Monitoring and evaluating the implementation of essential packages of health services

Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the 'what' and 'for whom' of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices

Bridging the Research to Policy Gap for Effective engagement in policy agenda setting in southern and eastern Africa

Thesis (Ph.D.)--University of Washington, 2022Increasingly, health conditions exist for which there are high quality local and international data; effective, feasible, and affordable interventions; and strong research communities advocating for attention in low- and middle-income countries (LMICs). Yet these conditions still lack the political priority to make it onto the agenda of health policy makers. Examples include both conditions well-resourced in high income countries, such as surgery and trauma care or most cancers, as well as issues neglected globally, such as access to pain relief and palliative care. The reasons for the persistent absence of these issues from national priority lists in LMICs are still poorly understood. In this dissertation I bring together concepts of implementation science and political science to identify evidence-based, context-appropriate recommendations for improving the effectiveness of research use in driving policy agendas and prioritization. I first focus on assessing the current landscape of theories and frameworks available to researchers interested in building political priority for health conditions in low- and middle-income countries. I then use the frameworks to guide to two case studies looking at commitment to new health technologies in Uganda and the political prioritization of tertiary care in Malawi. In Aim 1, I conduct a scoping review of evidence to policy and agenda setting frameworks and theories that have been applied to health topics in LMICs. In the absence of empirical research, frameworks and theories can provide a useful conceptual foundation for integration of current evidence-based strategies. The search included terms related to health, political priority, and frameworks and theories and looked for studies from 2000-2022. I found a total of 155 studies that applied 41 distinct frameworks and theories to understand the presence or absence of a health topic on the national or global health policy agenda. Theories relevant to political priority came from several academic disciplines, most notably political sciences public health, and vary substantially in complexity, orientation, and the extent to which they are adapted or modified prior to being applied. Of the 44% of studies that assessed health topics in LMICS, one-third were applied to questions of priority in African countries. Aim 2, I used a qualitative case study approach to understand the policy roll out of a web-based electronic medical record designed to facilitate case management of rheumatic heart disease (RHD) in Uganda, called the Active Community Case Management Tool (ACT). RHD is a significant cause of ill-health in young adults in Uganda, but access and adherence to diagnosis and treatment remain low. I combined primary data collection and analysis of interviews with RHD researchers and district health officials with secondary analysis of interviews with health care workers using the ACT software as part of a study to decentralize RHD care to health centers closer to patients in two districts in Uganda. Through mapping the national policy and regulatory approval process, I found strong evidence of expressed political commitment to this new technology, driven in part by trust in the local research community advocating for ACT’s use. However, these expressions have been slow to translate into implementation. The reasons for this are varied, but limitations in the local system available to adapt national strategies into operational policies and guidance is one contributing factor. In Aim 3, I use a process tracing methodology to map ongoing efforts to integrate tertiary care into the Malawi Essential Package of Health Services (EPHS). I draw from Shifffman and Smith framework for determinants of political priority and the SPIRIT action framework to identify determinants of tertiary care’s recent rise and fall on the national health policy agenda in Malawi. The results show that having an available repository of effective interventions, a cohesive political community, and an open political window of opportunity are the strongest predictors a health issues political prioritization. Moreover, for tertiary care, research serves as a catalyst for each of these dimensions in Malawi. This dissertation advances the limited body of literature in policy implementation science at a critical time in the field’s development, by providing a synthesis of relevant frameworks and theories complemented by empirical examples of their application. The focus on applying implementation science concepts to the agenda-setting stage of the policy cycle is particularly innovative, as much of the focus to date has centered on the policy implementation stage of the cycle. I hope that the findings presented here will provide a starting point for researchers interested in better engaging with the policy agenda setting process in southern and eastern Africa

Implementation measurement in global mental health: Results from a modified Delphi panel and investigator survey

Limited guidance exists to support investigators in the choice, adaptation, validation and use of implementation measures for global mental health implementation research. Our objectives were to develop consensus on best practices for implementation measurement and identify strengths and opportunities in current practice. We convened seven expert panelists. Participants rated approaches to measure adaptation and validation according to appropriateness and feasibility. Follow-up interviews were conducted and a group discussion was held. We then surveyed investigators who have used quantitative implementation measures in global mental health implementation research. Participants described their use of implementation measures, including approaches to adaptation and validation, alongside challenges and opportunities. Panelists agreed that investigators could rely on evidence of a measure’s validity, reliability and dimensionality from similar contexts. Panelists did not reach consensus on whether to establish the pragmatic qualities of measures in novel settings. Survey respondents (n = 28) most commonly reported using the Consolidated Framework for Implementation Research Inner Setting Measures (n = 9) and the Program Assessment Sustainability Tool (n = 5). All reported adapting measures to their settings; only two reported validating their measures. These results will support guidance for implementation measurement in support of mental health services in diverse global settings

