Patient-public engagement strategies for health system improvement in sub-Saharan Africa: a systematic scoping review

Background Actively involving patients and communities in health decisions can improve both peoples’ health and the health system. One key strategy is Patient-Public Engagement (PPE). This scoping review aims to identify and describe PPE research in Sub-Saharan Africa; systematically map research to theories of PPE; and identify knowledge gaps to inform future research and PPE development. Methods The review followed guidelines for conducting and reporting scoping reviews. A systematic search of peer-reviewed English language literature published between January 1999 and December 2019 was conducted on Scopus, Medline (Ovid), CINAHL and Embase databases. Independent full text screening by three reviewers followed title and abstract screening. Using a thematic framework synthesis, eligible studies were mapped onto an engagement continuum and health system level matrix to assess the current focus of PPE in Sub-Saharan Africa. Results Initially 1948 articles were identified, but 18 from 10 Sub-Saharan African countries were eligible for the final synthesis. Five PPE strategies implemented were: 1) traditional leadership support, 2) community advisory boards, 3) community education and sensitisation, 4) community health volunteers/workers, and 5) embedding PPE within existing community structures. PPE initiatives were located at either the ‘involvement’ or ‘consultation’ stages of the engagement continuum, rather than higher-level engagement. Most PPE studies were at the ‘service design’ level of the health system or were focused on engagement in health research. No identified studies reported investigating PPE at the ‘individual treatment’ or ‘macro policy/strategic’ level. Conclusion This review has successfully identified and evaluated key PPE strategies and their focus on improving health systems in Sub-Saharan Africa. PPE in Sub-Saharan Africa was characterised by tokenism rather than participation. PPE implementation activities are currently concentrated at the ‘service design’ or health research levels. Investigation of PPE at all the health system levels is required, including prioritising patient/community preferences for health system improvement.

Overwriting New Public Management with New Public Governance in New Zealand's approach to health system improvement

PurposeIn 2016, New Zealand's Ministry of Health introduced the System Level Measures Framework which marked a departure from health targets and pay-for-performance incentives towards an approach based on local, collaborative approaches to health system improvement. This exemplifies an attempt to “overwrite” New Public Management (NPM) institutional practices with New Public Governance (NPG). We aim to trace this process of overwriting so as to understand how attempts to change institutional practices were facilitated, blocked, translated and edited.Design/methodology/approachWe develop a conceptual framework for understanding and tracing institutional change towards NPG which emphasises the importance of discursive strategies in policy attempts to overwrite NPM with NPG. To analyse the New Zealand case, we drew on policy documents and interviews conducted in 2017–18 with twelve national key informants and fifty interviewees closely involved in local development and/or implementation of the SLMF.FindingsPolicy sponsors of collaborative approaches to health system improvement first attempted formal institutional change, arguing that adopting collaborative, quality improvement (NPG) approaches would supplement existing performance management (NPM) practices, to create a superior synthesis. When this formal approach was blocked, they adopted an approach based on informal persuasion of local organisational actors that quality improvement should supplant performance improvement. This approach was edited and translated by local actors, and the success of local implementation varied considerably.Research limitations/implicationsThis article offers a novel conceptualisation of public management institutional change, which can help explain why it is difficult to completely erase NPM practices in health.Originality/valueThis paper explores the rhetorical practices that are used in the introduction of a New Public Governance policy framework.

Micro-Stratification for Malaria Transmission Risk in a High Burden Area of Honduras

Background As Malaria cases are continuously reported across the globe, epidemiological and integral approaches should be considered for an optimal stratification on endemic areas for elimination goal. In Central America, a 75% reduction in malaria incidence has been reported between 2000 and 2015, similarly, in Honduras, more than 75% of total cases in 2016 were concentrated in 7 municipalities, mainly in Gracias Dios department. Achieve malaria elimination in Honduras demands the implementation of strategies to identify main hotspots. Methods Based on WHO guidelines, local malaria epidemiological data from case-based surveillance system of the Ministry of Health between January and December 2016 were analysed. Furthermore, on field evaluations were carried out in Puerto Lempira municipality, Gracias a Dios department to an analysis validation. Finally, a set of epidemiological components were generated and proposed together with risk-factor description and proposed actions for health system improvement. Results On 2016, Gracias a Dios reported 61% of total malaria cases in Honduras; based on our analysis, 12 micro-areas were identified, including epidemiological, entomological, and socio-demographic information from local technicians. Conclusions Malaria elimination in endemic areas urges implementation of different strategies, here we show the on-field micro-stratification process of 12 “micro-areas” carried out in one endemic department of Honduras. This information provides a more targeted strategy for diagnosis, treatment, and vector control interventions for malaria elimination goal in Honduras.

