Strengthening Of Systems Research Articles

Tackling breast cancer where almost no care is available. A Europe-Africa partnership

Abstract Background African and European societies share similar challenges, such as the growing cancer burden, and are committed to equity and women's health, as highlighted at the 2022 EU - African Union summit. Breast cancer - the most common cancer worldwide and the leading cause of cancer death among women - disproportionately affects individuals in low-resource settings such as Malawi, where only 9.5% of patients survive beyond 18 months. Early detection and treatment could bring hope and extend the healthy lives of these women. The Akazi project, a collaboration between partners from Ireland and Malawi, is implementing a health systems platform to achieve this goal. Methods Based on the six WHO health systems building blocks framework, a mixed methods health systems capacity assessment was done in Malawi in 2022 to inform the development of a national breast cancer strategy. Results Major gaps were identified in all building blocks, critically in human resources, as no training in breast health was available in the country, and the number of trained health workers was critically low. Only five breast surgeons, five oncologists and one pathologist practice nationwide. In response, a breast health course was developed, tested and implemented with endorsement from MoH. Two cohorts of frontline workers have been trained (n = 37). Local health authorities have designed and implemented community breast care awareness activities. Conclusions This simple intervention provides the basis for critical improvements in national breast cancer services in Malawi. Akazi-funded breast health training needs to be rolled out country-wide by the Ministry of Health and significant infrastructure and human resources investments. Technical and financial support from the global North is essential to ensure progress towards Universal Health Care in Africa. Key messages • Bridging inequities in breast cancer outcomes requires systematic health systems strengthening. • EU-Africa research collaborations can fill critical knowledge gaps through systems analyses to guide national cancer control strategies.

Strengthening Public Health Wales’ Global Health offer: refreshing our International Health Strategy

Abstract Problem Public health is inherently global. Public Health Wales (PHW) is the only public health institute with an International Health Strategy, published in 2017. Due to significant global and national contextual changes such as COVID-19, a refresh was required. Description The refresh, commenced in April 2022, aimed to evaluate the impact of the existing strategy, map global health work across PHW, and deliver an inspiring yet feasible update. Data were collected using a mixed methods approach: a scoping review of global health developments since 2017; wide consultation via online surveys for internal and external stakeholders; and key informant interviews. Qualitative data determined experiences, benefits, and priorities in international health work. Thematic analysis of findings, triangulation, and synthesis informed the strategy refresh. Emerging themes and priorities were presented across PHW for feedback. Results There are over 100 active international health projects/partnerships in PHW. Engagement findings identified their benefits including contributing to global challenges, sharing learning, and health system strengthening. Facilitators of global work included access to networks; practical support; and shared priorities. Participants emphasised the strategy's role in contributing to overarching organisational priorities; national aims such as the Well-being of Future Generations Act goals; and highlighted the strategic importance of international partnerships. Lessons The strategy strengthens PHW's global health offer. There is high recognition of the value of global work but still opportunity to reap benefits such as system leadership and staff development. Access to existing networks facilitated global health activities; strengthening this is a key vehicle to maximise bidirectional learning for policy and practice innovation. The methods and engagement findings may be transferable to other national Public Health Institutes planning a global health strategy. Key messages • International health activities are diverse, accessible, and integral to public health work; with wide-ranging benefits to staff, the organisation, and partners within and beyond Welsh borders. • The organisational International Health Strategy will enable Public Health Wales to reach its overarching goals through recognition of and building on the benefits of international health work.

