Engagement of non-governmental organisations in moving towards universal health coverage: a scoping review

Background
Developing essential health services through non-governmental organisations (NGOs) is an important strategy for progressing towards Universal Health Coverage (UHC), especially in low- and middle-income countries. It is crucial to understand NGOs’ role in reaching UHC and the best way to engage them.

Objective
This study reviewed the role of NGOs and their engagement strategies in progress toward UHC.

Method
We systematically reviewed studies from five databases (PubMed, Web of Science (ISI), ProQuest, EMBASE and Scopus) that investigated NGOs interventions in public health-related activities. The quality of the selected studies was assessed using the mixed methods appraisal tool. PRISMA reporting guidelines were followed.

Findings
Seventy-eight studies met the eligibility criteria. NGOs main activities related to service and population coverage and used different strategies to progress towards UHC. To ensure services coverage, NGOs provided adequate and competent human resources, necessary health equipment and facilities, and provided public health and health care services strategies. To achieve population coverage, they provided services to vulnerable groups through community participation. Most studies were conducted in middle-income countries. Overall, the quality of the reported evidence was good. The main funding sources of NGOs were self-financing and grants from the government, international organisations, and donors.

Conclusion
NGOs can play a significant role in the country’s progress towards UHC along with the government and other key health players. The government should use strategies and interventions in supporting NGOs, accelerating their movement toward UHC.

The Chiranjeevi Yojana (CY) : a public-private-partnership to promote institutional births in Gujarat, India : studies of providers and users

Introduction: National, regional and local governments, particularly in lower middleincome countries, are encouraged to pursue partnerships with the pool of private providers available to them, in order to achieve the Sustainable Development Goal for maternal health. The state of Gujarat in India (population 60 million) has been a pioneer in designing a large-scale Public-Private-Partnership (PPP), the Chiranjeevi Yojana (CY), for emergency obstetric care (EmOC) for vulnerable women through qualified obstetricians. The program was instituted in 2006-07 and 865 obstetricians partnered with the state at the time.

Methodology: The papers in this thesis examine this CY program through three quantitative and one qualitative study. The studies were conducted in three districts of Gujarat state, Sabarkantha, Surendranagar and Dahod. The methods included two crosssectional surveys (i.e., a facility survey and a facility-based survey of women who gave birth) and in-depth interviews.

These four studies elucidate characteristics of CY providers and CY beneficiaries, as well as outcomes in the health system environment and the population. In order to synthesise these results coherently, I adapted the Anderson’s theoretical model to synthesise, explain and discuss the findings in my studies. In the adapted model, I present my findings in three clear and linked domains – (1) Environment – Health system and population environment in which the CY program was implemented (2) Enabler – Characteristics of the health system and population that were enabled, i.e., made eligible, as per program criteria to participate in the CY program and (3) Outcomes – in the health system and population environment, examined through (a) Health system and provider behaviours (b) Users’ behaviours (c) Health status of the mothers and (d) Financial status of households with respect to using obstetric services.

Results: The CY program influenced the health system’s environment towards increasing the availability of free CEmOC by 10 times, from 0.32 to 3.65 per 500,000 population, but actual performance of notionally free CEmOC functions was only 2 per 500,000 population (Study I). Providers’ behaviour was reflected in the en masse participation or non-participation of providers in ten out of seventeen urban centres. The facilities that participated in the CY program had a significantly higher likelihood, independently, of being general facilities (PR 1.9, 95% CI 1.3–2.9), or conducting lower proportion of caesarean births (PR 2.1, 95% CI 1.2–3.5) or having obstetricians new in private practice (PR 1.9, 95% CI 1.2–3.1) or being less expensive (PR 1.8, 95% CI 1.1–3.0) (Study II). The CY program criteria influenced the population environment by enabling mothers to become eligible for CY benefit. These mothers were significantly more likely to be vulnerable – rural, multiparous, scheduled tribe, and less educated. Users’ behaviours showed that eligible mothers had significantly less prevalence of ante-natal visits, as well as shorter hospital stay after birth. The evaluated health status showed low caesarean rates among eligible vulnerable mothers (6%) and high caesarean (40%) and episiotomy (63%) rates among ineligible mothers (Study III). The perceived health status of the population was reflected in the fact that most mothers and families were very happy with the care they had received and none reported any preferential treatment of paying mothers over CY beneficiary mothers. However, a few mothers who experienced instances of poor quality of care or rude behaviour, reflected back on their experience and still reported it as a “good (sari) delivery”. The financial status of the population showed only 15% of eligible mothers were CY beneficiaries, and only 4 % of them received a completely cashless birth. The median degree of subsidy for women in CY who birthed vaginally was 85% and by caesarean section was 71 % compared to out-of-pocket expenditure sustained by non-beneficiaries in the private health sector. Mothers without formal education were significantly less likely (OR 0.4, 95% CI 0.3–0.7) to receive CY benefit. Only having CY program knowledge (OR 4.7, 95% CI 2.6–8.4) and showing proof of poverty (OR 2.6, 95% CI 1.3–5.4) increased the likelihood of receiving the benefit. (Study III).

Discussion: Although the CY program increased the availability of free emergency obstetric care to 10 times more than the UN standards, their actual performance increased by only twice. This indicated poor management mechanisms within the state authorities. Although the CY program criteria recognised vulnerable mothers adequately accurately, their behaviours, health status and financial status showed mixed outcomes. Vulnerable populations behaviours to ensure improved maternal health and access to the CY program were varied, despite the program being in effect for seven years before our study. The health status of the vulnerable population, in terms of low caesarean rates, were below established norms in the literature, and among the non-vulnerable populations was much higher. The financial status of the eligible population was not much eased by the program since 85% of them did not receive the CY benefit. However, the highest median expenditure in our study (INR 7224) was well below the mean cost in private facilities across the nation (INR 15000) thus indicating a possible partial protection from out-of-pocket cost due to the CY program activity in the region.

Conclusion: The recently established Prime Minister’s People’s Health Program in India depends on PPPs for secondary and tertiary care all over the country. As revealed in this thesis, improved, adequate and effective health systems through PPPs requires better contract designing and managing capacities within in the state system. The health status and users’ behaviours could be assisted by the ongoing digitization of health systems such that (a) maternal health data is collected by both public and private sectors in enough detail to be able to categorise it by Robson’s criteria and thus monitor BEmOC and CEmOC performance, ante-natal visits, length of stay in hospital and other relevant variables (b) user feed-back is collected in a manner that captures actual experiences of women during birth, and that of their families during their interactions with the health system.

Understanding patient health-seeking behaviour to optimise the uptake of cataract surgery in rural Kenya, Zambia and Uganda: findings from a multisite qualitative study

Background
Cataract is a major cause of visual impairment globally, affecting 15.2 million people who are blind, and another 78.8 million who have moderate or severe visual impairment. This study was designed to explore factors that influence the uptake of surgery offered to patients with operable cataract in a free-of-charge, community-based eye health programme.

Methods
Focus group discussions and in-depth interviews were conducted with patients and healthcare providers in rural Zambia, Kenya and Uganda during 2018–2019. We identified participants using purposive sampling. Thematic analysis was conducted using a combination of an inductive and deductive team-based approach.

Results
Participants consisted of 131 healthcare providers and 294 patients. Two-thirds of patients had been operated on for cataract. Two major themes emerged: (1) surgery enablers, including a desire to regain control of their lives, the positive testimonies of others, family support, as well as free surgery, medication and food; and (2) barriers to surgery, including cultural and social factors, as well as the inadequacies of the healthcare delivery system.

Conclusions
Cultural, social and health system realities impact decisions made by patients about cataract surgery uptake. This study highlights the importance of demand segmentation and improving the quality of services, based on patients’ expectations and needs, as strategies for increasing cataract surgery uptake.

The revival of telemedicine in the age of COVID-19: Benefits and impediments for Pakistan

Dear Editor

Defined as “the use of information and telecommunication technologies (ICT) in medicine, telemedicine intends to provide appropriate healthcare at a distance, hence eliminating the need for direct contact between a patient and physician [1]. It can be classified according to the type of interaction (pre-recorded or real-time) and type of format in which information is conveyed (videos, pictures, audio, etc.) [2]. Particularly in the setting of a natural or man-made disaster, telemedicine is known to function as a key component in the emergency response, enabling people to access routine care and health support despite widespread disruptions in health services [3].

The relevance of telemedicine to our health systems is more evident than ever today as we continue to battle the COVID- 19 pandemic that has modified our lifestyle and approach to medical care. In the face of lockdowns and social distancing protocols, telemedicine technologies are being employed for online consultations, monitoring and evaluating symptoms, tracking and circumventing COVID-19 hotspots, and addressing individual concerns through chat bots [4].

Although the age of COVID-19 has significantly propelled the adoption of telemedicine services globally, its market was booming even prior to the onset of the COVID-19 pandemic, with a market size estimated around US$50 billion as of 2019, projected to increase over 9-fold in the coming decade [5]. A growing body of literature supports the role of telemedicine in providing timely, affordable, and premium quality healthcare services surpassing geographical barriers, which is especially advantageous for resource limited countries. However, while it is being integrated in the health infrastructure in USA, Europe and South East Asia with increasing momentum, its future in the developing world remains obscure [6].

Although the rate is considerably slower than developed countries, developing countries are gradually adapting to the changing times with efforts to make high-quality healthcare accessible to the masses from the comfort of their residence via digital interventions. Sub-Saharan Africa, for example, has reported a significant increase in mobile health technology [7]. The implementation of telemedicine amid a concomitant burden of communicable and non-communicable diseases in low and middle income countries (LMICs) can have consequential impacts in addressing the basic health needs of the population. By reducing travel costs and time, telemedicine enables rural and marginalized communities to access the same quality of medical resources and care as urban dwellers, and promotes health equity [6].

Health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa: a systematic review

Background
Breast cancer patients in sub-Saharan Africa experience long time intervals between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing treatment time intervals has not been widely investigated. This review aimed to identify existing information on health system factors that influence diagnostic and treatment intervals in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.

Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program Quality-Assessment Tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.

Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence diagnostic and treatment intervals in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.

Conclusion
The present review shows that diagnostic and treatment intervals among women with breast cancer in sub-Saharan Africa are influenced by many related health system factors. Policy makers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region.

Assessing barriers to quality trauma care in low and middle-income countries

Background:
Most deaths from injury occur in Low and Middle Income Countries (LMICs) with one third potentially avoidable with better health system access. This study aimed to establish consensus on the most important barriers, within a Three Delays framework, to accessing injury care in LMICs that should be considered when evaluating a health system.
Methods:
A three round electronic Delphi study was conducted with experts in LMIC health systems or injury care. In round one, participants proposed important barriers. These were synthesized into a three delays framework. In round 2 participants scored four components for each barrier. Components measured whether barriers were feasible to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability, and potentially readily changed to improve care. In round 3 participants re-scored each barrier following review of feedback from round 2. Consensus was defined for each component as ≥70% agreement or disagreement.
Results:
There were 37 eligible responses in round 1, 30 in round 2, and 27 in round 3, with 21 countries represented in all rounds. Of the twenty conceptual barriers identified, consensus was reached on all four components for 11 barriers. This included 2 barriers to seeking care, 5 barriers to reaching care and 4 barriers to receiving care. The ability to modify a barrier most frequently failed to achieve consensus.
Conclusion:
11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable. We recommend these barriers are considered in assessments of LMIC trauma systems.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola

BACKGROUND:
The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014–2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country’s maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

METHODS:
Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible.

RESULTS:
Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1–3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided.

CONCLUSIONS:
Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

Emergency Department Characteristics and Capabilities in Quito, Ecuador

Background: Emergency care is an essential part of a health system. Ecuador has recognized emergency medicine as a specialty and has two emergency medicine
residency training programs. However, little has been published about emergency department characteristics and capabilities in Ecuador.
Objective: We described the characteristics and capabilities of emergency departments (EDs) in Quito, Ecuador, in 2017, using the National Emergency Department Inventory
(NEDI) survey.
Methods: The 23-item survey included questions pertaining to ED characteristics, including visit volume, physical and administrative structure, clinical capabilities, technological resources, and consult personnel availability. This study included all EDs in Quito operating 24 hours/day, 7 days/week, and serving all patients seeking care. One representative from each ED was asked to complete the survey based on calendar year 2017.
Findings: Thirty EDs met the inclusion criteria, and 26 completed the survey (87% response). The median number of ED beds was 17 (range 2–61). Median annual visit
volume was 22,580 (range 1,680 to 129,676). All but two EDs provided care for both children and adults. Cardiac monitors were available in 88% of EDs, CT scanners in 68%,
and rooms for respiratory isolation in 31%. Most EDs could manage patients with general medicine (92%), general surgery (92%), and gynecology (88%) emergencies 24/7. Fewer were able to provide hand surgery (45%) and dental (28%) care 24/7. Typical length of stay was 1–6 hours in 65% and >6 hours in 31% of EDs. Half of EDs reported operating at full capacity and 27% reported operating over their capacity. When compared to private EDs, government EDs (public and social security) had a higher mean number of visits per year (50,090 government vs. 13,968 private, p 6 hours in government EDs vs. 86% of patient stays 1–6 hours in private EDs, p = 0.009).
Conclusions: EDs in Quito varied widely with respect to annual visit volume, the ability to treat different pathologies 24/7, and resources. Most EDs are functioning at or over capacity, and a substantial number have long lengths of stay. Further research and investment in emergency care could help increase the capacity and efficiency of EDs in Ecuador.

Health System Factors That Influence Treatment Delay in Women With Breast Cancer in Sub-saharan Africa: A Systematic Review

Abstract
Background
Breast cancer patients in sub-Saharan Africa experience long delays between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing delay in treatment has not been widely investigated. This review aimed to identify existing information on health system factors that influence treatment delays in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.
Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyse (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program quality-assessment tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.
Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence treatment delay in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.
Conclusion
The present review shows that treatment delay among women with breast cancer in sub-Saharan Africa is influenced by many related health system factors. Policymakers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region

Estimated Impact of the COVID-19 Economic Recession on Under-5 Mortality Rates for 129 Countries

Background: This study estimates the potential loss of life in children under five years old attributable to the economic recessions of 2020. Multiple prior studies have shown a strong and independent effect of GDP per capita on child mortality in developing countries after controlling for health system effects, demography, politics, environment, and literacy.

Methods: Data were retrieved from the World Bank World Development Indicators database and the United Nations World Populations Prospects estimates for the years 1990-2020 for 129 countries with GDP per capita below 12,375 US$ (defined as low, lower-middle, and upper-middle income countries; LMICs). We used a multi-level, mixed effects, multivariate model to estimate the adjusted relationship between GDP per capita and the under-5 mortality rate (U5MR) specific to each country. The model’s country-specific parameters were used to simulate the impact on U5MR due to reductions in GDP per capita of 5%, 10%, and 15%.

Findings: In a conservative scenario, a 5% reduction in GDP per capita in 2020 is estimated to cause an additional 282,996 deaths in children under 5 in one year compared to a baseline of no economic recession. Recessions at 10% and 15% lead to higher losses of under-5 lives, increasing to 585,802 and 911,026 additional deaths, respectively. We estimate that nearly half of all the potential under-5 lives lost from economic recessions in LMICs are estimated to occur in Sub-Saharan Africa.

Interpretation: In developing countries, under-5 mortality rates are closely tied to national income. We estimate that the recessions of 2020 will lead to around 300,000 deaths in the under-5 population. Our results do not take into account the irreparable effects of economic deprivation on child development. We expect to see similar trends of child mortality in the next few years in the absence of sufficient SARS-CoV-2 vaccination or herd immunity.