Tracer Conditions Research Articles

Investigating a novel population health management system to increase access to healthcare for children: a nested cross-sectional study within a cluster randomised controlled trial

BackgroundEarly intervention for unmet needs is essential to improve health. Clear inequalities in healthcare use and outcomes exist. The Children and Young People’s Health Partnership (CYPHP) model of care uses...

Access to and quality of elective care: a prospective cohort study using hernia surgery as a tracer condition in 83 countries

Timely and safe elective health care facilitates return to normal activities for patients and prevents emergency admissions. Surgery is a cornerstone of elective care and relies on complex pathways. This study aimed to take a whole-system approach to evaluating access to and quality of elective health care globally, using inguinal hernia as a tracer condition. This was a prospective, international, cohort study conducted between Jan 30 and May 21, 2023, in which any hospital performing inguinal hernia repairs was eligible to take part. Consecutive patients of any age undergoing primary inguinal hernia repair were included. A measurement set mapped to the attributes of WHO's Health System Building Blocks was defined to evaluate access (emergency surgery rates, bowel resection rates, and waiting times) and quality (mesh use, day-case rates, and postoperative complications). These were compared across World Bank income groups (high-income, upper-middle-income, lower-middle-income, and low-income countries), adjusted for hospital and country. Factors associated with postoperative complications were explored with a three-level multilevel logistic regression model. 18 058 patients from 640 hospitals in 83 countries were included, of whom 1287 (7·1%) underwent emergency surgery. Emergency surgery rates increased from high-income to low-income countries (6·8%, 9·7%, 11·4%, 14·2%), accompanied by an increase in bowel resection rates (1·2%, 1·4%, 2·3%, 4·2%). Overall waiting times for elective surgery were similar around the world (median 8·0 months from symptoms to surgery), largely because of delays between symptom onset and diagnosis rather than waiting for treatment. In 14 768 elective operations in adults, mesh use decreased from high-income to low-income countries (97·6%, 94·3%, 80·6%, 61·0%). In patients eligible for day-case surgery (n=12 658), day-case rates were low and variable (50·0%, 38·0%, 42·1%, 44·5%). Complications occurred in 2415 (13·4%) of 18 018 patients and were more common after emergency surgery (adjusted odds ratio 2·06, 95% CI 1·72-2·46) and bowel resection (1·85, 1·31-2·63), and less common after day-case surgery (0·39, 0·34-0·44). This study demonstrates that elective health care is essential to preventing over-reliance on emergency systems. We identified actionable targets for system strengthening: clear referral pathways and increasing mesh repair in lower-income settings, and boosting day-case surgery in all income settings. These measures might strengthen non-surgical pathways too, reducing the burden on society and health services. NIHR Global Health Research Unit on Global Surgery and Portuguese Hernia and Abdominal Wall Society (Sociedade Portuguesa de Hernia e Parede Abdominal).

Changing contexts of child health: an assessment of unmet physical, psychological and social needs of children with common chronic childhood illness

BackgroundWe assessed the biopsychosocial needs and key health drivers among children living with a common chronic illness, as baseline for a cluster randomised controlled trial of a child health system...

Evaluation of Estonia’s enhanced care management program: protocol for a cluster randomized trial

Background: Estonia’s aging population faces an increasing burden of non-communicable diseases (NCDs) and a growing population suffers with multiple chronic conditions. These changes have reduced well-being and quality of life for many older Estonians, while increasing the use of high cost specialist and emergency care. In response, the Estonia Health Insurance Fund (EHIF) is working to support primary care physicians to improve care for complex patients with multiple chronic conditions. A new EHIF program, Enhanced Care Management (ECM), trains family physicians to identify complex patients, co-develop proactive care plans with them, and conduct more active outreach and management of these patients. Methods: In this protocol we describe a randomized controlled trial, developed in partnership with EHIF, to evaluate the impact of ECM training for physicians. The RCT enrolled a randomly selected 97 family physicians out of the 786 family physicians practicing in Estonia. Among those physicians’ 6,739 ECM-eligible patients, 2,389 patients were randomly selected for enrolment into the ECM program. Results: Using administrative records, we evaluated the effects of ECM enrolment on: (1) health care utilization; (2) provider management of tracer conditions; and (3) markers of quality of care such as hospital admission for primary health care-sensitive conditions. Conclusions: This protocol presents a pre-specified analysis plan for this evaluation of Estonia’s ECM program. Trial registration: First registered with the American Economics Association, AEARCTR-0003661. Registered May 1, 2019. Retrospective secondary registration with www.clinicaltrials.gov P169891. Registered April 26, 2023.

Acceptability, Feasibility and Appropriateness of Care of Patients with Depression at Health and Wellness Centre in a District of India

Abstract Objective: To study implementation of mental health services delivery with depression as tracer condition through Health and Wellness Centres (HWCs) under Ayushman Bharat programme in India. Materials and Methods: Mixed methods approach. The outcomes of acceptability, appropriateness and feasibility were measured and analysed. Results: The study found a low level of appropriateness and a medium level of acceptability for using HWCs as a platform for the management of patients with depression. Increased availability of trained human resources, improved infrastructure and drug availability, integration with other programmes and coordination with higher centres for referral and follow-up are suggested as key interventions to enhance the appropriateness and acceptability of depression care. Conclusion: There is a need for innovative model of care that places an emphasis on the integration and implement strategies to maximise the implementation outcomes of depression care through HWCs.

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis

BackgroundPrimary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance.MethodsWe developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010–2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics.ResultsCountries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider.ConclusionsOur results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.

Effect of the Children and Young People's Health Partnership model of paediatric integrated care on health service use and child health outcomes: a pragmatic two-arm cluster randomised controlled trial.

Paediatric health systems across high-income countries are facing avoidable adverse outcomes and increasing demands and costs. The aim of this study was to compare the effect of an enhanced usual care model with that of an integrated health-care model that offers local health clinics for general paediatric problems and early intervention and care for children and young people with tracer conditions. In this pragmatic two-arm cluster randomised controlled trial, we compared the Children and Young People's Health Partnership (CYPHP) model of care versus enhanced usual care (EUC) among children registered at general practices in south London, UK. The CYPHP trial intervention was delivered between April 1, 2018, and June 30, 2021, and children younger than 16 years during the intervention period and registered at study practices on June 30, 2021, were included in the analysis. A restricted randomisation (1:1) following a computer-generated sequence was done by a masked independent statistician at the level of general practice cluster, stratified by borough (Lambeth or Southwark). Cluster allocation and data collection were masked, with unmasking of trial statisticians before analysis. The CYPHP model comprised all elements of EUC (electronic decision support, a primary care hotline, health checks, self-management support and health promotion, and resilience building and mental health first aid) plus local child health clinics delivered by paediatricians and general practitioners, and a nurse-led early intervention service for children with tracer conditions (asthma, eczema, and constipation). Primary outcomes were non-elective admissions (NELA; admissions coded as an emergency) among the whole trial population up to June 30, 2021, and paediatric quality of life (Pediatric Quality of Life Inventory [PedsQL]) among participants with tracer conditions at 6 months after recruitment. Secondary outcomes were primary and secondary care use, child mental health, parental wellbeing, standardised symptom scores for asthma, eczema, and constipation, health-care quality, and child absences from school and parent absences from work. The trial was registered on ClinicalTrials.gov, NCT03461848, and is complete. The trial was conducted between April 1, 2018, and Dec 31, 2021. In total, 23 general practice clusters, consisting of 70 practices with 97 970 registered children, were randomised to CYPHP (n=11) or EUC (n=12). We found no effect, at the population level, of CYPHP versus EUC on non-elective admissions during the intervention period (adjusted mean incidence rate ratio [IRR] 1·00 [95% CI 0·91 to 1·10], p=0·99). Among children with tracer conditions, we found no difference in paediatric quality of life (PedsQL score) at 6 months (adjusted mean difference -0·033 [95% CI -0·122 to 0·055], p=0·46). As a secondary outcome, among children with tracer conditions and requiring care, NELA rates at 12 months did not differ between the CYPHP and EUC groups (66·1 per 1000 person-years vs 75·3 per 1000 person-years; adjusted mean IRR 0·87 [0·61-1·22], p=0·42). In children requiring care, a statistically significant improvement was observed in eczema symptoms at 6 months from baseline in the CYPHP group versus the EUC group (adjusted mean difference -1·370 [-2·630 to -0·122], p=0·032). Quality of asthma care significantly improved among children in the CYPHP group compared with children in the EUC group. No significant improvement was seen for all other secondary outcomes. Although the CYPHP trial found a null effect for the primary outcomes, we found clinically important improvements in some secondary outcomes including care quality. Previous research has shown that large-scale system change requires time to observe a potential positive effect. Guy's and St Thomas Charity, the Lambeth and Southwark Clinical Commissioning Groups, and Evelina London Children's Hospital.

Challenges to implementing planning processes in Brazilian health regions.

To recognize elements that facilitated or hindered the PlanificaSUS implementation stages. A multiple case study was carried out in four pre-selected health regions in Brazil-Belo Jardim (PE), Fronteira Oeste (RS), Sul-Mato-Grossense (MT) and Valença (BA) using systemic arterial hypertension and maternal and child care as tracer conditions. Participant observation (in regional interagency commissions) and in-depth interviews with key informants from state and municipal management and primary health care and specialized outpatient care service professionals within the project were carried out in these four regions. Analysis was built according to political, technical-operational, and contextual dimensions. The political dimension evinced that the regions found the project an opportunity to articulate states and municipalities and an important political bet to build networks and lines of care but that there remained much to be faced in the disputes related to building the Unified Health System (SUS). In the technical operational dimension, it is important to consider that primary health care stimulated a culture of local planning and favored traditional tools to organize and improve it, such as organizing registrations, agendas, and demands. However, centralized training and planning-inducing processes fail to always respond to local needs and can produce barriers to implementation. It is worth considering the central and regional role of state managers in the commitment related to the project and the effect of mobilizing primary health care and expanding its power. There remains much to be faced in the disputes at stake in bullring SUS.

Toward Comprehensive Care Integration in Canada: Delphi Process Findings from Researchers, Clinicians, Patients and Decision Makers.

From a larger study examining policy and program information on how Canadian provinces integrate care services, this study aimed to create "priority lists" of 10-15 services that are "absolutely needed" for care integration. A diverse group of over 50 Canadian stakeholders participated in virtual consensus-building using the nominal group technique and a modified e-Delphi method to identify services that focused on two different groups: children and youth with high functional health needs and older adults in functional decline. Three lists - containing services, processes and infrastructure elements - emerged: one per tracer condition group and a consolidated list. The latter identified the following five services as top priority for primary care integration: mental health and addictions services; home care; transition between urgent-emergency-acute care; medication reconciliation in community pharmacies; and respite care. No single social service was a clear priority, but those that mitigate material deprivation emerged within the top 10. This humble pan-Canadian study shows that priority services in health and social services are neither well integrated nor connected to primary care. It also suggests that effective policy strategizing for primary care integration for those with complex care needs may require thinking beyond the logic of services - given their siloed organization.

Measurement of unmet healthcare needs to assess progress on universal health coverage - exploring a novel approach based on household surveys

