What we need is health system transformation and not health system strengthening for universal health coverage to work: Perspectives from a National Health Insurance pilot site in South Africa

Background: Globally, universal health coverage (UHC) has gained traction as a major health priority. In 2011, South Africa embarked on a UHC journey to ensure that everyone has access to quality healthcare services without suffering financial impoverishment. National Health Insurance (NHI) and primary healthcare (PHC) re-engineering were two vehicles chosen to reach UHC over a 14-year period (2012–2026). The first phase of health system strengthening (HSS) initiatives to improve the quality of health services in the public sector began in 2012. These HSS initiatives are still being carried out by the Department of Health in conjunction with other partners.Methods: A qualitative case study design utilising a theory of change (TOC) approach was employed. Data were collected from key informants (n = 71) during three phases: 2011–2012 (contextual mapping), 2013–2014 (Phase 1) and 2015 (Phase 2). In-depth face-to-face interviews were conducted with participants using a TOC interview guide, adapted for each phase. All interviews were audio-recorded and transcribed verbatim. An iterative, inductive and deductive data analysis approach was utilised. Transcripts were coded with the aid of MAXQDA 2018.Results: Six broad themes emerged: make PHC work, transform policy development, transform policy implementation, establish public–private partnerships, transform systems and processes and adopt a systems lens.Conclusion: A third great transition seems to be sweeping the globe, changing how health systems are organised. Actors in our study have identified this need also. Health system transformation rather than strengthening, they say, is needed to make UHC a reality. Who is listening

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease