Future health expenditures and its determinants in Latin America and the Caribbean: a multi-country projection study

Summary Background Countries in Latin America and the Caribbean (LAC) have experienced important demographic, epidemiological, economic, and policy developments that raise concerns about their ability to afford health expenditures in the future. This paper forecasts how current health expenditures (CHE) in LAC countries will change over the next 30 years and identifies key drivers of health expenditure growth. Methods A statistical model to forecast CHE based on changing disease burden, economic growth, technology, and demography was developed. CHE by age and disease group at baseline (2018/19) were estimated for countries in the LAC region based on seven index countries. Baseline expenditures were projected to 2050. Findings Per capita CHE will increase across the LAC region (median increase 2.75 times) between baseline and 2050. All Latin American countries are expected to double per capita CHE in this period. Expected increases in Caribbean countries are more variable. Large increases in CHE growth related to neoplasms, circulatory system and genitourinary conditions are observed. Growth in CHE will be highest in older age groups. Interpretation Increases in health expenditures will be driven largely by economic growth and technology, while demography and epidemiology had smaller effects. The control of health expenditures and more efficient use of health resources must become a priority for the LAC region. Funding This study was funded by the Inter-American Development Bank.Fil: Rao, Krishna D.. University Johns Hopkins; Estados UnidosFil: Roberton, Timothy. The University of Western Australia; AustraliaFil: Vecino Ortiz, Andres I.. University Johns Hopkins; Estados UnidosFil: Noonan, Caitlin M.. University Johns Hopkins; Estados UnidosFil: Lopez Hernandez, Angelica. University Johns Hopkins; Estados UnidosFil: Mora Garcia, Claudio A.. Instituto Centroamericano de Administración de Empresas; Puerto RicoFil: Prado, Andrea M.. Instituto Centroamericano de Administración de Empresas; Puerto RicoFil: Machado, Carla Jorge. Universidade Federal de Minas Gerais; BrasilFil: Vega Landaeta, Angela. Pontificia Universidad Javeriana; ColombiaFil: Palacio Martínez, Natalia. Pontificia Universidad Javeriana; ColombiaFil: Flóres, Yvonne N.. University of California at Los Angeles; Estados UnidosFil: Samuels, T. Alafia. University of the West Indies; Trinidad y TobagoFil: Metivier, Charmaine. University of the West Indies; Trinidad y TobagoFil: Laptiste, Christine. University of the West Indies; Trinidad y TobagoFil: La Foucade, Althea. University of the West Indies; Trinidad y TobagoFil: Beharry, Vyjanti. University of the West Indies; Trinidad y TobagoFil: Maceira, Daniel Alejandro. Universidad de Buenos Aires; Argentina. Centro de Estudios de Estado y Sociedad; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentin

Early effects of COVID-19 on maternal and child health service disruption in Mozambique

This article is part of the Research Topic ‘Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'IntroductionAfter the World Health Organization declared COVID-19 a pandemic, more than 184 million cases and 4 million deaths had been recorded worldwide by July 2021. These are likely to be underestimates and do not distinguish between direct and indirect deaths resulting from disruptions in health care services. The purpose of our research was to assess the early impact of COVID-19 in 2020 and early 2021 on maternal and child healthcare service delivery at the district level in Mozambique using routine health information system data, and estimate associated excess maternal and child deaths.MethodsUsing data from Mozambique's routine health information system (SISMA, Sistema de Informação em Saúde para Monitoria e Avaliação), we conducted a time-series analysis to assess changes in nine selected indicators representing the continuum of maternal and child health care service provision in 159 districts in Mozambique. The dataset was extracted as counts of services provided from January 2017 to March 2021. Descriptive statistics were used for district comparisons, and district-specific time-series plots were produced. We used absolute differences or ratios for comparisons between observed data and modeled predictions as a measure of the magnitude of loss in service provision. Mortality estimates were performed using the Lives Saved Tool (LiST).ResultsAll maternal and child health care service indicators that we assessed demonstrated service delivery disruptions (below 10% of the expected counts), with the number of new users of family planing and malaria treatment with Coartem (number of children under five treated) experiencing the largest disruptions. Immediate losses were observed in April 2020 for all indicators, with the exception of treatment of malaria with Coartem. The number of excess deaths estimated in 2020 due to loss of health service delivery were 11,337 (12.8%) children under five, 5,705 (11.3%) neonates, and 387 (7.6%) mothers.ConclusionFindings from our study support existing research showing the negative impact of COVID-19 on maternal and child health services utilization in sub-Saharan Africa. This study offers subnational and granular estimates of service loss that can be useful for health system recovery planning. To our knowledge, it is the first study on the early impacts of COVID-19 on maternal and child health care service utilization conducted in an African Portuguese-speaking country

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

NGO perspectives on the challenges and opportunities for real-world evaluation: a qualitative study