Changes in Determinants and Equity of Family Planning Utilization after the Implementation of a National Health Insurance Policy in Indonesia: A Secondary Analysis of The 2012-2016 National Socio-Economic Survey of Indonesia

Background: The Indonesian government has been implementing the National Health Insurance Policy (Jaminan Kesehatan Nasional-JKN) since 2014. The utilization of family planning service is one of the programs to increase maternal and child health status that is included in the benefit package in JKN. This study aimed to describe determinants and to evaluate JKN based on equity indicators, especially in family planning services. Methods: Data were obtained from the 2012-2016 National Socio-Economic Survey (SUSENAS) of Indonesia. Contraceptive Prevalence Rate (CPR) and Long-acting contraceptives (LACs) use were used as indicators to evaluate family planning utilization. Chi-square and logistic regression tests were used to analyze the data. Respondents were married women between 15 and 49 years of age. Results: There was no progress in CPR after the implementation of JKN. At the national level, CPR decreased within five years (2012-2016). Decreasing in urban areas and in the group that does not have health insurance were more than in rural areas and in the group that has health insurance. Utilization of non-LACs, especially injection (56%-57%) and pill (21%-24%), were still high within 2012-2016. At the national level, LACs use increased 3.18% between 2012-2016 (15.54%-18.72%). Increasing in urban areas and in the group that has subsidized health insurance were more than in rural areas and in the group that does not have subsidized. In 2016, the geography factor (rural-urban) and household economic status associated negatively with the use of overall contraceptive methods (p<0.05). Conversely, all the determinants were positively associated with LACs use (p<0.05). Conclusions: Up to 2016, the JKN program did not increase CPR. Conversely, the JKN program obtained only small increases in LACs use. LACs use in rural areas is less than in urban areas. JKN program can increase LACs use in the group that has subsidized health insurance. CPR and LACs coverage could increase through health system improvement, and the societal norms approach. Health system improvement is operationalized through improving supply-side and regulations, increasing coordination among multiple agencies in the family planning program.

“Hybrid” medical leadership emergency medicine training for international medical graduates

Purpose The purpose of this paper is to outline the “Hybrid” “International” Emergency Medicine (HIEM) programme, which is an ethical pathway for the recruitment, employment and training of Emergency Medicine doctors; with a rotation through the NHS on a two-year medical training initiative with a Tier 5 visa, “earn, learn and return” programme. The HIEM programme offers an advantage to the Tier 2 visa by combining training, education and employment resulting in new learning to help improve the health system in Nepal and provide continued cultural support, clinical and leadership development experience in the UK NHS. Finally, this programme also provides a Return on Investment to the NHS. Design/methodology/approach A shortage of doctors in the UK, combined with a need to develop Emergency Medicine doctors in Nepal, led to a UK Emergency Medicine Physician (PS) to facilitate collaboration between UK/Nepal partners. A mapping exercise of the Royal College of Emergency Medicine curriculum with the competencies for the health system and quality improvement leaders and partners with patients produced a “HIEM programme”. The HIEM programme aims to develop first-class doctors to study in Emergency Departments in the UK NHS while also building trainee capability to improve the health system in Nepal with a research thesis. Findings The HIEM programme has 12 doctors on its programme across years one and two, with the first six doctors working in the UK NHS and progressing well. There are reports of high levels of satisfaction with the trainees in their transition from Nepal to the UK and the hospital is due to save £720,000 (after costs) over two years. Each trainee will earn £79,200 over two years which is enough to pay back the £16,000 cost for the course fees. Nepal as a country will benefit from the HIEM programme as each trainee will submit a health system improvement Thesis. Research limitations/implications The HIEM programme is in its infancy as it is two years through a four-year programme. Further evaluation data are required to assess the full impact of this programme. In addition, the HIEM programme has only focussed on the development of one medical speciality which is Emergency Medicine. Further research is required to evaluate the impact of this model across other medical and surgical specialties. Practical implications The HIEM programme has exciting potential to support International Medical Graduates undertake a planned programme of development while they study in the UK with a Tier 5 visa. IMGs require continuous support while in the UK and are required to demonstrate continued learning through continuous professional development (CPD). The HIEM programme offers an opportunity for this CPD learning to be structured, meaningful and progressive to enable new learning. There is also specific support to develop academic and research skills to undertake a thesis in an area that requires health system improvement in Nepal. Originality/value This is the first time an integrated clinical, leadership, quality improvement and patient partnership model curriculum has been developed. The integrated nature of the curriculum saves precious time, money and resources. The integrated nature of this “hybrid” curriculum supports the development of an evidence-based approach to generating attitudes of collaboration, partnership and facilitation and team building in medical leadership with patient engagement. This “hybrid” model gives hope for the increased added value of the programme at a time of global austerity and challenges in healthcare.