, I suggest HSS was an inevitable policy choice, but partially coercive. Such changes are neither counter-hegemonic nor capable of ameliorating foreign distortions in the developing world.

Better occupational health surveillance system needed in U.S., National Academies report says

The U.S. should invest in a more robust occupational health and safety surveillance system to help understand and prevent workplace injuries, illnesses, and deaths, a new National Academies of Sciences, Engineering & Medicine report says. The current system, which is fragmented among several federal agencies and states, undercounts workplace illnesses and injuries and their costs. Among the recommendations, the report suggests improved monitoring of hazards and exposures in the workplace that can lead to acute and chronic diseases. Currently, federal and state agencies collect little data about chemical and other workplace exposures, which makes risks hard to identify and prevent. The report also recommends a household survey that would fill in data gaps about injuries to self-employed, contract, and small-farm workers. “We are experiencing rapid changes in the nature of work, and with new risks developing, the nation is in dire need of a smarter surveillance system that tracks occupational

Health systems in the SDG era: consolidating and building on the gains

Global health today stands at cross-roads, with unanticipated problems challenging the unprecedented progress achieved over the last two decades. To achieve the targets established for the sustainable development goal 3 of “ensuring healthy lives and promote well-being for all at all ages”, significant resources and comprehensive health systems must play a critical and integral role. World Health Organization’s (WHO) framework for action on “Strengthening Health Systems to Improve Health Outcomes” has well identified the challenges of global health. The Global Strategy for Women's, Children's and Adolescents' Health 2015-2030 states that for women’s and children’s health investments in high-impact health interventions for RMNCH at a cost of US$5 per person per year up to 2035 in 74 high-burden countries, could yield up to nine times that value in economic and social benefits. As global health marches towards achieving universal health coverage (UHC), innovative health financing schemes and health system design will be the major determinants of equity and efficiency in resource allocation and health care delivery. Because we are now in a critical phase, it is imperative that the initial years of the SDGs receive utmost thrust from all relevant stakeholders across countries to initiate and maintain a sustained momentum for achieving the targets. The primary priority for the health-related targets’ therefore’ necessitates the need for formulation of robust, responsive and resilient health systems strategies by all the major policy makers and concerned stakeholders.

Interrelationship of canonical and non-canonical Wnt signalling pathways in chronic metabolic diseases.

Chronic diseases account for approximately 45% of all deaths in developed countries and are particularly prevalent in countries with the most sophisticated and robust public health systems. Chronic metabolic diseases, specifically lifestyle-related diseases pertaining to diet and exercise, continue to be difficult to treat clinically. The most prevalent of these chronic metabolic diseases include obesity, diabetes, non-alcoholic fatty liver disease, chronic kidney disease and cardiovascular disease and will be the focus of this review. Wnt proteins are highly conserved glycoproteins best known for their role in development and homeostasis of tissues. Given the importance of Wnt signalling in homeostasis, aberrant Wnt signalling likely regulates metabolic processes and may contribute to the development of chronic metabolic diseases. Expression of Wnt proteins and dysfunctional Wnt signalling has been reported in multiple chronic diseases. It is interesting to speculate about an interrelationship between the Wnt signalling pathways as a potential pathological mechanism in chronic metabolic diseases. The aim of this review is to summarize reported findings on the contrasting roles of Wnt signalling in lifestyle-related chronic metabolic diseases; specifically, the contribution of Wnt signalling to lipid accumulation, fibrosis and chronic low-grade inflammation.