Deployment of Point‐of‐Care Echocardiography to Improve Cardiac Diagnostic Access Among American Indians

Background American Indians face significant barriers to diagnosis and management of cardiovascular disease. We sought to develop a real‐world implementation model for improving access to echocardiography within the Indian Health Service, the American Indian Structural Heart Disease Partnership. Methods and Results The American Indian Structural Heart Disease Partnership was implemented and evaluated via a 4‐step process of characterizing the system where it would be instituted, building point‐of‐care echocardiography capacity, deploying active case finding for structural heart disease, and evaluating the approach from the perspective of the clinician and patient. Data were collected and analyzed using a parallel convergent mixed methods approach. Twelve health care providers successfully completed training in point‐of‐care echocardiography. While there was perceived usefulness of echocardiography, providers found it difficult to integrate screening point‐of‐care echocardiography into their workday given competing demands. By the end of 12 months, 6 providers continued to actively utilize point‐of‐care echocardiography. Patients who participated in the study felt it was an acceptable and effective approach. They also identified access to transportation as a notable challenge to accessing echocardiograms. Over the 12‐month period, a total of 639 patients were screened, of which 36 (5.6%) had a new clinically significant abnormal finding. Conclusions The American Indian Structural Heart Disease Partnership model exhibited several promising strategies to improve access to screening echocardiography for American Indian populations. However, competing priorities for Indian Health Service providers' time limited the amount of integration of screening echocardiography into outpatient practice. Future endeavors should explore community‐based solutions to develop a more sustainable model with greater impact on case detection, disease management, and improved outcomes

Palliative Care and Pain Control

Palliative care has been shown to provide significant and diverse benefits for patients with serious, complex, or life-limiting health problems. Such benefits include the following: Reduced physical, psychological, and spiritual suffering (Abernethy and others 2003; Gwyther and Krakauer 2011; Higginson and others 2014; Krakauer 2008; Singer and others 2016; Temel and others 2010; WHO 2008; Zimmerman and others 2014) Improved quality of life (Singer and others 2016; Zimmerman and others 2014) Prolonged survival in some situations (Connor and others 2007; Temel and others 2010). Palliative care also can lower costs to health care systems (Chalkidou and others 2014; DesRosiers and others 2014; Gomez-Batiste and others 2012; Jamison and others 2013; Knaul and others 2017; Summers 2016). For these reasons, it is recognized globally as an ethical responsibility of all health care systems and a necessary component of universal health coverage (World Health Assembly 2014). Yet palliative care is rarely accessible in low- and middle-income countries (LMICs). This chapter describes an essential package (EP) of palliative care services and treatments that could and should be accessible to everyone everywhere, as well as the sites or platforms where those services and treatments could be offered. Thus, it was necessary to make a preliminary estimate of the burden of health-related suffering requiring palliative care.To roughly estimate the need for palliative care, we identified the serious, complex, or life-limiting conditions listed in the International Classification of Diseases (ICD)-10 that most commonly result in physical, psychological, social, or spiritual suffering (WHO 2015a). We then estimated the types, prevalence, and duration of suffering resulting from each condition. On the basis of this characterization of the burden of suffering, we propose an EP of palliative care and pain control designed to do the following: Prevent or relieve the most common and severe suffering related to illness or injury. Be affordable, even in LMICs. Provide financial risk protection for patients and families by providing a realistic alternative to expensive, low-value treatment. We costed the EP in one low-income country (Rwanda), one lower-middle-income country (Vietnam), and one upper-middle-income country (Mexico) and projected these costs for LMICs in general (Knaul and others 2017). At the conclusion of this chapter, we provide guidance on how to integrate the EP into health systems as an essential element of universal health coverage (UHC) in LMICs. We also discuss how to augment the EP as soon as is feasible to further prevent and relieve suffering.This chapter draws directly on the work of the Lancet Commission on Global Access to Palliative Care and Pain Control (the Lancet Commission) (Knaul and others 2017)

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected