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Palliative Care in Rwanda: Aiming for Universal Access

Jue, 10/08/2017 - 20:42
Publication date: Available online 10 August 2017
Source:Journal of Pain and Symptom Management

Author(s): Eric L. Krakauer, Marie-Aimee Muhimpundu, Diane Mukasahaha, Jean-Claude Tayari, Christian Ntizimira, Blaise Uhagaze, Théodosie Mugwaneza, Aimable Ruzima, Egide Mpanumusingo, Magnus Gasana, Vincent Karamuka, Jean-Luc Nkurikiyimfura, Paul Park, Peter Barebwanuwe, Neo Tapela, Shekinah N. Elmore, Gene Bukhman, Mhoira Leng, Liz Grant, Agnes Binagwaho, Richard Sezibera

In 2011, Rwanda’s Ministry of Health (MoH) set a goal of universal access to palliative care by 2020. Toward this audacious egalitarian and humanitarian goal, the MoH worked with partners to develop palliative care policies and a strategic plan, secure adequate supplies of opioid for the country, initiate palliative care training programs, and begin studying a model for integrating coordinated palliative care into the public healthcare system at all levels. It also initiated training of a new cadre of home-based care practitioners (HBCPs) to provide palliative care in the home. Based on these developments, the goal appears within reach.





Categorías: Investigaciones

Second-line antiretroviral therapy: so much to be done

Sáb, 05/08/2017 - 19:08
Publication date: Available online 4 August 2017
Source:The Lancet HIV

Author(s): Yibeltal Assefa, Charles F Gilks







Categorías: Investigaciones

Bibliometric Review: Identifying Evolving and Emergent Regulatory Trends

Sáb, 29/07/2017 - 17:33
Publication date: July 2017
Source:Journal of Nursing Regulation, Volume 8, Issue 2, Supplement

Author(s): David Benton







Categorías: Investigaciones

Cervical cancer control in HIV-infected women: Past, present and future

Vie, 21/07/2017 - 15:41
Publication date: Available online 21 July 2017
Source:Gynecologic Oncology Reports

Author(s): Rahel Ghebre, Surbhi Grover, Melody J. Xu, Linus T. Chuang, Hannah Simonds

Since the initial recognition of acquired immunodeficiency syndrome (AIDS) in 1981, an increased burden of cervical cancer was identified among human immunodeficiency virus (HIV)-positive women. Introduction of antiretroviral therapy (ART) decreased risks of opportunistic infections and improved overall survival. HIV-infected women are living longer. Introduction of the human papillomavirus (HPV) vaccine, cervical cancer screening and early diagnosis provide opportunities to reduce cervical cancer associated mortality. In line with 2030 Sustainable Development Goals to reduce mortality from non-communicable diseases, increased efforts need to focus on high burden countries within sub-Saharan Africa (SSA). Despite limitations of resources in SSA, opportunities exist to improve cancer control. This article reviews advancements in cervical cancer control in HIV-positive women.





Categorías: Investigaciones

Health Policy in Times of Austerity—A Conceptual Framework for Evaluating Effects of Policy on Efficiency and Equity Illustrated with Examples from Europe since 2008

Jue, 20/07/2017 - 15:26
Publication date: Available online 19 July 2017
Source:Health Policy

Author(s): Martin Wenzl, Huseyin Naci, Elias Mossialos

The objective of this paper is to provide a framework for evaluation of changes in health policy against overarching health system goals. We propose a categorisation of policies into seven distinct health system domains. We then develop existing analytical concepts of insurance coverage and cost-effectiveness further to evaluate the effects of policies in each domain on equity and efficiency. The framework is illustrated with likely effects of policy changes implemented in a sample of European countries since 2008. Our illustrative analysis suggests that cost containment has been the main focus and that countries have implemented a mix of measures that are efficient or efficiency neutral. Similarly, policies are likely to have mixed effects on equity. Additional user charges were a common theme but these were frequently accompanied by additional exemptions, making their likely effects on equity difficult to evaluate. We provide a framework for future, and more detailed, evaluations of changes in health policy.





Categorías: Investigaciones

Can adverse effects of excessive vitamin D supplementation occur without developing hypervitaminosis D?

Jue, 20/07/2017 - 15:26
Publication date: Available online 19 July 2017
Source:The Journal of Steroid Biochemistry and Molecular Biology

Author(s): Mohammed S. Razzaque

Vitamin D is a fat-soluble hormone that has endocrine, paracrine and autocrine functions. Consumption of vitamin D-supplemented food & drugs have increased significantly in the last couple of decades due to campaign and awareness programs. Despite such wide use of artificial vitamin D supplements, serum levels of 25 hydroxyvitamin D [25(OH)D] does not always reflect the amount of uptake. In contrast to the safe sunlight exposure, prolonged and disproportionate consumption of vitamin D supplements may lead to vitamin D intoxication, even without developing hypervitaminosis D. One of the reasons why vitamin D supplementation is believed to be safe is, it rarely raises serum vitamin D levels to the toxic range even after repeated intravenous ingestion of extremely high doses of synthetic vitamin D analogs. However, prolonged consumption of vitamin D supplementation may induce hypercalcemia, hypercalciuria and hyperphosphatemia, which are considered to be the initial signs of vitamin D intoxication. It is likely that calcium and phosphorus dysregulation, induced by exogenous vitamin D supplementation, may lead to tissue and organ damages, even without developing hypervitaminosis D. It is needed to be emphasized that, because of tight homeostatic control of calcium and phosphorus, when hypercalcemia and/or hyperphosphatemia is apparent following vitamin D supplementation, the process of tissue and/or organ damage might already have been started.





Categorías: Investigaciones

Financing transformative health systems towards achievement of the health Sustainable Development Goals: a model for projected resource needs in 67 low-income and middle-income countries

Lun, 17/07/2017 - 14:41
Publication date: Available online 17 July 2017
Source:The Lancet Global Health

Author(s): Karin Stenberg, Odd Hanssen, Tessa Tan-Torres Edejer, Melanie Bertram, Callum Brindley, Andreia Meshreky, James E Rosen, John Stover, Paul Verboom, Rachel Sanders, Agnès Soucat

Background The ambitious development agenda of the Sustainable Development Goals (SDGs) requires substantial investments across several sectors, including for SDG 3 (healthy lives and wellbeing). No estimates of the additional resources needed to strengthen comprehensive health service delivery towards the attainment of SDG 3 and universal health coverage in low-income and middle-income countries have been published. Methods We developed a framework for health systems strengthening, within which population-level and individual-level health service coverage is gradually scaled up over time. We developed projections for 67 low-income and middle-income countries from 2016 to 2030, representing 95% of the total population in low-income and middle-income countries. We considered four service delivery platforms, and modelled two scenarios with differing levels of ambition: a progress scenario, in which countries' advancement towards global targets is constrained by their health system's assumed absorptive capacity, and an ambitious scenario, in which most countries attain the global targets. We estimated the associated costs and health effects, including reduced prevalence of illness, lives saved, and increases in life expectancy. We projected available funding by country and year, taking into account economic growth and anticipated allocation towards the health sector, to allow for an analysis of affordability and financial sustainability. Findings We estimate that an additional $274 billion spending on health is needed per year by 2030 to make progress towards the SDG 3 targets (progress scenario), whereas US$371 billion would be needed to reach health system targets in the ambitious scenario—the equivalent of an additional $41 (range 15–102) or $58 (22–167) per person, respectively, by the final years of scale-up. In the ambitious scenario, total health-care spending would increase to a population-weighted mean of $271 per person (range 74–984) across country contexts, and the share of gross domestic product spent on health would increase to a mean of 7·5% (2·1–20·5). Around 75% of costs are for health systems, with health workforce and infrastructure (including medical equipment) as the main cost drivers. Despite projected increases in health spending, a financing gap of $20–54 billion per year is projected. Should funds be made available and used as planned, the ambitious scenario would save 97 million lives and significantly increase life expectancy by 3·1–8·4 years, depending on the country profile. Interpretation All countries will need to strengthen investments in health systems to expand service provision in order to reach SDG 3 health targets, but even the poorest can reach some level of universality. In view of anticipated resource constraints, each country will need to prioritise equitably, plan strategically, and cost realistically its own path towards SDG 3 and universal health coverage. Funding WHO.