BackgroundUniversal Health Coverage (UHC) aims to ensure universal access to quality healthcare according to health needs. The extent to which population health needs are met should be a key measure for progress on UHC. The indicators in use for measuring access mostly relate to physical accessibility or insurance coverage. Or, utilization of services is taken as indirect measure for access but it is assessed against only the perceived healthcare needs. The unperceived needs do not get taken into account. The present study was aimed at demonstrating an approach for measuring the unmet healthcare needs using household survey data as an additional measure of UHC.MethodsA household survey was conducted in Chhattisgarh state of India, covering a multi-stage sample of 3153 individuals. Healthcare need was measured in terms of perceived needs which would be self-reported and unperceived needs where clinical measurement supplemented the interview response. Estimation of unperceived healthcare needs was limited to three tracer conditions- hypertension, diabetes and depression. Multivariate analysis was conducted to find the determinants of the various measures of the perceived and unperceived needs.ResultsOf the surveyed individuals, 10.47% reported perceived healthcare needs for acute ailments in the last 15 days. 10.62% individuals self-reported suffering from chronic conditions. 12.75% of those with acute ailment and 18.40% with chronic ailments received no treatment, while 27.83% and 9.07% respectively received treatment from unqualified providers. On an average, patients with chronic ailments received only half the medication doses required annually. The latent need was very high for chronic ailments. 47.42% of individuals above 30 years age never had blood pressure measured. 95% of those identified with likelihood of depression had not sought any healthcare and they did not know they could be suffering from depression.ConclusionTo assess progress on UHC more meaningfully, better methods are needed to measure unmet healthcare needs, taking into account both the perceived and unperceived needs, as well as incomplete care and inappropriate care. Appropriately designed household surveys offer a significant potential to allow its periodic measurement. Their limitations in measuring the ‘inappropriate care’ may necessitate supplementation with qualitative methods.

Cost Effectiveness of Strategies for Caring for Critically Ill Patients with COVID-19 in Tanzania.

The resources for critical care are limited in many settings, exacerbating the significant morbidity and mortality associated with critical illness. Budget constraints can lead to choices between investing in advanced critical care (e.g. mechanical ventilators in intensive care units) or more basic critical care such as Essential Emergency and Critical Care (EECC; e.g. vital signs monitoring, oxygen therapy, and intravenous fluids). We investigated the cost effectiveness of providing EECC and advanced critical care in Tanzania in comparison with providing 'no critical care' or 'district hospital-level critical care' using coronavirus disease 2019 (COVID-19) as a tracer condition. We developed an open-source Markov model ( https://github.com/EECCnetwork/POETIC_CEA ) to estimate costs and disability-adjusted life-years (DALYs) averted, using a provider perspective, a 28-day time horizon, patient outcomes obtained from an elicitation method involving a seven-member expert group, a normative costing study, and published literature. We performed a univariate and probabilistic sensitivity analysis to assess the robustness of our results. EECC is cost effective 94% and 99% of the time when compared with no critical care (incremental cost-effectiveness ratio [ICER] $37 [-$9 to $790] per DALY averted) and district hospital-level critical care (ICER $14 [-$200 to $263] per DALY averted), respectively, relative to the lowest identified estimate of the willingness-to-pay threshold for Tanzania ($101 per DALY averted). Advanced critical care is cost effective 27% and 40% of the time, when compared with the no critical care or district hospital-level critical care scenarios, respectively. For settings where there is limited or no critical care delivery, implementation of EECC could be a highly cost-effective investment. It could reduce mortality and morbidity for critically ill COVID-19 patients, and its cost effectiveness falls within the range considered 'highly cost effective'. Further research is needed to explore the potential of EECC to generate even greater benefits and value for money when patients with diagnoses other than COVID-19 are accounted for.

Essential emergency and critical care as a health system response to critical illness and the COVID19 pandemic: what does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, effective, low-cost, life-saving care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in Tanzania and Kenya.The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.The costs per patient day of EECC is estimated to be 1 USD, 11 USD and 33 USD in Tanzania and 2 USD, 14 USD and 37 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13 USD and 294 USD in Tanzania and USD 17 USD and 345 USD in Kenya for severe and critical COVID-19 patients, respectively.EECC is a novel approach for providing the essential care to all critically ill patients. The low costs and lower tech approach inherent in delivering EECC mean that EECC could be provided to many and suggests that prioritizing EECC over ACC may be a rational approach when resources are limited.Graphical

Baseline Inappropriate Antibiotic Use in Primary Care Patients with Viral Respiratory Tract Infections with 2019 and 2020.

Context: Respiratory tract infection (RTI) is the leading cause of avoidable antimicrobial use in primary care. How the COVID-19 pandemic has impacted antibiotic prescribing practices across Canada is unknown. The purpose of this study was to examine rates of antibiotic prescribing for RTI in primary care during the first year of the pandemic (2020), compared to baseline in 2019. Study Design and Analysis: Cross sectional study. Dataset: Canadian Primary Care Sentinel Surveillance Network electronic medical record data from sites in British Columbia, Alberta, Manitoba, Ontario, Quebec, Nova Scotia and Newfoundland. Population Studied: Patients that met the case definition criteria for an RTI or a Urinary Tract Infection (UTI) in 2019, and in 2020. Outcome measures: We examined oral antibiotic prescribing for patients who were identified as having a primary care visit for RTI. The same analysis was repeated for urinary tract infection (UTI) as a tracer condition. The antibiotic use considered avoidable for RTI was defined by Choosing Wisely Canada. Results: A total of 1,692,876 patients with a valid birth year and sex and at least one visit to primary care in 2019 and 2020 were included. Patient visits for RTI decreased from 2.3% in 2019 to 1.6% in 2020 (p<.0001), as did patient visits for UTI (1.1% vs 0.7%, p<.0001). In 2019, 28.0% of patients visits for RTI were prescribed an antibiotic, and this proportion decreased significantly to 20.6% in 2020 (<.0001). The drop in antibiotic prescriptions for RTI was driven by a decrease in prescribing for common cold (13.6% vs. 11.3%, <.0001) and for acute bronchitis/asthma (15.2% vs. 7.3%, p<.0001). In comparison, antibiotic prescribing for visits related to UTI increased marginally between 2019 and 2020 (71.6% vs. 72.3%, p=0.007). Conclusions: A significant decrease in antibiotic prescribing for RTI across primary care was observed during the first year of the COVID-19 pandemic, likely related to the changes in epidemiology and care delivery models in primary care. CPCSSN can provide pan-Canadian surveillance of antibiotic prescribing practices in primary care that can be used for provider feedback and quality improvement.

Bottlenecks to child health service delivery – how can Health System Performance Assessment help?

Abstract Health System Performance Assessment (HSPA) is an established tool that can help identify issues with the way health systems work to achieve their intended goals, improve transparency and account-ability, and provide stimulus for reform. However, HSPA frameworks tend to be adult-centric and therefore not generally sensitive to child health challenges. Using a new HSPA framework for Universal Health Coverage, we show how child health tracer conditions can be used to pinpoint system under-performance and flag major bottlenecks impeding service delivery overall. Based on the HSPA framework, health system bottlenecks can be traced backwards to explore possible origins (areas to be targeted for improvement) or forwards to understand potential implications for the achievement of health system goals. The following qualitative and quantitative data are used to highlight major bottlenecks to child health service delivery: eight health system-focused child health assessments which show that one of the main bottlenecks is weak primary care coverage of sexual, reproductive, maternal, newborn, child, and adolescent health services, leading to parents bypassing PHC in favour of hospitals; results from WHO missions (e.g. in Romania and Tajikistan) showing that paediatric patients were often admitted to hospitals for treatment, even for conditions that could be safely managed in the outpatient setting; quantitative data on responsiveness, user experience, client satisfaction and people-centredness from publicly available datasets and national datasets obtained in collaboration with WHO Country Offices for national level data, to contextualize the aforementioned findings.

Rationale for integration of services for diabetes mellitus and diabetic retinopathy in Kenya

BackgroundGood diabetes mellitus (diabetes) and diabetic retinopathy (DR) management depends on the strength of the health system, prompting us to conduct a health system assessment for diabetes and DR in Kenya. We used diabetes and DR as tracer conditions to assess the strengths and weaknesses in the health system, and potential interventions to strengthen the health system. In this paper, we report on the need and relevance of integration to strengthen diabetes and DR care. This theme emerged from the health system assessment.MethodsUsing a mixed methods study design, we collected data from service providers in diabetes clinics and eye clinics in three counties, from key informants at national and county level, and from documents review.ResultsThere is interest in integration of diabetes and DR services to address discontinuity of care. We report the findings describing the context of integration, why integration is a goal and how these services can be integrated. We use the results to develop a conceptual framework for implementation.ConclusionsThe principal rationale for integrated service provision is to address service gaps and to prevent complications of diabetes and DR. The stakeholder interest and the existing infrastructure can be leveraged to improve these health outcomes.

