Governance arrangements for health systems in low-income countries: an overview of systematic reviews

Herrera, Cristian A; Ciapponi, Agustín; Bastías, Gabriel; Lewin, Simon; Martí, Sebastián García; Okwundu, Charles I; Opiyo, Newton; Oxman, Andrew D; Pantoja, Tomás; Paulsen, Elizabeth; Peñaloza, Blanca; Rada, Gabriel; Wiysonge, Charles Shey

doi:10.1002/14651858.cd011085

Cited by 12 publications

(11 citation statements)

References 11 publications

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“…Our finding that out of pocket healthcare expenditure of $30 versus $5 was independently associated with increased odds of being in the lowest versus combined moderate and highest access tertiles is consistent with evidence from a number of recent studies (34)(35)(36)(37). In particular, poor financial protection in low resources settings is attributable to inadequate funding, fragmentation of healthcare resources and inadequate health insurance coverage (32).…”

Section: Discussionsupporting

confidence: 90%

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Otieno

Wambiya

Mohamed

et al. 2020

Preprint

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Background: Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage (UHC) policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. Methods: The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recoded into tertiles with categories labeled as poor, moderate and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios and 95 percent confident intervals were used to interpret the strength of associations. Results : The odds of being in the lowest versus combined moderate and highest access tertile were significantly higher for female than male-headed households (AOR 1.91 [95% CI 1.03-3.54]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥$30 had significantly lower odds of being in the lowest versus combined moderate and highest access tertile compared to those spending ≤ $5 quarterly (AOR 0.33 [95% CI 0.50-1.90]; p< .001). Households that sought care from private facilities had significantly higher odds of being in the lowest versus combined moderate and highest access compared to the public facilities (AOR 3.77 [95% CI 2.16-6.56]; p < .05). Conclusion : In Nairobi slums in Kenya, living in a female-headed household and seeking care from private facilities are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize the regulation of private health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare. Keywords: Access to primary healthcare, Universal health coverage, Urban slums, Penchansky and Thomas’s model.

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Section: Discussionsupporting

confidence: 90%

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Otieno

Wambiya

Mohamed

et al. 2020

Preprint

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“…27 From our example of neurosurgical service delivery, the undersupply and depletion of relevant medical supplies such as aneurysm clips, arterial line, bone ap implants, and other surgical implements highlight the ine ciencies inherent in the procurement processes and supply chain management of government-funded centers of any health system. 28,29,30 Improving systemslevel governance 31 and nancial arrangements 32 by streamlining how common neurosurgical supplies are purchased might improve access to care, and in turn health outcomes. 11 Given that hemorrhagic stroke, including SAH, is one of the leading causes of mortality in the country, 27 it becomes necessary to make essential neurosurgical care as one of the priorities for long-term capital expenditures and investments by the governing health sector.…”

Section: Late Timing Of Surgical Clipping-a Symptom Of Systemic Problemsmentioning

confidence: 99%

Predictors of poor outcome from aneurysmal subarachnoid hemorrhage and an exploratory analysis into the causes of delayed neurosurgical clipping at a major public hospital in the Philippines

Ferraris¹,

Golidtum²,

Palabyab³

et al. 2021

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Objective:The provision of neurosurgical care for patients with aneurysmal subarachnoid hemorrhage (SAH) is beset with particular challenges in low- to middle-income countries (LMICs) like the Philippines. In this study located in a low-resource setting, we identify the factors that contribute to unfavorable outcomes of dependency and death. Methods:The authors retrospectively reviewed 106 patients who underwent surgery for aneurysmal subarachnoid hemorrhage in a single institution from January 2016 to September 2018. Data were obtained on exposure variables comprising patient demographics, clinical features, perioperative management, and complications and other interventions; while outcomes on discharge were investigated using the modified Rankin scale (mRS). Descriptive statistics and multivariate logistic regression analyses were done. Root cause analysis was done to identify the causes of delay.Results:The percentage of patients who had unfavorable outcome (mRS ≥ 3) was 29.2%. The timing of surgery—whether early (<3 days), intermediate (3-10 days), or late (>10 days)—was not found to be significantly associated with dependency or mortality. On multiple logistic regression, the factors associated with unfavorable outcome were: intraoperative rupture (OR 23.98, 95%CI 3.56–161.33, p=0.001), vasospasm (OR 12.47, 95%CI 3.01–51.57, p<0.001), and a high Hunt & Hess grade (OR 5.96, 95%CI 1.47–24.18, p=0.012). Intraoperative rupture and vasospasm were further found to be independent predictors of mortality. Many causes of delay were identified in terms of patient-, provider-, and health system-levels. These constitute as barriers to timely care and also contribute to the gap in quality and efficiency of neurosurgical treatment situated in low-resource settings in LMICs.Conclusion:The identified predictors of poor outcomes, as well as the causes delays in neurosurgical treatment, pose as significant challenges to the care of socioeconomically-disadvantaged SAH patients. When considering the solutions to these challenges, the broader environment of practice ought to be taken into account.

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“…The worse outcomes appear to be explained not only by patient factors but also by the perioperative care systems situated in a given hospital or country. The level of functionality of a country's health system -which depends on economic infrastructure [11], public policy [12,13], responsive governance [14] and effective nancing [15] arrangements-can in turn mitigate barriers and increase access to neurosurgical care. In this respect, the Global Surgery indicators can become useful in assessing and providing insight into the effectiveness and responsiveness of the surgical system in a neurosurgical center of a given country.…”

Section: Outcome Disparities Borne From Country Of Origin and Social Determinantsmentioning

confidence: 99%

“…Policies that increase government expenditure on health appear to improve the composite metric that re ects nation-level performance of a health system [22,34]. Advocacy for more strategic policies and investments that address social determinants of health can strengthen governance and nancing arrangements [14,15]. These in turn help to re-shape more responsive and equitable health and surgical systems, as certain strategies can be undertaken to reduce variation in the use of surgery [40].…”

Section: Policy Work and Resource Management Can Be The Way Forwardmentioning

confidence: 99%

Global Surgery indicators and pediatric hydrocephalus: a multicenter cross-country comparative study building the case for health systems strengthening

Ferraris

Palabyab

Kim

et al. 2021

Preprint

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Purpose: The aim of this study is to compare specific three-institution, cross-country data that are relevant to the Global Surgery indicators and the functioning of health systems. Methods: We retrospectively reviewed clinical and socioeconomic characteristics of pediatric patients who underwent CSF diversion surgery for hydrocephalus in three different centers: University of Tsukuba Hospital in Ibaraki, Japan (HIC), Jose R. Reyes Memorial Medical Center in Manila, Philippines (LMIC), and the Federal Neurosurgical Center in Novosibirsk, Russia (UMIC). The outcomes of interest were timing of CSF diversion surgery and mortality. Statistical tests included descriptive statistics, Cox proportional hazards model, and logistic regression. Nation-level data were also obtained to provide the relevant socioeconomic contexts in discussing the results. Results: In total, 159 children were included—13 from Japan, 99 from the Philippines, and 47 from the Russian Federation. The median time to surgery at the specific neurosurgical centers were 6 days in the Philippines and 1 day in both Japan and Russia. For the cohort from the Philippines, non-poor patients were more likely to receive CSF diversion surgery at an earlier time (HR=4.74, 95%CI 2.34–9.61, p<0.001). In the same center, those with infantile or post-hemorrhagic hydrocephalus (HR=3.72, 95%CI 1.70–8.15, p=0.001) were more likely to receive CSF diversion earlier compared to those with congenital hydrocephalus, and those with post-infectious (HR=0.39, 95%CI 0.22–0.70, p=0.002) or myelomeningocele-associated hydrocephalus (HR=0.46, 95%CI 0.22–0.95, p=0.037) were less likely to undergo surgery at an earlier time. For Russia, older patients were more likely to receive or require early CSF diversion (HR=1.07, 95%CI 1.01–1.14, p=0.035). EVD insertion was found to be associated with mortality (cOR 14.45, 95% CI 1.28–162.97, p = 0.031). Conclusion: In this study, Filipino children underwent late time-interval of CSF diversion surgery and had mortality differences compared to their Japanese and Russian counterparts. These disparities may reflect on the functioning of the respective country’s health systems.

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Governance arrangements for health systems in low-income countries: an overview of systematic reviews

Cited by 12 publications

References 11 publications

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya

Predictors of poor outcome from aneurysmal subarachnoid hemorrhage and an exploratory analysis into the causes of delayed neurosurgical clipping at a major public hospital in the Philippines

Global Surgery indicators and pediatric hydrocephalus: a multicenter cross-country comparative study building the case for health systems strengthening

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