Health system strengthening: prospects and threats for its sustainability on the global health policy agenda

In 2013, Hafner and Shiffman applied Kingdon's public policy process model to explain the emergence of global attention to health system strengthening (HSS). They questioned, however, HSS's sustainability on the global health policy agenda, citing various concerns. Guided by the Grindle and Thomas interactive model of policy implementation, we advance and elaborate a proposition: a confluence of developments will contribute to maintaining HSS's prominent place on the agenda until at least 2030. Those developments include (1) technical, managerial, financial, and political responses to unpredictable public health crises that imperil the routine functioning of health systems, such as the 2014-2015 Ebola virus disease (Ebola) epidemic in West Africa; (2) similar responses to non-crisis situations requiring fully engaged, robust health systems, such as the pursuit of the new Sustainable Development Goal for health (SDG3); and (3) increased availability of new knowledge about system change at macro, meso, and micro levels and its effects on people's health and well-being. To gauge the accuracy of our proposition, we carried out a speculative assessment of credible threats to our premise by discussing all of the Hafner-Shiffman concerns. We conclude that (1) the components of our proposition and other forces that have the potential to promote continuing attention to HSS are of sufficient strength to counteract these concerns, and (2) prospective monitoring of HSS agenda status and further research on agenda sustainability can increase confidence in our threat assessment.

Applying a New Framework for Public Health Systems Recovery following Emergencies and Disasters: The Example of Haiti following a Major Earthquake and Cholera Outbreak.

.Emergencies can often directly impact health systems of an affected region or country, especially in resource-constrained areas. Health system recovery following an emergency is a complex and dynamic process. Health system recovery efforts have often been structured around the World Health Organization’s health systems building blocks as demonstrated by the Post-Disaster Needs Assessment. Although this structure is valuable and well known, it can overlook the intricacies of public health systems. We retrospectively examine public health systems recovery, a subset of the larger health system, following the 2010 Haiti earthquake and cholera outbreak, through the lens of the 10 essential public health services. This framework illustrates the comprehensive nature of and helps categorize the activities necessary for a well-functioning public health system and can complement other assessments. Outlining the features of a public health system for recovery in structured manner can also help lay the foundation for sustainable long-term development leading to a more robust and resilient health system.

\u2018I stayed with my illness\u2019: a grounded theory study of health seeking behaviour and treatment pathways of patients with obstetric fistula in Kenya

BackgroundObstetric fistula classic symptoms of faecal and urinary incontinence cause women to live with social stigma, isolation, psychological trauma and lose their source of livelihoods. There is a paucity of studies on the health seeking behaviour trajectories of women with fistula illness although women live with the illness for decades before surgery. We set out to establish the complete picture of women’s health seeking behaviour using qualitative research. We sought to answer the question: what patterns of health seeking do women with obstetric fistula display in their quest for healing?MethodsWe used grounded theory methodology to analyse data from narratives of women during inpatient stay after fistula surgery in 3 hospitals in Kenya. Emergent themes contributed to generation of substantive theory and a conceptual framework on the health seeking behaviour of fistula patients.ResultsWe recruited 121 participants aged 17 to 62 years whose treatment pathways are presented. Participants delayed health seeking, living with fistula illness after their first encounter with unresponsive hospitals. The health seeking trajectory is characterized by long episodes of staying home with illness for decades and consulting multiple actors. Staying with fistula illness entailed health seeking through seven key actions of staying home, trying home remedies, consulting with private health care providers, Non-Governmental organisations, prayer, traditional medicine and formal hospitals and clinics. Long treatment trajectories at hospital resulted from multiple hospital visits and surgeries. Seeking treatment at hospital is the most popular step for most women after recognizing fistula symptoms.ConclusionsWe conclude that the formal health system is not responsive to women’s needs during fistula illness. Women suffer an illness with a chronic trajectory and seek alternative forms of care that are not ideally placed to treat fistula illness. The results suggest that a robust health system be provided with expertise and facilities to treat obstetric fistula to shorten women’s treatment pathways.

Considerations for developing chronic care system for traumatic brain injury based on comparisons of cancer survivorship and diabetes management care

Experts in traumatic brain injury (TBI) rehabilitation recently proposed the framing of TBI as a chronic disease rather than a discrete event. Within the framework of the Chronic Care Model (CCM), a systematic comparison of three diseases – cancer survivorship, diabetes management and TBI chronic care – was conducted regarding chronic needs and the management of those needs. In addition, comparisons of these conditions require comparative evaluations of disease management characteristics and the survivor concept. The analysis found diabetes is more established within the CCM, where care is integrated across specialists and primary care providers. No single comparison provides a full analogue for understanding the chronic care health delivery system for TBI, indicating the need for a separate model to address needs and resources for TBI survivors. The findings from this research can provide practitioners with a context to develop a robust continued care health system for TBI.Practitioner Summary: We examine development of a chronic care system for traumatic brain injury. We conducted a systematic comparison of Chronic Care Model elements of decision and information support. Development of capabilities using a benchmark of diabetes care, with additional insights from cancer care, provides insights for implementing TBI chronic care systems.

From the Memphis Model to the North Carolina Way: Lessons Learned from Emerging Health System and Faith Community Partnerships.

National health care policy has encouraged health systems to develop community partnerships designed to decrease costs and readmissions, particularly for underserved populations. This commentary describes and compares the Congregational Health Network's Memphis Model to early local efforts at clinical-faith community partnerships in North Carolina, which we call "The North Carolina Way." Necessary components for building robust health system and congregational partnerships to address social determinants of health and impact health care utilization include partnership growth, allocation of health system resources, community trust, and time.

Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: applying a structural equation model

BackgroundSouth Africa faces a complex dual burden of chronic communicable and non-communicable diseases (NCDs). In response, the Integrated Chronic Disease Management (ICDM) model was initiated in primary health care (PHC) facilities in 2011 to leverage the HIV/ART programme to scale-up services for NCDs, achieve optimal patient health outcomes and improve the quality of medical care. However, little is known about the quality of care in the ICDM model. The objectives of this study were to: i) assess patients’ and operational managers’ satisfaction with the dimensions of ICDM services; and ii) evaluate the quality of care in the ICDM model using Avedis Donabedian’s theory of relationships between structure (resources), process (clinical activities) and outcome (desired result of healthcare) constructs as a measure of quality of care.MethodsA cross-sectional study was conducted in 2013 in seven PHC facilities in the Bushbuckridge municipality of Mpumalanga Province, north-east South Africa - an area underpinned by a robust Health and Demographic Surveillance System (HDSS). The patient satisfaction questionnaire (PSQ-18), with measures reflecting structure/process/outcome (SPO) constructs, was adapted and administered to 435 chronic disease patients and the operational managers of all seven PHC facilities. The adapted questionnaire contained 17 dimensions of care, including eight dimensions identified as priority areas in the ICDM model - critical drugs, equipment, referral, defaulter tracing, prepacking of medicines, clinic appointments, waiting time, and coherence. A structural equation model was fit to operationalise Donabedian’s theory, using unidirectional, mediation, and reciprocal pathways.ResultsThe mediation pathway showed that the relationships between structure, process and outcome represented quality systems in the ICDM model. Structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Of the 17 dimensions of care in the ICDM model, three structure (equipment, critical drugs, accessibility), three process (professionalism, friendliness and attendance to patients) and three outcome (competence, confidence and coherence) dimensions reflected their intended constructs.ConclusionOf the priority dimensions, referrals, defaulter tracing, prepacking of medicines, appointments, and patient waiting time did not reflect their intended constructs. Donabedian’s theoretical framework can be used to provide evidence of quality systems in the ICDM model.

Our Shared Vulnerability to Dangerous Pathogens.

The international community vastly underestimates the risk and scale of our shared vulnerability to fast moving pathogens. Ranging from SARS and novel influenzas to Ebola and Zika, the world seems to be caught off guard, despite the regularity of global health threats historically. More importantly, when governments and international institutions underestimate the threat, they also underinvest in preparedness. Failure to prepare has deep costs in human lives and economic productivity. Here, I offer a pathway to preparedness for, and rapid response to, infectious disease threats: robust and resilient national health systems; strong institutions capable of leading, particularly the World Health Organization; and investments in research and development. Overall, the world needs a strong system of laws and governance, ranging from the International Health Regulations through to norms of transparency and accountability. To secure our common future, the world needs sustained investment and leadership. I propose a 'security dividend', both financial and institutional, to remake the global health security system.

Screening-detected rheumatic heart disease can progress to severe disease

ObjectivesEchocardiography is a sensitive test for rheumatic heart disease (RHD) screening; however the natural history of RHD detected on screening has not been established. We aimed to evaluate the progression...

Protecting human security: proposals for the G7 Ise-Shima Summit in Japan.

In today's highly globalised world, protecting human security is a core challenge for political leaders who are simultaneously dealing with terrorism, refugee and migration crises, disease epidemics, and climate change. Promoting universal health coverage (UHC) will help prevent another disease outbreak similar to the recent Ebola outbreak in west Africa, and create robust health systems, capable of withstanding future shocks. Robust health systems, in turn, are the prerequisites for achieving UHC. We propose three areas for global health action by the G7 countries at their meeting in Japan in May, 2016, to protect human security around the world: restructuring of the global health architecture so that it enables preparedness and responses to health emergencies; development of platforms to share best practices and harness shared learning about the resilience and sustainability of health systems; and strengthening of coordination and financing for research and development and system innovations for global health security. Rather than creating new funding or organisations, global leaders should reorganise current financing structures and institutions so that they work more effectively and efficiently. By making smart investments, countries will improve their capacity to monitor, track, review, and assess health system performance and accountability, and thereby be better prepared for future global health shocks.

Development assistance for health: past trends, associations, and the future of international financial flows for health

Disbursements of development assistance for health (DAH) have risen substantially during the past several decades. More recently, the international community's attention has turned to other international challenges, introducing uncertainty about the future of disbursements for DAH. We collected audited budget statements, annual reports, and project-level records from the main international agencies that disbursed DAH from 1990 to the end of 2015. We standardised and combined records to provide a comprehensive set of annual disbursements. We tracked each dollar of DAH back to the source and forward to the recipient. We removed transfers between agencies to avoid double-counting and adjusted for inflation. We classified assistance into nine primary health focus areas: HIV/AIDS, tuberculosis, malaria, maternal health, newborn and child health, other infectious diseases, non-communicable diseases, Ebola, and sector-wide approaches and health system strengthening. For our statistical analysis, we grouped these health focus areas into two categories: MDG-related focus areas (HIV/AIDS, tuberculosis, malaria, child and newborn health, and maternal health) and non-MDG-related focus areas (other infectious diseases, non-communicable diseases, sector-wide approaches, and other). We used linear regression to test for structural shifts in disbursement patterns at the onset of the Millennium Development Goals (MDGs; ie, from 2000) and the global financial crisis (impact estimated to occur in 2010). We built on past trends and associations with an ensemble model to estimate DAH through the end of 2040. In 2015, US$36·4 billion of DAH was disbursed, marking the fifth consecutive year of little change in the amount of resources provided by global health development partners. Between 2000 and 2009, DAH increased at 11·3% per year, whereas between 2010 and 2015, annual growth was just 1·2%. In 2015, 29·7% of DAH was for HIV/AIDS, 17·9% was for child and newborn health, and 9·8% was for maternal health. Linear regression identifies three distinct periods of growth in DAH. Between 2000 and 2009, MDG-related DAH increased by $290·4 million (95% uncertainty interval [UI] 174·3 million to 406·5 million) per year. These increases were significantly greater than were increases in non-MDG DAH during the same period (p=0·009), and were also significantly greater than increases in the previous period (p<0·0001). Between 2000 and 2009, growth in DAH was highest for HIV/AIDS, malaria, and tuberculosis. Since 2010, DAH for maternal health and newborn and child health has continued to climb, although DAH for HIV/AIDS and most other health focus areas has remained flat or decreased. Our estimates of future DAH based on past trends and associations present a wide range of potential futures, although our mean estimate of $64·1 billion (95% UI $30·4 billion to $161·8 billion) shows an increase between now and 2040, although with a large uncertainty interval. Our results provide evidence of two substantial shifts in DAH growth during the past 26 years. DAH disbursements increased faster in the first decade of the 2000s than in the 1990s, but DAH associated with the MDGs increased the most out of all focus areas. Since 2010, limited growth has characterised DAH and we expect this pattern to persist. Despite the fact that DAH is still growing, albeit minimally, DAH is shifting among the major health focus areas, with relatively little growth for HIV/AIDS, malaria, and tuberculosis. These changes in the growth and focus of DAH will have critical effects on health services in some low-income countries. Coordination and collaboration between donors and domestic governments is more important than ever because they have a great opportunity and responsibility to ensure robust health systems and service provision for those most in need. Bill & Melinda Gates Foundation.

Global Neurosurgery: The Unmet Need

Globally, the lack of access to basic surgical care causes 3times as much deaths as HIV/AIDS, tuberculosis, and malaria combined. The magnitude of this unmet need has been described recently, and the numbers are startling. Major shifts in global health agenda have highlighted access to essential and emergency surgery as a high priority. A broad examination of the current global neurosurgical efforts to improve access has revealed some strengths, particularly in the realm of training; however, the demand grossly outstrips the supply; most people in low-income countries do not have access to basic surgical care, either due to lack of availability or affordability. Projects that help create a robust and resilient health system within low- and middle-income countries require urgent implementation. In this context, concurrent scale-up of human resources, investments in capacity building, local data collection, and analysis for accurate assessment are essential. In addition, through process of collaboration and consensus building within the neurosurgical community, a unified voice of neurosurgery is necessary to effectively advocate for all those who need neurosurgical care wherever, whenever.

Health managers' views on the status of national and decentralized health systems for child and adolescent mental health in Uganda: a qualitative study.

BackgroundRobust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15–30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective.MethodsSeven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes.ResultsEleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning.ConclusionManagers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent.

Psychosis, Socioeconomic Disadvantage, and Health Service Use in South Australia: Findings from the Second Australian National Survey of Psychosis.

The association between mental illness and poor physical health and socioeconomic outcomes has been well established. In the twenty-first century, the challenge of how mental illnesses, such as psychosis, are managed in the provision of public health services remains complex. Developing effective clinical mental health support and interventions for individuals requires a coordinated and robust mental health system supported by social as well as health policy that places a priority on addressing socioeconomic disadvantage in mental health cohorts. This paper, thus, examines the complex relationship between socioeconomic disadvantage, family/social supports, physical health, and health service utilization in a community sample of 402 participants diagnosed with psychosis. The paper utilizes quantitative data collected from the 2010 Survey of High Impact Psychosis research project conducted in a socioeconomically disadvantaged region of Adelaide, SA, Australia. Participants (42% female) provided information about socioeconomic status, education, employment, physical health, contact with family and friends, and health service utilization. The paper highlights that socioeconomic disadvantage is related to increased self-reported use of emergency departments, decreased use of general practitioners for mental health reasons, higher body mass index, less family contact, and less social support. In particular, the paper explores the multifaceted relationship between socioeconomic disadvantage and poor health confronting individuals with psychosis, highlighting the complex link between socioeconomic disadvantage and poor health. It emphasizes that mental health service usage for those with higher levels of socioeconomic disadvantage differs from those experiencing lower levels of socioeconomic disadvantage. The paper also stresses that the development of health policy and practice that seeks to redress the socioeconomic and health inequalities created by this disadvantage be an important focus for mental health services. Such health policy would provide accessible treatment programs and linked pathways to illness recovery and diminish the pressure on the delivery of health services. Consequently, the development of policy and practice that seeks to redress the socioeconomic and health inequalities created by disadvantage should be an important focus for the improvement of mental health services.

Why a renewed focus on regional governance is needed post-2015.

Why a renewed focus on regional governance is needed post-2015.