Improving services for chronic non‐communicable diseases in Samoa: an implementation research study using the care cascade framework

ObjectiveSamoa needs to intensify the response to the growing non‐communicable disease burden. This study aimed to assess bottlenecks in the care continuum and identify possible solutions. MethodsThe mixed‐methods study used the cascade framework as an analysis tool and hypertension as a tracer condition for chronic non‐communicable diseases. Household survey data were integrated with medical record data of hypertension patients and results from focus group discussions with patients and healthcare providers. ResultsHypertension prevalence was 38.1% but only 4.7% of hypertensive individuals had controlled blood pressure. There were large gaps in the care continuum especially at screening and referral due to multiple socio‐cultural, economic and service delivery constraints. ConclusionsIn Samoa, care for chronic non‐communicable diseases is not effectively addressing patient needs. This calls for better health communication, demand creation, treatment support, nutritional interventions and health service redesign, with a focus on primary healthcare and effective patient and community engagement. Implications for public healthThe proposed actions can improve the reach, accessibility, quality and effectiveness of Samoa's chronic care services. Health system redesign is necessary to ensure continuity of care and more effective primary prevention. The findings are useful for other countries in the region facing similar challenges.

Measuring quality of pre-hospital traumatic shock care-development and validation of an instrument for resource-limited settings.

Background and AimsImproving the quality of pre‐hospital traumatic shock care, especially in low‐ and middle‐income countries, is particularly relevant to reducing the large global burden of disease from injury. What clinical interventions represent high‐quality care is an actively evolving field and often dependent on the specific injury pattern. A key component of improving the quality of care is having a consistent way to assess and measure the quality of shock care in the pre‐hospital setting. The objective of this study was to develop and validate a chart abstraction instrument to measure the quality of trauma care in a resource‐limited, pre‐hospital emergency care setting.MethodsTraumatic shock was selected as the tracer condition. The pre‐hospital quality of traumatic shock care (QTSC) instrument was developed and validated in three phases. A content development phase utilized a rapid literature review and expert consensus to yield the contents of the draft instrument. In the instrument validation phase, the QTSC instrument was created and underwent end user and content validation. A pilot‐testing phase collected user feedback and performance characteristics to iteratively refine draft versions into a final instrument. Accuracy and inter‐ and intra‐rater agreement were calculated.ResultsThe final QTSC instrument contains 10 domains of quality, each with specific criteria that determine how the domain is measured and the level of quality of care rendered. The instrument is over 90% accurate and has good inter‐ and intra‐rater reliability when used by trained pre‐hospital provider users in South Africa. Pre‐hospital provider user feedback indicates the tool is easy to learn and quick to use.ConclusionWe created and validated a novel chart abstraction instrument that can reliably and accurately measure the quality of pre‐hospital traumatic shock care. We provide a systematic methodology for developing and validating a quality of care tool for resource‐limited care settings.

Forty years after Alma-Ata: primary health-care preparedness for chronic diseases in Mozambique, Nepal and Peru

ABSTRACT Background Four decades after the Alma-Ata Declaration, strengthening primary health care (PHC) remains a priority for health systems, especially in low- and middle-income countries (LMICs). Given the prominence of chronic diseases as a global health issue, PHC must include a wide range of components in order to provide adequate care. Objective To assess PHC preparedness to provide chronic care in Mozambique, Nepal and Peru, we used, as ‘tracer conditions’, diabetes, hypertension and a country-specific neglected tropical disease with chronic sequelae in each country. Methods By implementing a health system assessment, we collected quantitative and qualitative data from primary and secondary sources, including interviews of key informants at three health-system levels (macro, meso and micro). The World Health Organization’s health-system building blocks provided the basis for content analysis. Results In total, we conducted 227 interviews. Our findings show that the ambitious policies targeting specific diseases lack the support of technical, administrative and financial resources. Data collection systems do not allow the monitoring of individual patients or provide the health system with the information it requires. Patients receive limited disease-specific information. Clinical guidelines and training are either non-existent or not adapted to local contexts. Availability of medicines and diagnostic tests at the PHC level is an issue. Although medicines available through the public health care system are affordable, some essential medicines suffer shortages or are not available to PHC providers. This need, along with a lack of clear referral procedures and available transportation, generates financial issues for individuals and affects access to health care. Conclusion PHC in these LMICs is not well prepared to provide adequate care for chronic diseases. Improving PHC to attain universal health coverage requires strengthening the identified weaknesses across health-system building blocks.

Cheaper Medicines for the Better Off? A Comparison of Medicine Prices and Client Socioeconomic Status Between Chain and Independent Retail Pharmacies in Urban India.

Background: The growth of chain pharmacies in India, and other low- and middle-income countries (LMICs), is challenging the status quo of pharmacy retail markets which have historically been dominated by independent pharmacies. This raises the question of whether such organisations will have a positive impact on affordability and access to medicines. Methods: This paper draws on a standardised patient (SP) survey to measure the prices of medicines and expenditure on consultations for two tracer conditions (suspected tuberculosis [TB] in an adult and diarrhoea in an absent child) at a random sample of 230 chain and independent pharmacies in Bengaluru. Asset data were collected from 808 exit interviews with pharmacy customers to determine socioeconomic profiles of clients. Results: Chain pharmacies were found to provide lower priced medicines for patients seeking care for diarrhoea and TB, with expenditure also lower for diarrhoea patients, compared to independent pharmacies. This was seemingly driven by lower prices rather than number of medicines dispensed or prescribing habits. Despite the availability of cheaper medicines, chains served wealthier clients, compared to independent pharmacies.Conclusion: The findings indicate the potential for chains to contribute to improving medicine affordability as they expand. However, any attempt to leverage this organisational model for public health good would need to take account of the current client-mix of these pharmacies and be accompanied by appropriate regulatory constraints in order to realise the potential benefits for poorer groups.

The choices and consequences of seeking care for chronic conditions for disadvantaged populations in Malaysia and the Philippines

Abstract Disadvantaged populations in LMICs suffering from chronic conditions are often forced to make care choices that increase the risk of receiving substandard care and facing catastrophic bills. These negative impacts widen health disparities across social, economic and urban-rural lines. This study aimed to understand the economic consequences of the choices made by those living with NCD in disadvantaged communities in Malaysia and the Philippines. Using hypertension as a tracer condition, we analysed longitudinal data from surveys of 1200 hypertensive adults from low-income communities in both countries to estimate the prevalence and drivers of catastrophic health expenditure and the coping strategies employed. Interviews and digital diary data from a sub-sample of 80 participants was analysed thematically to elicit how such choices lead to sub-optimal management of their condition. More Filipino households with at least one hypertensive adult experienced catastrophic health spending (40% threshold) than in Malaysia (14.3% vs. 0.4%). Although the average cost of clinic visits in the Philippines was much higher than what was observed in the public sector-dominated system in Malaysia, consultation fees were main drivers of costs in Malaysia, while medication costs predominated in the Philippines (accounting for 38.6% and 70.5% of typical household health expenditure respectively). In both countries, nearly all diagnosed participants were taking antihypertensive medications, however, levels of adherence varied. Participants cited the unavailability, cost and adverse effects of antihypertensives as reasons for poor adherence, delaying treatment and substituting prescriptions. Understanding the barriers faced by disadvantaged populations in LMICs and the ways that they overcome them as they seek care for a chronic disorder may challenge the assumptions of decision makers, and is crucial for designing responsive and equitable health systems that leave none behind.