Enhancing global health accountability through results-oriented monitoring: EC/WHO collaboration

Abstract Issue Governments and organizations must demonstrate accountability and delivery of results. Results-Oriented Monitoring is a European Commission mechanism to enhance internal control and management. The Health System Strengthening for Universal Health Coverage program - the largest Commission grant to the World Health Organization - provides support towards achieving Universal Health Coverage through policy dialogue in 119 countries. Description We employ a Results-Oriented Monitoring review of the program conducted in October 2021- April 2022 as a case study to examine the question: what is the value of the Commission's Results-Oriented Monitoring system as a tool to enhance accountability of large Global Health interventions?. We conducted 87 face-to-face/remote interviews to engage stakeholders in assessing specific criteria such as relevance, efficiency, effectiveness, sustainability and human rights, in 12 purposively selected countries including Timor Leste, Colombia, the Democratic Republic of Congo, Zambia, Burkina Faso, Nigeria, Uzbekistan, the Philippines, Mongolia, Egypt, Jordan and Morocco. Results The Health System Strengthening for Universal Health Coverage program is a relevant intervention that responds to the needs of target groups because it is demand driven, flexible, and well-integrated within national health plans/regional frameworks. The absence of robust Monitoring and Evaluation frameworks for Universal Health Coverage at country level is a missed opportunity to pull the case for continued investment in health systems strengthening. Co-developing country level monitoring and evaluation frameworks could enhance multi-stakeholder policy dialogues anchored in the Universal Health Coverage concept. Lessons Our innovative adaptation of Results-Oriented Monitoring approaches to assess a large Global Health intervention (+100 countries) provided critical data to inform program implementation and fostered consensus building over subsequent steps. Key messages • The European commission’s results-oriented monitoring system is a valuable instrument to assess large scale global health interventions. • Co-developing monitoring and evaluation frameworks at country level could serve as a tool to facilitate multi-stakeholder policy dialogues and to track progress towards universal health coverage.

3.M. Round table: Health System Strengthening in the European Union: infrastructure, digitization, health workforce

Abstract The COVID-19 pandemic has been a severe external shock for health systems across Europe. While immediate responses included building surge capacity and rolling out mass vaccination programmes, the pandemic has highlighted longstanding problems in all health systems. Consequently, policy responses are now focussed on health system strengthening to protect health systems and health workers during future health shocks. For European Union member states, building resilience into health systems has been supported by funding for National Recovery and Resilience Plans that have focussed on investing in infrastructure and digital architecture to future-proof health systems. However, there is also an urgent need to support the health workforce and addressing shortages of health workers will require long-term solutions. This workshop will provide a platform for sharing knowledge on health system strengthening in EU countries. The objectives of the roundtable are to i) identify cross-cutting themes and approaches to health system strengthening in the EU, and ii) establish opportunities for cross-border research and learning. In the workshop we will describe the recent developments in Czechia, Denmark, France and Italy from a comparative perspective. The workshop will consist of a roundtable with four speakers, followed by a broad discussion with audience interventions to bring in the experience of other Member States. The moderated discussion will emphasise learning from other countries in the European Union and the potential for cross-border solutions. Each panel member will make a short presentation on the latest developments in Czechia, Denmark, France, and Italy, drawing on their work writing the latest Health Systems Reviews - highlighting common themes and the role of EU Recovery Funds. Health System Reviews underpin the Health Systems in Transition (HiT) series, a core part of country monitoring undertaken by the European Observatory on Health Systems and Policies. These Reviews are routinely updated and provide a systematic description of the functioning of health systems in countries as well as reform and policy initiatives in progress or under development. As these are in-depth descriptions which detail the intricacies of health systems and an assessment of their performance, they provide the ideal basis for understanding the true complexity of acute system-wide challenges countries are currently facing. Key messages • Even health systems in high-income countries need strengthening to better cope with future external shocks and building sufficient health workforce capacity is a long-term policy goal. • Drawing on evidence, the workshop will help to identify trends in how health systems are adapting and building resilience in the face of acute system-wide challenges. Speakers/Panelists Karsten Vrangbaek University of Copenhagen, Copenhagen, Denmark Zeynep Or IRDES, Paris, France Antonio Giulio de Belvis Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy Nathan Shuftan Berlin University of Technology, Berlin, Germany

Health System Strengthening Through Professional Midwives in Bangladesh: Best Practices, Challenges, and Successes.

In 2008, a cadre of professional midwives was introduced in Bangladesh. Since then, 120 midwifery educational programs have been established. There are 2,556 midwives serving at 667 government health facilities, and there are more midwives working in nongovernmental organizations and the private sector. This case study documents the process of establishing a midwifery profession with distinct midwifery expertise in Bangladesh and aims to guide other low- and middle-income countries in best practices and challenges. We describe the national administrative groundwork for the profession's launch, roll-out of an education program aligned with the International Confederation of Midwives, national deployment, enabling environments in deployment, and the professional association. Bangladesh's professional midwives' roles in humanitarian response and the COVID-19 pandemic are also discussed. The first and final authors were closely involved in supporting the government's establishment of the profession, and their direct experience is drawn upon to contextualize the topics. In addition, the authors conducted a desk review of documents that supported the profession's integration into the health system and documented its results. Both routine program data and existing research studies were reviewed. Outcomes show that midwives are deployed to 95% of government subdistrict hospitals. About 50% of these hospitals are fully staffed with 4 midwives, and within the hospitals, midwives are in charge of 90% of the maternity wards and attend 75%-85% of the births. Since the midwives' deployment, significant quality improvement for most World Health Organization indicators has been found, along with increases in service utilization. The experience of establishing a new midwifery profession in Bangladesh shows that it is possible for a lower middle-income country to introduce a globally standard midwifery profession, distinct from nursing, to improve quality sexual, reproductive, maternal, newborn, and adolescent health services in both humanitarian and development settings.

Relevance of a citizen participation technology platform to strengthen sub-Saharan health systems

A citizen participation intervention using a toll-free number combined with an interactive voice server to collect citizens’ opinions on their health systems was conducted in Burkina Faso, Benin, and the Democratic Republic of Congo between 2020 and 2021. This paper aims to assess the effectiveness, sustainability, and transferability of this m-participation intervention to the health systems strengthening. The analysis shows the relevance of the telephone to include citizens in the governance of sub-Saharan health systems. Information and communication technologies are an important support in the quest for better health democracy in sub-Saharan Africa.

An Analysis of the Social Impacts of a Health System Strengthening Program Based on Purchasing Health Services

Access to universal health coverage is a fundamental right that ensures that even the most disadvantaged receive health services without financial hardship. The Democratic Republic of Congo is among the poorest countries in the world, yet healthcare is primarily made by direct payment which renders care inaccessible for most Congolese. Between 2017 and 2021 a purchasing of health services initiative (Le Programme de Renforcement de l’Offre et Développement de l’accès aux Soins de Santé or PRO DS), was implemented in Kongo Central and Ituri with the assistance of the non-governmental organization Memisa Belgium. The program provided funding for health system strengthening that included health service delivery, workforce development, improved infrastructure, access to medicines and support for leadership and governance. This study assessed the social and health impacts of the PRO DS Memisa program using a health impact assessment focus. A documentary review was performed to ascertain relevant indicators of program effect. Supervision and management of health zones and health centers, use of health and nutritional services, the population’s nutritional health, immunization levels, reproductive and maternal health, and newborn and child health were measured using a controlled longitudinal model. Positive results were found in almost all indicators across both provinces, with a mean proportion of positive effect of 60.8% for Kongo Central, and 70.8% in Ituri. Barriers to the program’s success included the arrival of COVID-19, internal displacement of the population and resistance to change from the community. The measurable positive impacts from the PRO DS Memisa program reveal that an adequately funded multi-faceted health system strengthening program can improve access to healthcare in a low-income country such as the Democratic Republic of Congo.

The burden of non-communicable diseases among people living with HIV in Sub-Saharan Africa: a systematic review and meta-analysis

Non-communicable diseases (NCDs) are increasing among people living with HIV (PLHIV), especially in Sub-Saharan Africa (SSA). We determined the prevalence of NCDs and NCD risk factors among PLHIV in SSA to inform health policy makers. We conducted a systematic review and meta-analysis on the prevalence of NCDs and risk factors among PLHIV in SSA. We comprehensively searched PubMed/MEDLINE, Scopus, and EBSCOhost (CINAHL) electronic databases for sources published from 2010 to July 2023. We applied the random effects meta-analysis model to pool the results using STATA. The systematic review protocol was registered on PROSPERO (registration number: CRD42021258769). We included 188 studies from 21 countries in this meta-analysis. Our findings indicate pooled prevalence estimates for hypertension (20.1% [95% CI:17.5-22.7]), depression (30.4% [25.3-35.4]), diabetes (5.4% [4.4-6.4]), cervical cancer (1.5% [0.1-2.9]), chronic respiratory diseases (7.1% [4.0-10.3]), overweight/obesity (32.2% [29.7-34.7]), hypercholesterolemia (21.3% [16.6-26.0]), metabolic syndrome (23.9% [19.5-28.7]), alcohol consumption (21.3% [17.9-24.6]), and smoking (6.4% [5.2-7.7]). People living with HIV have a high prevalence of NCDs and their risk factors including hypertension, depression, overweight/obesity, hypercholesterolemia, metabolic syndrome and alcohol consumption. We recommend strengthening of health systems to allow for improved integration of NCDs and HIV services in public health facilities in SSA. NCD risk factors such as obesity, hypercholesterolemia, and alcohol consumption can be addressed through health promotion campaigns. There is a need for further research on the burden of NCDs among PLHIV in most of SSA. This study did not receive any funding.

Zoonotic Diseases in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Frequent animal–human interactions in sub-Saharan Africa (SSA) pose an increased risk for the transmission of zoonotic diseases. While there are sporadic reports of zoonotic diseases outbreaks in SSA, a synthetic overview is necessary to better understand how the sub-region is impacted by these pathologies. We conducted a systematic review of zoonotic diseases studies conducted in SSA between 2000 and 2022. Quantitative reports including case reports/series from countries spanning West, Central, East, and Southern SSA and that provided empirical data on the occurrence of zoonotic diseases in humans with documented evidence of animal origin were eligible for inclusion. The 55 eligible articles provided 82 reports of zoonotic diseases for a total of 28,934 human cases (pooled attack rate: 54.4 per 1000) and 1182 deaths (pooled fatality rate: 345.4 per 1000). Only 31 (37.8%) of the studies were conducted during ongoing outbreaks. We identified the zoonotic diseases in SSA with the highest attack rates (rickettsiosis, toxoplasmosis, Q-fever) and CFR (Marburg, Ebola, leptospirosis), which should be prioritized for surveillance and response preparedness. Addressing the threat of zoonotic diseases in SSA requires the strengthening of health systems and implementation of a one health approach. Importantly, research should be encouraged during ongoing epidemics to fortify immediate response strategies and work toward preventing future outbreaks.

Benchmarking Drug Regulatory Systems for Capacity Building: An Integrative Review of Tools, Practice, and Recommendations.

Benchmarking has been increasingly used on drug regulatory systems to achieve sustainable pharmaceutical system strengthening. This study aimed to identify the scope, tools and benefits of benchmarking regulatory capacities and the most recent development in such phenomenon. Method: This study employed an integrative and critical review of the literature and documents on benchmarking drug regulatory capacities identified from 6 databases and 5 websites of related organizations and government agencies in compliance with the Preferred Reporting Items for Systematic Review (PRISMA) guidelines. Forty-three studies and 6 documents about regulatory benchmarking published between 2005 and 2022 were included in this review. Five benchmarking assessment tools or programmes recommended or adopted by international organizations or government agencies had been identified, which collectively covered 12 major regulatory functions (4 at system level and 8 at operational level) involving 9 indicator categories and 382 sub-indicators. Benchmarking drug regulatory systems was reportedly employed at national, regional and international levels for either internal assessment (mostly on regulatory system establishment, drug review process and post marketing surveillance) or external evaluation (mostly on regulatory standards, drug review process and pharmacovigilance systems) to assess current status, monitor performance, determine major challenges and inform actions for capacity building. Priority of actions in areas such as regulatory process, resources allocation, cooperation and communication, and stakeholder engagement have been suggested for strengthening drug regulatory systems. Nevertheless, the evidence about benchmarking in optimizing regulatory capacities remained underreported. This integrative review depicted a framework for decision-makers about why and how benchmarking drug regulatory systems should be undertaken. For effective benchmarking, well-informed decisions about the goals, the scope, the choice of reference points and benchmarking tools are essential to guide the implementation strategies. Further studies about the positive effects of regulatory benchmarking are warranted to engage continuous commitment to the practice.

Are outpatient costs for hypertension and diabetes care affordable? Evidence from Western Kenya.

Diabetes and hypertension pose a significant socio-economic burden in developing countries such as Kenya, where financial risk-protection mechanisms remain inadequate. This proves to be a great barrier towards achieving universal health care in such settings unless mechanisms are put in place to ensure greater access and affordability to non-communicable disease (NCD) management services. This article aims to examine outpatient management services costs for patients with diabetes and hypertension attending public primary healthcare facilities. The study was conducted in Busia and Trans-Nzoia counties in Western Kenya in facilities supported by the PIC4C project, between August 2020 and December 2020. This cross-sectional survey included 719 adult participants. Structured interviewer-administered questionnaires were used to collect information on healthcare-seeking behaviour and associated costs. The annual direct and indirect costs borne by patients were computed by disease type and level of healthcare facility visited. Patients with both diabetes and hypertension incurred higher annual costs (KES 13 149) compared to those with either diabetes (KES 8408) or hypertension (KES 7458). Patients attending dispensaries and other public healthcare facilities incurred less direct costs compared to those who visited private clinics. Furthermore, a higher proportionate catastrophic healthcare expenditure of 41.83% was noted among uninsured patients. Despite this study being conducted in facilities that had an ongoing NCDs care project that increased access to subsidised medication, we still reported a substantially high cost of managing diabetes and hypertension among patients attending primary healthcare facilities in Western Kenya, with a greater burden among those with comorbidities.Contribution: Evidenced by the results that there is enormous financial burden borne by patients with chronic diseases such as hypertension and diabetes; we recommend that universal healthcare coverage that offers comprehensive care for NCDs be urgently rolled out alongside strengthening of lower-level public healthcare systems.

Assessing national land administration reform in Mongolia: A mixed method evaluation using bank loan and historical land administration data

This study presents the findings from a rigorous performance evaluation of a land registry strengthening project in Mongolia. The paper contributes to a small but growing body of systematic evaluations on land administration interventions—and particularly on efforts to build the national capacity of state agencies through institutional strengthening initiatives. The research highlights a methodological approach that utilizes mixed method data sources to explore outcomes in a more rigorous way and through a gendered lens. We rely on a unique set of primary quantitative data sources, including extensive land administration and bank loan data. In addition to ex- ploring outcomes associated with credit access and lending, our extensive data sources enable us to delve into transaction cost, efficiency, and volume. We complement the quantitative data with comprehensive qualitative data from interviews and focus group discussions. This study finds that the project improved Mongolia’s registration process and land administration system. There are notable increases in transaction efficiency; digitization and strengthening of information systems; and improved transparency and access to land records. In contrast, there is more limited evidence about the program’s effect on facilitating improvements in the accuracy of land records, land markets, access to credit, and gender equality in land rights. While the project helped to reduce some instances of corruption, there remain broad challenges to land governance reform.

Health Systems Strengthening: A Panacea to Improving Consumption of Public Healthcare Services in Northern Namibia: A Cross Sectional Study

The aim of the study was to assess the impact of health systems strengthening on the consumption of public healthcare services in Northern Namibia. The study assessed how the following components of health systems strengthening influence the consumption of public health care services; (1) timeliness and readiness of services rendered, (2) health workforce competence, (3) health information systems, (4) availability of essential medicines, (5) healthcare financing and lastly (6) leadership and governance. We used a quantitative descriptive cross-sectional study design. 672 respondents were identified using the purposive sampling technique and a well-structured Likert-scaled questionnaire was used for the interviews. Collected information was entered into data sets and analysis was done using Excel and Statistical Package for Social Sciences (SPSS) version 23.0 software. The results were that over 95% of the respondents strongly agreed with each of the factors assessed. Health systems strengthening remains an important factor in the delivery of health services. This was taken note of when 48% of the participants agreed that a good competent health workforce determines their choice of healthcare facility when they are not feeling well. This was further augmented when 49% of the participants agreed that healthcare financing influences people’s choice to go and seek healthcare services from government facilities. It was concluded that health systems strengthening is the cornerstone for improved consumption of public health care services in Northern Namibia. We recommend that governments should develop strong health systems at all levels of health service delivery. Keywords: Consumption, Health Systems Strengthening, Public Healthcare Services.

The IDEAL PROCESS for developing Assistive Technology policy

ABSTRACT Policy development and implementation are key to improving access to Assistive Technology (AT). In this paper, we describe a strength-based framework for doing this at national level. We used an action research approach, with the United Nations Conventions on the Rights of Persons with Disability (UNCRPD) as the primary frame of reference. Primary data were collected using the World Health Organisation’s rapid Assistive Technology Assessment (rATA). We describe the process of applying our emergent framework and how our findings support it. We identified seven guiding principles for effective policy process: Participatory, Resource aware, Outcomes focused, Collaborative, Evidence-informed, supporting good practices, and System strengthening – which can be summarized by the acronym PROCESS. Five crucial building blocks for effective AT policy development emerged: Identification of the assistive technology ecosystem, Demography of disability and AT use, Evaluation of inclusion and participation in existing policy, Alignment with UNCRPD and Sustainable Development Goals (SDGs), and Locality of implementation – which can be summarized with the acronym IDEAL. The IDEAL PROCESS incorporates key content building blocks and core process principles, constituting a systematic framework for guiding the development of context sensitive AT policy and a strength-based pathway to improving access AT.

Young Adults' Hopes Regarding Noncommunicable Disease (NCD) Prevention and Management After the SARS-CoV-2 Virus Pandemic: Reflections From the NCD Child #YouthCOVIDCHAT Campaign

PurposeThe SARS-CoV-2 virus pandemic has left a massive global death toll in its wake. Associated restrictions, precautions and lockdowns have disrupted daily routines, which has been associated with social isolation and major health implications for the world's youth. This paper shares young adults' visions for life beyond the pandemic as it relates to the prevention and management of noncommunicable diseases (NCDs). MethodsNCD Child hosted a global Twitter campaign for young adults, some of whom are living with NCDs, to express their reflections on life beyond the pandemic. Contributions were subjected to qualitative thematic analysis. Results52 responses from the campaign described six main themes: Health system strengthening; Access to care; Issues of sustainability, including the environment and the economy; Human rights, equity, and social issues; Mental health, and NCD prevention. DiscussionYoung adults expressed optimism about postpandemic life and emphasized the importance of comprehensive intersectoral approaches to create resilient health systems.

Neonatal, Infant, and Child Mortality in India: Progress and Future Directions.

In India, considerable progress has been made in reducing child mortality rates. Despite this achievement, wide disparities persist across and socio-economic strata, and persistent challenges, such as malnutrition, poor sanitation, and lack of clean water. This paper provides a comprehensive review of the state of child health in India, examining key risk factors and causes of child mortality, assessing the coverage of child health interventions, and highlighting critical public health programs and policies. The authors also discuss future directions and recommendations for bolstering ongoing efforts to improve child health. These include state- and region-specific interventions, prioritizing social determinants of health, strengthening data systems, leveraging existing programs like the National Health Mission (NHM) and Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), and the proposed Public Health Management Cadre (PHMC). The authors argue that reducing child mortality requires not only scaled-up interventions but a comprehensive approach that addresses all dimensions of health, from social determinants to system strengthening.

Promoting equitable health workforce distribution through improved migration governance: A mixed methods study of African health professionals' perceptions in Australia.

This study examined skilled health worker (SHW) migration governance in African countries and Australia, with an emphasis on areas of influence for achieving an equitable global health workforce distribution. We used a mixed-methods research design with African SHW migrants in Australia. An institutional and rights-based framing of governance guided thematic analysis of the interviews, which was mapped to survey findings from a Bayesian Exploratory Factor Analysis. The findings imply that Australian state actors enforce laws that attract SHW migrants and promote safe clinical practice, but do not adequately address their integration concerns or role in health system strengthening. Non-state actors in Australia make donations to African health institutions but rarely promote health workforce equity. African state actors respond to increased SHW migration trends by increasing health worker training and limiting migration, but they lack a comprehensive governance framework for involving citizens and engaging foreign governments. There is limited evidence of a shared community definition of SHW migration governance in many African countries. When stakeholders in both sending and receiving countries recognise the indivisibility of the rights at stake (for example, SHW rights as migrants and the right to health), support for an equity-focused SHW migration governance system may increase. Promoting these rights can result in policies that enhance health system strengthening in destination and source countries. Similarly, growing adoption of these rights in sending countries should help inspire a coordinated plan for strengthening health system and SHW migration governance.

Healthcare Bioethics: A Vital Branch of Bioethics and a New Possible Pillar for Modern Healthcare Systems Strengthening Worldwide

Globally, all people deserve the highest level of respect for their dignity, rights, and health. Bioethics has been recognized as a powerful discipline that aims to ensure such respect. Fritz Jar (1895–1953) and Van Rensselar Potter (1911–2001) will remain heroic men who ushered in the existence of the discipline of bioethics. Bioethics has been recognized as the science of survival and a bridge to the future. Thus, bioethics aims to enrich people’s wisdom. Wisdom is the knowledge of how to use knowledge for human survival and improvement in the quality of life. Worldwide, all people must widely possess such knowledge. Unfortunately, after many years of existence, implementing the principles and goals of bioethics remains centralized and confined to academic fields. Due to its centralized status, few branches of bioethics have been recognized. Besides, both pre-standard and standard practices still exist in the field of bioethics. Healthcare bioethical principles have been mentioned in numerous publications. However, healthcare bioethics has not been recognized as a vital branch of bioethics. The lack of well-established healthcare bioethics hinders strategies for eradicating many of the ephemeral and heuristic approaches that are still obstructing the achievement of optimum health status for numerous people worldwide. Integrating bioethical principles in all healthcare sectors in decentralized manners would lead to the existence of healthcare bioethics. The purpose of this manuscript is to describe healthcare bioethics as a vital branch of bioethics with respect to its description, branches, core principles, functions, system components, and pre-standard and standard practices of healthcare bioethics.

Strengthening community-based surveillance: lessons learned from the 2018–2020 Democratic Republic of Congo (DRC) Ebola outbreak

IntroductionThere has been little documentation of the large networks of community health workers that contributed to Ebola Virus Disease (EVD) surveillance during the 2018–2020 Democratic Republic of Congo (DRC) epidemic in the form of community-based surveillance (CBS). These networks, comprised entirely of local community members, were a critical and mostly unrecognized factor in ending the epidemic. Challenges with collection, compilation, and analysis of CBS data have made their contribution difficult to quantify. From November 2019 to March 2020, the DRC Ministry of Health (MoH), the World Health Organization (WHO), and Médecins Sans Frontières (MSF) worked with communities to strengthen existing EVD CBS in two key health areas in Ituri Province, DRC. We describe CBS strengthening activities, detail collaboration with communities and present results of these efforts. We also provide lessons learned to inform future outbreak responses.MethodsAs the foundation of CBS, community health workers (CHW) completed training to identify and report patients who met the EVD alert definitions. Alerts were investigated and if validated, the patient was sent for isolation and EVD testing. Community members provided early and ongoing input to the CBS system. We established a predefined ratio of community- elected CHW, allocated by population, to assure equal and adequate coverage across areas. Strong performing CHW or local leaders managed the CHWs, providing a robust supervision structure. We made additional efforts to integrate rural villages, revised tools to lighten the reporting burden and focused analysis on key indicators. Phased roll-out of activities ensured time for community discussion and approval. An integrated treatment center (ITC) combined EVD testing and isolation with free primary health care (PHC), referral services, and an ambulance network.ResultsA total of 247 CHW and supervisors completed training. CBS had a retention rate of 94.3% (n = 233) with an average daily reporting rate of 97.4% (range 75.0-100.0%). Local chiefs and community leaders participated in activities from the early stages. Community feedback, including recommendations to add additional CHW, run separate meetings in rural villages, and strengthen PHC services, improved system coverage and performance. Of 6,711 community referrals made, 98.1% (n = 6,583) were classified as alerts. Of the alerts, 97.4% (n = 6,410) were investigated and 3.0% (n = 190) were validated. Of the community referrals, 73.1% (n = 4,905) arrived for care at the ITC. The contribution of CBS to total alerts in the surveillance system increased from an average of 47.3% in the four weeks prior to system strengthening to 69.0% after. In one of the two health areas, insufficient reporting in rural villages suggested inadequate coverage, with 8.3% of the total population contributing 6.1% of alerts.DiscussionCBS demonstrated the capacity of community networks to improve early disease detection and expand access to healthcare. Early and consistent community involvement proved vital to CBS, as measured by system performance, local acceptance of EVD activities, and health service provision. The CBS system had high reporting rates, number of alerts signaled, proportion of alerts investigated, and proportion of community referrals that arrived for care. The change in contribution of CBS to total alerts may have been due in part to system strengthening, but also to the expansion in the EVD suspect case definition. Provision of PHC, referral services, and an ambulance network linked EVD response activities to the existing health system and facilitated CBS performance. More importantly, these activities provided a continuum of care that addressed community prioritized health needs. The involvement of local health promotion teams was vital to the CBS and other EVD and PHC activities. Lessons learned include the importance of early and consistent community involvement in surveillance activities and the recommendation to assure local representation in leadership positions.

Continuity of health care: measurement and application in two rural counties of Guangxi Province, China

BackgroundContinuity of care (COC) is highly regarded in health promotion and health system strengthening. However, there is a lack of multidimensional quantitative assessment of continuity, making it challenging to evaluate and compare. Our objective was to create a novel measurement for COC and apply it in two rural counties in China to assess its validity and feasibility in evaluating health system reform.MethodThis study conducted a scoping literature review on COC, examining existing frameworks and indicators. Following an online expert poll, a composite indicator was developed using the analytical hierarchy process (AHP). The measurement tool was then applied to assess the current state of COC in two rural counties in China. In addition to descriptive analysis, demographic and economic characteristics were analyzed for their association with COC scores using t-tests and multiple linear regression models.ResultsThe final COC measurement encompasses three dimensions, six sub-dimensions, and ten individual indicators, which integrated and improved the current frameworks and indicators. Relational continuity, informational continuity, and management continuity were identified as the primary dimensions of COC measurement. The COC score is 0.49 in County A and 0.41 in County B, with information continuity being the highest-scoring dimension. Notably, the disparity in continuity scores is most pronounced among individuals with varying attitudes towards health, demonstrating a positive correlation.ConclusionThe construction of the composite indicator in this study offers a scientific and effective metric for comprehensively measuring continuity of care. The empirical data analysis conducted in Western China serves as an illustrative application of the indicator, demonstrating its efficiency. The results obtained from this analysis provide a solid foundation and valuable reference for strengthening the health system.