Networks of care to strengthen primary healthcare in resource constrained settings

Networks of care are a promising way to provide support and resources for isolated primary care workers and deserve more research, argue Enoch Oti Agyekum and colleague

Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap

Large disparities in maternal and neonatal mortality exist between low- and high-income countries. Mothers and babies continue to die at high rates in many countries despite substantial increases in facility birth. One reason for this may be the current design of health systems in most low-income countries where, unlike in high-income countries, a substantial proportion of births occur in primary care facilities that cannot offer definitive care for complications. We argue that the current inequity in care for childbirth is a global double standard that limits progress on maternal and newborn survival. We propose that health systems need to be redesigned to shift all deliveries to hospitals or other advanced care facilities to bring care in line with global best practice. Health system redesign will require investing in high-quality hospitals with excellent midwifery and obstetric care, boosting quality of primary care clinics for antenatal, postnatal, and newborn care, decreasing access and financial barriers, and mobilizing populations to demand high-quality care. Redesign is a structural reform that is contingent on political leadership that envisions a health system designed to deliver high-quality, respectful care to all women giving birth. Getting redesign right will require focused investments, local design and adaptation, and robust evaluation

Decolonisation and quality of care.

Delivering high quality healthcare for all requires recognising the legacies of colonialism in driving power asymmetries and producing inequitable health outcomes both within and between countries say Bernice Yanful and colleagues

PHC Progression Model: A novel mixed-methods tool for measuring primary health care system capacity

High-performing primary health care (PHC) is essential for achieving universal health coverage. However, in many countries, PHC is weak and unable to deliver on its potential. Improvement is often limited by a lack of actionable data to inform policies and set priorities. To address this gap, the Primary Health Care Performance Initiative (PHCPI) was formed to strengthen measurement of PHC in low-income and middle-income countries in order to accelerate improvement. PHCPI´s Vital Signs Profile was designed to provide a comprehensive snapshot of the performance of a country´s PHC system, yet quantitative information about PHC systems´ capacity to deliver high-quality, effective care was limited by the scarcity of existing data sources and metrics. To systematically measure the capacity of PHC systems, PHCPI developed the PHC Progression Model, a rubric-based mixed-methods assessment tool. The PHC Progression Model is completed through a participatory process by in-country teams and subsequently reviewed by PHCPI to validate results and ensure consistency across countries. In 2018, PHCPI partnered with five countries to pilot the tool and found that it was feasible to implement with fidelity, produced valid results, and was highly acceptable and useful to stakeholders. Pilot results showed that both the participatory assessment process and resulting findings yielded novel and actionable insights into PHC strengths and weaknesses. Based on these positive early results, PHCPI will support expansion of the PHC Progression Model to additional countries to systematically and comprehensively measure PHC system capacity in order to identify and prioritise targeted improvement efforts.Fil: Ratcliffe, Hannah L.. Brigham And Women's Hospital; Estados Unidos. Harvard T.H. Chan School of Public Health; Estados UnidosFil: Schwarz, Dan. Harvard T.H. Chan School of Public Health; Estados Unidos. Brigham And Women's Hospital; Estados UnidosFil: Hirschhorn, Lisa R.. Northwestern University; Estados UnidosFil: Cejas, Cintia. Ministerio de Desarrollo Social; Argentina. Ministerio de Salud de la Nación; ArgentinaFil: DIallo, Abdoulaye. Ministry Of Health And Social Action; SenegalFil: Garcia Elorrio, Ezequiel. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; ArgentinaFil: Fifield, Jocelyn. Brigham And Women's Hospital; Estados Unidos. Harvard T.H. Chan School of Public Health; Estados UnidosFil: Gashumba, DIane. Ministry of Health; RuandaFil: Hartshorn, Lucy. Harvard T.H. Chan School of Public Health; Estados Unidos. Brigham And Women's Hospital; Estados UnidosFil: Leydon, Nicholas. Bill And Melinda Gates Foundation; Estados UnidosFil: Mohamed, Mohamed. Ministry Of Health And Social Welfare Dar Es Salaam; TanzaniaFil: Nakamura, Yoriko. Results For Development; Estados UnidosFil: Ndiaye, Youssoupha. Ministry Of Health And Social Action; SenegalFil: Novignon, Jacob. Kwame Nkrumah University Of Science And Technology; GhanaFil: Ofosu, Anthony. Ghana Health Service; GhanaFil: Roder Dewan, Sanam. Organización de las Naciones Unidas. Unicef. Fondo de las Naciones Unidas para la Infancia; ArgentinaFil: Rwiyereka, Angelique. Global Health Issues and Solutions; Estados UnidosFil: Secci, Federica. The World Bank Group; Estados UnidosFil: Veillard, Jeremy H.. The World Bank Group; Estados UnidosFil: Bitton, Asaf. Harvard T.H. Chan School of Public Health; Estados Unidos. Brigham And Women's Hospital; Estados Unido

Decentralization and Regionalization: Redesigning Health Systems for High Quality Maternity Care Comment on "Decentralization and Regionalization of Surgical Care: A Review of Evidence for the Optimal Distribution of Surgical Services in Low- and Middle-Income Countries"

The question of how to optimally design health systems in low- and middle-income countries (LMICs) for high quality care and survival requires context-specific evidence on which level of the health system is best positioned to deliver services. Given documented poor quality of care for surgical conditions in LMICs, evidence to support intentional health system design is urgently needed. Iverson and colleagues address this very important question. This commentary explores their findings with particular attention to how they apply to maternity care. Though surgical maternity care is a common healthcare need, maternal complications are often unpredictable and require immediate surgical attention in order to avert serious morbidity or mortality. A discussion of decentralization for maternity services must grapple with this tension and differentiate between facilities that can provide emergency surgical care and those that can not.</jats:p

Improving Quality in Low- and Middle-Income Health Systems by Raising Expectations of Care

A growing body of literature shows that the quality of healthcare experienced by people in low-and middle-income countries (LMICs) is remarkably poor. Effective systemic improvement approaches that can have large-scale impact are urgently needed. Though quality improvement usually focuses on the supply of healthcare, this doctoral work explores the potential of demand-side approaches that engage populations and raise expectations of care. A thorough review of the theoretical and empirical literature on expectations of healthcare led to a new conceptual framework. This conceptual framework then drove an empirical examination of expectations of care in LMICs using the results of a 12-country internet survey. Internet users who made errors in entering webpages in 12 LMICs were sampled in August and September of 2017 using random domain intercept technology (RDITtm). A 24-question survey about experiences and perceptions of healthcare quality was administered. The survey included vignettes of hypothetical healthcare scenarios designed to describe poor quality care which were used to measure expectations of care. Descriptive statistics were calculated and a multivariable logistic regression based on the conceptual framework of expectations of care was fit to understand predictors of low expectations. A theory of change was then developed to better explore implications of translating the evidence into health system improvement strategies that raise expectations of care in LMICs. The analysis of 17,996 surveys showed that over half of respondents have low expectations of healthcare and that male gender, low education, good self-reported health status and a history of discrimination in the healthcare system are associated with these low expectations. Though the gap in expectations is large, an examination of the literature suggests that several promising intervention types do exist that may raise expectations of health care and generate demand for quality care. Raising expectations is theorized to put demand-side pressure on health systems to improve when people preferentially use higher quality options and when they directly advocate for better services. Approaches that raise expectations and generate demand for quality care warrant more attention from the global quality improvement community and should be considered when planning national health system improvement strategies.Quality of care; expectations; healthcare expectations; LMIC, patient satisfaction; quality improvement; patient engagement; patient experience