Categorías: Investigaciones

A comprehensive assessment of breast and cervical cancer control infrastructure in Zambia

Mar, 11/07/2017 - 13:19
Publication date: Available online 11 July 2017
Source:Journal of Cancer Policy

Author(s): Carla Chibwesha, Leeya F. Pinder, Agnes Musonda, Kombatende Sikombe, Jane Matambo, Allen C. Bateman, Claire-Helene Mershon, Mulindi Mwanahamuntu, Sharon Kapambwe, Kennedy Lishimpi, Groesbeck P. Parham

Introduction: By 2030 cancer will kill one million Africans each year. Women will bear the heaviest burden, as cancers of the breast and cervix are the most common malignancies and causes of cancer-related death in the African region. National-level data that map the status of women’s cancer control services are needed to inform strategies for implementing platforms for the early detection and treatment of these “priority” cancers. Methods: Using mixed-methods, we assessed available services for breast and cervical cancer detection and treatment at all provincial hospitals, the national referral hospital, and the national cancer treatment center in Zambia. Results: A system for cervical cancer prevention using visual inspection with acetic acid (VIA) and ablation/excision of precancerous lesions has been established at the provincial level. The potential for mammography, clinical breast examination, diagnostic ultrasound and biopsy exist at the provincial level, albeit on a much smaller scale. Breast wedge resections and mastectomy can be performed in provinces where general surgeons are located; however, breast conserving and reconstructive surgery are not available. Invasive cancers are generally referred to University Teaching Hospital in Lusaka, where services for radiation, chemotherapy and hormonal therapy are available but overburdened. Pathology services nationwide are woefully inadequate. Discussion: The assessment revealed a critical need for centrally coordinated, but decentralized, public service platforms for women’s cancer control. Efforts are underway, through multiple stakeholders, to implement recommendations related to training healthcare workers who can provide advanced diagnostic and therapeutic services, improving pathology services, and innovative financing for these initiatives.





Categorías: Investigaciones

How do nurse practitioners work in primary health care settings? A scoping review

Jue, 29/06/2017 - 09:17
Publication date: Available online 28 June 2017
Source:International Journal of Nursing Studies

Author(s): Julian Grant, Lauren Lines, Philip Darbyshire, Yvonne Parry

Objectives This scoping review explores the work of nurse practitioners in primary health care settings in developed countries and critiques their contribution to improved health outcomes. Design A scoping review design was employed and included development of a research question, identification of potentially relevant studies, selection of relevant studies, charting data, collating, summarising and reporting findings. An additional step was added to evaluate the methodological rigor of each study. Data Data sources included literature identified by a search of electronic databases conducted in September 2015 (CINAHL, Informit, Web of Science, Scopus and Medline) and repeated in July 2016. Additional studies were located through hand searching and authors’ knowledge of other relevant studies. Results 74 articles from eight countries were identified, with the majority emanating from the United States of America. Nurse practitioners working in communities provided care mostly in primary care centres (n=42), but also in community centres (n=6), outpatient departments (n=6), homes (n=5), schools (n=3), child abuse clinics (n=1), via communication technologies (n=6), and through combined face-to-face and communication technologies (n=5). The scope of nurse practitioner work varied on a continuum from being targeted towards a specific disease process or managing individual health and wellbeing needs in a holistic manner. Enhanced skills included co-ordination, collaboration, education, counselling, connecting clients with services and advocacy. Measures used to evaluate outcomes varied widely from physiological data (n=25), hospital admissions (n=10), use of health services (n=15), self-reported health (n=13), behavioural change (n=14), patient satisfaction (n=17), cost savings (n=3) and mortality/morbidity (n=5). Conclusions The majority of nurse practitioners working in community settings did so within a selective model of primary health care with some examples of nurse practitioners contributing to comprehensive models of primary health care. Nurse practitioners predominantly worked with populations defined by an illness with structured protocols for curative and rehabilitative care. Nurse practitioner work that also incorporated promotive activities targeted improving social determinants of health for people rendered vulnerable due to ethnicity, Aboriginal identity, socioeconomic disadvantage, remote location, gender and aging. Interventions were at individual and community levels with outcomes including increased access to care, cost savings and salutogenic characteristics of empowerment for social change.





Categorías: Investigaciones

What are Chinese nurses’ experiences whilst working overseas? A narrative scoping review

Vie, 23/06/2017 - 08:20
Publication date: Available online 22 June 2017
Source:International Journal of Nursing Studies

Author(s): Yaping Zhong, Lisa McKenna, Beverley Copnell

Background Transnational nurse migration has become an apparent attribute of the global nurse shortage and it is foreseeable that China will play an increasingly significant role in nurse exports. These nurses have unique cultural and professional needs throughout their journey of migration and in-depth analysis of Chinese migrant nurses’ experiences is urgently required to manage and empower an ethnically diverse workforce. Objective To synthesise Chinese migrant nurses’ experiences by examining the findings of existing studies. Design Scoping review methods incorporating narrative synthesis were conducted. Method Arksey and O’Malley’s five-stage scoping review framework was utilised to identify Chinese migrant nurses’ experiences. 13 databases were searched, and 5009 articles were retrieved. After screening the titles and abstracts, 169 articles were assessed in full text for eligibility, and finally 22 articles plus 2 manually included ones, representing 19 discrete studies, were further analysed and synthesised with a three-step narrative synthesis. Results 13 qualitative studies, 5 quantitative studies and 1 mixed- methods study met inclusion criteria. Two main themes were identified. “Contexts and migration” comprised three subthemes: perceptions of nursing, original culture and nursing differences. “The self and migration” included four subthemes: initiating, transition, reality and future. Conclusion This scoping review revealed the literature on Chinese migrant nurses and provided insight into their stories and circumstances. There were external factors which affected Chinese nurses’ interpretations and choices. Throughout their migration journeys, they encountered various challenges and also successes. They responded with positive or negative behavioural and psychosocial changes.





Categorías: Investigaciones

The SELFIE Framework for Integrated Care for Multi-Morbidity: development and description

Mié, 21/06/2017 - 08:08
Publication date: Available online 20 June 2017
Source:Health Policy

Author(s): Fenna R.M. Leijten, Verena Struckmann, Ewout van Ginneken, Thomas Czypionka, Markus Kraus, Miriam Reiss, Apostolos Tsiachristas, Melinde Boland, Antoinette de Bont, Roland Bal, Reinhard Busse, Maureen Rutten-van Mölken

Background The rise of multi-morbidity constitutes a serious challenge in health and social care organisation that requires a shift from disease- towards person-centred integrated care. The aim of the current study was to develop a conceptual framework that can aid the development, implementation, description, and evaluation of integrated care programmes for multi-morbidity. Methods A scoping review and expert discussions were used to identify and structure concepts for integrated care for multi-morbidity. A search of scientific and grey literature was conducted. Discussion meetings were organised within the SELFIE research project with representatives of five stakeholder groups (5Ps): patients, partners, professionals, payers, and policy makers. Results In the scientific literature 11,641 publications were identified, 92 were included for data extraction. A draft framework was constructed that was adapted after discussion with SELFIE partners from 8 EU countries and 5P representatives. The core of the framework is the holistic understanding of the person with multi-morbidity in his or her environment. Around the core, concepts were grouped into adapted WHO components of health systems: service delivery, leadership & governance, workforce, financing, technologies & medical products, and information & research. Within each component micro, meso, and macro levels are distinguished. Conclusion The framework structures relevant concepts in integrated care for multi-morbidity and can be applied by different stakeholders to guide development, implementation, description, and evaluation.





Categorías: Investigaciones

An International Collaboration for the Training of Medical Chief Residents in Rwanda

Mar, 13/06/2017 - 06:50
Publication date: March–April 2017
Source:Annals of Global Health, Volume 83, Issue 2

Author(s): Tim Walker, Vincent Dusabejambo, Janet J. Ho, Claudine Karigire, Bradley Richards, Andre N. Sofair

Background The year-long position of chief medical resident is a time-honored tradition in the United States that serves to provide the trainee with an opportunity to gain further skills as a clinician, leader, teacher, liaison, and administrator. However, in most training programs in the developing world, this role does not exist. Objectives We sought to develop a collaborative program to train the first medical chief residents for the University of Rwanda and to assess the impact of the new chief residency on residency training, using questionnaires and qualitative interviews with Rwandan faculty, chief residents, and residents. Methods The educational context and the process leading up to the appointment of Rwandan chief residents, including selection, job description, and necessary training (in the United States and Rwanda), are described. One year after implementation, we used a parallel, mixed methods approach to evaluate the new chief medical resident program through resident surveys as well as semistructured interviews with key informants, including site chief residents, chief residents, and faculty. We also observed chief residents and site chief residents at work and convened focus groups with postgraduate residents to yield additional qualitative information. Results Rwandan faculty and residents generally felt that the new position had improved the educational and administrative structure of the teaching program while providing a training ground for future academicians. Conclusions A collaborative training program between developing and developed world academic institutions provides an efficient model for the development of a new chief residency program in the developing world.





Categorías: Investigaciones

Recurrent failings of medical humanitarianism: intractable, ignored, or just exaggerated?

Vie, 09/06/2017 - 06:13
Publication date: Available online 8 June 2017
Source:The Lancet

Author(s): Sandro Colombo, Enrico Pavignani

Humanitarian health workers operate in dangerous and uncertain contexts, in which mistakes and failures are common, often have severe consequences, and are regularly repeated, despite being documented by many reviews. This Series paper aims to discuss the failures of medical humanitarianism. We describe why some of these recurrent failings, which are often not identified until much later, seem intractable: they are so entrenched in humanitarian action that they cannot be addressed by simple technical fixes. We argue that relief health-care interventions should be contextualised. Perhaps medical humanitarianism deserves a better reputation than the one at times tarnished by unfair criticism, resulting from inapplicable guiding principles and unrealistic expectations. The present situation is not conducive to radical reforms of humanitarian medicine; complex crises multiply and no political, diplomatic, or military solutions are in sight. Relief agencies have to compete for financial resources that do not increase at the same pace as health needs. Avoiding the repetition of failures requires recognising previous mistakes and addressing them through different policies by donors, stronger documentation and analysis of humanitarian programmes and interventions, increased professionalisation, improved, opportunistic relationships with the media, and better ways of working together with local health stakeholders and through indigenous institutions.





Categorías: Investigaciones

Cervical cancer screening at a tertiary care center in Rwanda

Sáb, 27/05/2017 - 04:33
Publication date: Available online 26 May 2017
Source:Gynecologic Oncology Reports

Author(s): George Ruzigana, Lisa Bazzet-Matabele, Stephen Rulisa, Allison N. Martin, Rahel Ghebre

In limited resource settings such as Rwanda, visual inspection with acetic acid (VIA) is the primary model for cervical cancer screening. The objective of this study was to describe clinical characteristics and outcomes for women presenting for cervical cancer screening. A prospective, observational study was conducted between September 2015 and February 2016 at Kigali University Teaching Hospital (CHUK). Women referred to the VIA clinic were enrolled and completed a semi-structured questionnaire. During the six-month study period, 150 women were enrolled and evaluated with VIA followed by colposcopy directed biopsy for VIA positive. The median age was 42years (IQR 36–49). Only 20 (13.3%) asymptomatic women presented for screening exam, whereas 126 (84%) were symptomatic. Among symptomatic patients, more than one-third had never had a speculum exam prior to referral (n=43). Twenty-two (14.7%) women were VIA positive, and 8 (5.3%) had lesions suspicious for cancer, while 120 (80%) were found to be VIA negative. Among women undergoing biopsy (n=30), 11 were normal (36.7%), 5 cases showed CIN 1 (16.6%), 4 cases showed CIN 2 (13.3%), 2 cases showed CIN 3 (6.7%) and 8 were confirmed cervical cancers (26.7%). In Rwanda, VIA is the current method for cervical cancer screening. In this study, few asymptomatic patients presented for cervical cancer screening. Increasing knowledge about cervical cancer screening and expanding access are key elements to improving cervical cancer control in Rwanda.





Categorías: Investigaciones

Explaining regional variation in home care use by demand and supply variables

Sáb, 27/05/2017 - 04:33
Publication date: Available online 26 May 2017
Source:Health Policy

Author(s): Olivier van Noort, Fredo Schotanus, Joris van der Klundert, Jan Telgen

In the Netherlands, home care services like district nursing and personal assistance are provided by private service provider organizations and covered by private health insurance companies which bear legal responsibility for purchasing these services. To improve value for money, their procurement increasingly replaces fee-for-service payments with population based budgets. Setting appropriate population budgets requires adaptation to the legitimate needs of the population, whereas historical costs are likely to be influenced by supply factors as well, not all of which are necessarily legitimate. Our purpose is to explain home care costs in terms of demand and supply factors. This allows for adjusting historical cost patterns when setting population based budgets. Using expenses claims of 60 Dutch municipalities, we analyze eight demand variables and five supply variables with a multiple regression model to explain variance in the number of clients per inhabitant, costs per client and costs per inhabitant. Our models explain 69% of variation in the number of clients per inhabitant, 28% of costs per client and 56% of costs per inhabitant using demand factors. Moreover, we find that supply factors explain an additional 17 to 23% of variation. Predictors of higher utilization are home care organizations that are integrated with intramural nursing homes, higher competition levels among home care organizations and the availability of complementary services.





Categorías: Investigaciones

SY-10 Status of SRHR in Africa - Examining Commitments, Policy and Actions (Africa Symposium by AFSHR & ACCPD)

Sáb, 27/05/2017 - 04:33
Publication date: May 2017
Source:The Journal of Sexual Medicine, Volume 14, Issue 5, Supplement 4









Categorías: Investigaciones

Education, Practice, and Competency Gaps of Anesthetists in Ethiopia: Task Analysis

Vie, 26/05/2017 - 04:25
Publication date: Available online 25 May 2017
Source:Journal of PeriAnesthesia Nursing

Author(s): Sharon Kibwana, Mihereteab Teshome, Yohannes Molla, Catherine Carr, Leulayehu Akalu, Jos van Roosmalen, Jelle Stekelenburg

Purpose This study assessed the needs and gaps in the education, practice and competencies of anesthetists in Ethiopia. Design A cross-sectional study design was used. Methods A questionnaire consisting of 74 tasks was completed by 137 anesthetists who had been practicing for 6 months to 5 years. Findings Over half of the respondents rated 72.9% of the tasks as being highly critical to patient outcomes, and reported that they performed 70.2% of all tasks at a high frequency. More than a quarter of respondents reported that they performed 15 of the tasks at a low frequency. Nine of the tasks rated as being highly critical were not learned during pre-service education by more than one-quarter of study participants, and over 10% of respondents reported that they were unable to perform five of the highly critical tasks. Conclusions Anesthetists rated themselves as being adequately prepared to perform a majority of the tasks in their scope of practice.





Categorías: Investigaciones

Performance of the Antiretroviral Treatment Program in Ethiopia, 2005-2015: strengths and weaknesses toward ending AIDS

Sáb, 20/05/2017 - 03:27
Publication date: Available online 19 May 2017
Source:International Journal of Infectious Diseases

Author(s): Yibeltal Assefa, Charles F. Gilks, Lutgarde Lynen, Owain Williams, Peter S. Hill, Taye Tolera, Alankar Malvia, Wim Van Damme

Background Ethiopia is one of the countries which has scaled up antiretroviral treatment (ART) over the past decade. This study reviews the performance of the ART program in Ethiopia during the past decade, and identifies successes and weaknesses toward ending AIDS in the country. Methods A review and synthesis of data was conducted using multiple data sources: reports from all health facilities in Ethiopia to the Federal Ministry of Health, HIV/AIDS estimates and projections, and retrospective cohort and cross-sectional studies conducted between 2005/6 and 2014/15. Findings The ART program has been successful over several critical areas: (1) ART coverage improved from 4% to 54%; (2) the median CD4 count/mm3 at the time of ART initiation increased from 125 in 2005/6 to 231 in 2012/13; (3) retention in care after 12 months on ART has increased from 82% to 92%. In spite of these successes, important challenges also remain: (1) ART coverage is not equitable: among regions (5.6%-93%), between children (25%) and adults (60%), and between female (54%) and male patients (69%); (2) retention in care is variable among regions (83%-94%); and, (3) the shift to second-line ART is slow and low (0·58%). Interpretation The findings suggest that the ART program should sustain the successes and reflect on the shortcomings toward the goal of ending AIDS. It is important to capitalize on and calibrate the interventions and approaches utilized to scale up ART in the past. Analysis of the treatment cascade, in order to pinpoint the gaps and identify appropriate solutions, is commendable in this regard.





Categorías: Investigaciones

Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015

Vie, 19/05/2017 - 03:16
Publication date: Available online 18 May 2017
Source:The Lancet

Author(s): GBD 2015 Healthcare Access and Quality CollaboratorsRyan MBarberNancyFullmanReed J DSorensenThomasBollykyMartinMcKeeEllenNolteAmanuel AlemuAbajobirKalkidan HassenAbateCristianaAbbafatiKaja MAbbasFoadAbd-AllahAbdishakur MAbdulleAhmed AbdulahiAbdurahmanSemaw FeredeAberaBijuAbrahamGirmatsion FissehaAbrehaKelemeworkAdaneAdemola LukmanAdelekanIfedayo Morayo OAdetifaAshkanAfshinArnavAgarwalSanjay KumarAgarwalSunilkumarAgarwalAnuragAgrawalAliasghar AhmadKiadaliriAlirezaAhmadiKedir YimamAhmedMuktar BeshirAhmedRufus OlusolaAkinyemiTomi FAkinyemijuNadiaAkseerZiyadAl-AlyKhurshidAlamNooreAlamSayed SaidulAlamZewdie AderawAlemuKefyalew AddisAleneLilyAlexanderRaghibAliSyed DanishAliRezaAlizadeh-NavaeiAla'aAlkerwiFrançoisAllaPeterAllebeckChristineAllenRajaaAl-RaddadiUbaiAlsharifKhalid AAltirkawiElena AlvarezMartinNelsonAlvis-GuzmanAzmeraw TAmareErfanAminiWalidAmmarJoshuAmo-AdjeiYaw AmpemAmoakoBenjamin OAndersonSofiaAndroudiHosseinAnsariMustafa GeletoAnshaCarl Abelardo 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SUchenduKingsley NUkwajaEduardo AUndurragaChigozie JesseUnekeOlalekan AUthmanJob F Mvan BovenRitaVan DingenenSantoshVarugheseTommiVasankariNarayanaswamyVenketasubramanianFrancesco SViolanteSergey KVladimirovVasiliy VictorovichVlassovStein EmilVollsetTheoVosJoseph AWagnerTolassaWakayoStephen GWallerJudd LWalsonHaidongWangYuan-PangWangDavid AWatkinsElisabeteWeiderpassRobert GWeintraubChi-PangWenAndreaWerdeckerJoshuaWesanaRonnyWestermanHarvey AWhitefordJames DWilkinsonCharles SheyWiysongeBelete GetahunWoldeyesCharles D AWolfeSunghoWonAbdulhalikWorkichoShimelash BitewWorkieMamoWubshetDenisXavierGelinXuAjit KumarYadavMohsenYaghoubiBereketYakobLijing LYanYuichiroYanoMehdiYaseriHassen HamidYimamPaulYipNaohiroYonemotoSeok-JunYoonMustafa ZYounisChuanhuaYuZoubidaZaidiMaysaaEl Sayed ZakiCarlosZambrana-TorrelioTomasZapataZerihun MenlkalewZenebeSanjayZodpeyLeoZoecklerLiesl JoannaZuhlkeChristopher J LMurray

Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Funding Bill & Melinda Gates Foundation.





Categorías: Investigaciones

Processes and experiences of Portugal’s international recruitment scheme of Colombian physicians: did it work?

Jue, 18/05/2017 - 03:03
Publication date: Available online 17 May 2017
Source:Health Policy

Author(s): Erika Masanet

The Portuguese Ministry of Health performed five international recruitment rounds of Latin American physicians due to the need for physicians in certain geographic areas of the country and in some specialties, as a temporary solution to shortages. Among these recruitments is that of Colombian physicians in 2011 that was the largest of the five groups. This paper presents an evaluation of the international recruitment procedure of Colombian physicians based on the criteria of procedural outcomes and health system outcomes. The methodology used is qualitative, based on semi-structured interviews with key informants and Colombian physicians recruited in Portugal and also on documentary analysis of secondary sources. International recruitment of Colombian physicians coincided with a period of political change and severe economic crisis in Portugal that caused some problems in the course of this recruitment, mainly family reunification in the later group of Colombian physicians and non-compliance of the salary originally agreed upon. Furthermore, due to the continuous resignations of Colombian physicians throughout the 3-year contract, procedural outcomes and health system outcomes of this international recruitment were not fulfilled and therefore the expected results to meet the temporary needs for medical personnel in some areas of the country were not accomplished.





Categorías: Investigaciones

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