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Health Policy and Planning - current issue - Recent Educational Updates

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Factors influencing the establishment of hospital accreditation programs in low- and middle-income countries: a scoping review
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Hospital accreditation programs are globally recognized as an important tool for enhancing quality and safety in health care; however, many programs in low- and middle-income countries (LMICs) are discontinued shortly after their establishment. This scoping review synthesized published evidence on factors influencing the establishment and sustainability of hospital accreditation programs in LMICs, to provide guidance to health stakeholders involved in these processes. Six databases were searched using the terms “accreditation,” “health,” “hospital,” and the country list of LMICs. Screening was undertaken collaboratively for validation. A framework to guide data extraction was developed by amalgamating eight existing classifications, theories, models, and frameworks concerning policy diffusion and implementation. The framework comprised the following domains: antecedent influences (A), contextual factors (C), establishment factors (E), standards, surveyors, stimulants (incentives), and survey-related factors (S-4S), governance (G), legislation (L), execution (implementation; E), and assessment and monitoring (AM), forming the ACES-GLEAM framework. Thirty-two sources were identified, with an increasing publication trend over time. The included studies reported upon a broad range of patterns, innovations, influencers, enablers, and barriers concerning accreditation program establishment in LMICs. Key questions emerged, including the degree of government involvement, incorporation of international standards versus development of bespoke standards, the use of local versus external surveyors, the use of financial and other incentives to promote engagement, and mandatory versus voluntary approaches of program implementation. Resource constraints were recognized as the most important barriers to sustainable establishment, while the influence of global accreditation and donor agencies were viewed as presenting both positive and negative impacts. Health stakeholders are encouraged to reflect upon and apply the ACES-GLEAM framework, incorporating the guiding principles outlined in this paper, to help establish hospital accreditation programs in LMICs in a way that facilitates sustainability and effectiveness over time.</span>


Community health worker payment processes: a qualitative assessment of experiences in two Indian states
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Community health worker (CHWs) remuneration has received some attention in terms of the design of incentives, however, there is a lack of systematic data on the processes by which CHWs are paid. We aimed to study existing payment processes including the role of digitization and its effects on CHW experiences with receiving full and timely compensation, and identify barriers and facilitators to the payment process. We studied payment processes for the Accredited Social Health Activist (ASHA) in India in two states with varying levels of performance and payment systems and conducted 53 in-depth interviews and eight focus group discussions across three categories of respondents (37 ASHA workers, 46 supervisors, and 34 managers/health system leaders). The data was coded thematically using inductive and deductive coding methods organized around five steps of the payment process: (i) recording of work, (ii) claim submission, (iii) claim verification, (iv) claim processing, and (v) payment disbursement. We observed complex sub-processes within each stage of the payment process that adversely impacted payment timelines, CHW workload, and motivation, even where digital tools provide support. Local administrative initiative and positive organizational culture overcame these challenges to standardize and simplify processes for recording work, submitting claims, and maintaining adequate funds, facilitating timely payments. Complete digitization of disbursement through the public financial management system improved timeliness, transparency, and satisfaction among CHWs compared to earlier cash and cheque-based payments. The potential digitization of service delivery records for claim submission was met with mixed perceptions among CHWs and their supervisors. Our study contributes to the body of knowledge on CHW compensation by delineating the processes by which financial incentives are paid and offering insights for low and middle-income countries to improve the efficiency of payment systems</span>


Correction to: Indonesian medical interns’ intention to practice in rural areas


Institutionalizing linkages between informal healthcare providers and the formal health system in Nigeria: what are the facilitating and constraining contextual influences?
<span class="paragraphSection"><div class="boxTitle">Abstract</div>With most households in rapidly urbanizing cities in low- and medium-income countries using private and informal providers for basic healthcare, the need to establish linkages with the formal sector is paramount in the drive for universal health coverage. Successful and effective linkage of informal healthcare providers to the formal health system requires an understanding of prevailing contextual factors and how they can be modulated to support the linkages. Context plays a pivotal role in shaping the nature and success of any integration efforts. This paper, based on a qualitative study, explored the facilitating and constraining contextual influences shaping the linkage of informal healthcare providers into the formal health system in governance, service delivery, and data reporting. The research was conducted in Enugu and Anambra states in southeastern Nigeria. In-depth interviews were held with 12 senior healthcare managers, 16 primary healthcare facility managers, 32 informal providers, and 16 community leaders. Eight sex-disaggregated focus group discussions were held with health service users. Transcripts were coded in NVivo using a pre-defined coding framework comprising facilitators and constraints at the individual, organisational, and environmental levels. Individual factors that influence linkage of informal providers into the formal health system include personal attitudes towards linkage, capacity of informal providers to deliver quality services, nature of existing relationships between formal and informal providers, and trust in the formal health system. Organizational factors include leadership structure, coordination and accountability mechanisms, functional management capacity of the formal health system, and multiple regulatory frameworks. External factors include supportive health policies on integration, sustainable funding for continuous training and supportive supervision, and global agenda/support for integration. This study has provided valuable insights for decision makers and practitioners for harnessing the contextual factors to link informal healthcare providers successfully and effectively to the formal health system in order to improve access to quality health services in urban slums</span>


A political economy analysis of health policymaking in Nigeria: the genesis of the 2014 National Health Act
<span class="paragraphSection"><div class="boxTitle">Abstract</div>This article explores the ideologies, interests, and institutions affecting health policymaking in Nigeria, and the role of the private sector therein. It covers the period from the late-1950s, the years leading up to independence, to 2014, when the country enacted its first-ever law to govern its healthcare system. The National Health Act (NHAct) was adopted after a decade of preparation and civil society-driven advocacy, making the objective of universal health coverage (UHC) explicit. However, in its final version, the NHAct earmarked only a small share of public funds for UHC, solidifying the country’s reliance on private healthcare and out-of-pocket payments. To examine the specific set of ideologies, interests, and institutions defining Nigeria’s pathway toward UHC and the contribution of the private sector, we adopted the political economy framework, situating the genesis of the 2014 NHAct within the broader political and economic context of Nigeria’s health system reform process since the 1950s. Drawing on qualitative data collected during interviews and focus groups, we found that the deep entrenchment of private-sector healthcare in Nigeria is the result of a path-dependent process. This implies that Nigeria’s current reliance on the private sector is influenced by historical patterns, competing interests, and institutional practices that have reinforced the role of private actors over time. We identified three major explanatory factors that have shaped health policymaking in Nigeria. First, since the 1980s, the ideology that private healthcare is the solution to an underfunded and underperforming public healthcare system has been reinforced by leading international organizations. Second, private actors in Nigeria have been in a strong position to influence health policymaking since independence. Third, Nigeria’s challenging socio-economic context and the limitations of its federal governance structure have fostered a general level of public distrust in the capacity of the public sector to provide quality healthcare.</span>


Can public education campaigns equitably counter the use of substandard and falsified medical products in African countries?
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Substandard and falsified (SF) medical products are a serious health and economic concern that disproportionately impact low- and middle-income countries and marginalized groups. Public education campaigns are demand-side interventions that may reduce the risk of SF exposure, but the effectiveness of such campaigns, and their likelihood of benefitting everybody, is unclear. Nationwide pilot risk communication campaigns, involving multiple media, were deployed in Ghana, Nigeria, Sierra Leone, and Uganda in 2020–21. Focus group discussions (<span style="font-style:italic;">n</span> = 73 with <span style="font-style:italic;">n</span> = 611 total participants) and key informant interviews (<span style="font-style:italic;">n</span> = 80 individual interviews and <span style="font-style:italic;">n</span> = 4 group interviews with <span style="font-style:italic;">n</span> = 111 total informants) were conducted within each of the four countries to ascertain the reach and effectiveness of the campaign. Small proportions of focus group discussants (8.0–13.9%) and key informants (12.5–31.4%) had previously encountered the campaign materials. Understandability varied: the use of English and select local languages, combined with high rates of illiteracy, meant that some were not able to understand the campaign. The capacity for people to act on the messages was extremely limited: inaccessibility, unavailability, and unaffordability of quality-assured medicines from official sources, as well as illiteracy, constrained what people could realistically do in response to the campaign. Importantly, reach, understandability, and capacity to respond were especially limited among marginalized groups, who are already at the greatest risk of exposure to SF products. These findings suggest that there may be potential for public education campaigns to help combat the issue of SF medicines through prevention, but that the impact of public education is likely to be limited and may even inadvertently widen health inequities. This indicates that public education campaigns are not a single solution; they can only be properly effective if accompanied by health system strengthening and supply-side interventions that aim to increase the effectiveness of regulation.</span>