Background The move towards robust monitoring and evaluation (M&E) has been increasing in global health, motivated by both an accountability agenda and to increase learning from M&E activities. Many international non-governmental organizations (NGOs) receive funding from one or more large institutional donors. Objective To understand NGOs’ perspective on their own role in terms of accountability to both donors and the populations they serve. Methods We conducted a series of in-depth interviews with M&E staff in 11 NGOs with projects related to maternal and child health to better understand how M&E is being implemented in these organizations. We then examined the data based on a priori identified themes. Results We found that despite flexibility from some donors, rigid reporting structures remain a barrier for NGOs to fully communicate the impact of their projects. While NGOs do utilize M&E findings, their use is limited by low staff capacity. The primary audience for the results remains the donor agency, and the primary motivation for M&E remains donor reporting. Reporting remains a burdensome affair, with ongoing limitations around streamlining results for donors. To reduce the burden of reporting for individual projects, the participants in our study suggested placing greater emphasis on process evaluations rather than impact evaluations. Participants also suggested increased data sharing between organizations working in the same regions and making better use of secondary data sources; in both cases to reduce the need for primary data collection. Conclusion We carried out this work to advance the conversation on how NGOs currently manage their M&E – a conversation which should involve NGOs, donors, local health system actors, and the communities with whom they work. More flexibility from donors, increased use of technology, and more transparency on if and how data is being used would help NGOs with their M&E process

Monitoring iCCM: a feasibility study of the indicator guide for monitoring and evaluating integrated community case management

Abstract Most countries in sub-Saharan Africa have now adopted integrated community case management (iCCM) of common childhood illnesses as a strategy to improve child health. In March 2014, the iCCM Task Force published an Indicator Guide for Monitoring and Evaluating iCCM: a 'menu' of recommended indicators with globally agreed definitions and methodology, to guide countries in developing robust iCCM monitoring systems. The Indicator Guide was conceived as an evolving document that would incorporate collective experience and learning as iCCM programmes themselves evolve. This article presents findings from two studies that examined the feasibility of collecting the Indicator Guide's 18 routine monitoring indicators with the iCCM monitoring systems that countries currently have in place. We reviewed iCCM monitoring tools, protocols and reports from a purposive sample of 10 countries in sub-Saharan Africa. We developed a scorecard system to assess which of the Indicator Guide's 18 routine monitoring indicators could be calculated with the given monitoring tools, and at which level of the health system the relevant information would be available. We found that the data needed to calculate many of the Indicator Guide's routine monitoring indicators are already being collected through existing monitoring systems, although much of these data are only available at health facility level and not aggregated to district or national levels. Our results highlight challenge of using supervision checklists as a data source, and the need for countries to maintain accurate deployment data for CHWs and CHW supervisors. We suggest that some of the recommended indicators need revising. Routine monitoring will be more feasible, effective and efficient if iCCM programmes focus on a smaller set of high-value indicators that are easy to measure, reliably interpreted and useful both for global and national stakeholders and for frontline health workers themselves

All things to all people: trade-offs in pursuit of an ideal modeling tool for maternal and child health

Abstract Background Modeling tools have potential to aid decision making for program planning and evaluation at all levels, but are still largely the domain of technical experts, consultants, and global-level staff. One model that can improve decision making for maternal and child health is the Lives Saved Tool (LiST). We examined respondents’ perceptions of LiST’s strengths and weaknesses, to identify ways in which LiST – and similar modeling tools – can adapt to be more accessible and helpful to policy makers. Methods We interviewed 21 purposefully sampled LiST users. First, we identified the characteristics that respondents explicitly stated, or implicitly implied, were important in a modeling tool, and then used these results to create a framework for reviewing a modeling tool. Second, we used this framework to categorize the strengths and weaknesses of LiST that respondents articulated. Results Two overarching qualities were important to respondents: usability and accuracy. For some users, LiST already meets these criteria: it allows for customized input parameters to increase specificity; the interface is intuitive; the assumptions and calculations are scientifically sound; and the standard metric of “additional lives saved” is understood and comparable across settings. Other respondents had different views, although their complaints were typically not that the tool is unusable or inaccurate, but that aspects of the tool could be better explained or easier to understand. Conclusion Government and agency staff at all levels should be empowered to use the data available to them, including the use of models to make full use of these data. For this, we need tools that meet a threshold of both accuracy, so results clarify rather than mislead, and usability, so tools can be used readily and widely, not just by select experts. With these ideals in mind, there are ways in which LiST might continue to be improved or adapted to further advance its uptake and impact

Leveraging water, sanitation and hygiene for nutrition in low‐ and middle‐income countries: A conceptual framework

Abstract In low‐ and middle‐income countries (LMICs), access to water, sanitation and hygiene (WASH) is associated with nutritional status including stunting, which affects 144 million children under 5 globally. Despite the consistent epidemiological association between WASH indicators and nutritional status, the provision of WASH interventions alone has not been found to improve child growth in recent randomized control trials. We conducted a literature review to develop a new conceptual framework that highlights what is known about the WASH to nutrition pathways, the limitations of certain interventions and how future WASH could be leveraged to benefit nutritional status in populations. This new conceptual framework will provide policy makers, program implementors and researchers with a visual tool to bring into perspective multiple levels of WASH and how it may effectively influence nutrition while identifying existing gaps in implementation and research

Visualizing the drivers of an effective health workforce: a detailed, interactive logic model

Background: A strong health workforce is a key building block of a well-functioning health system. To achieve health systems goals, policymakers need information on what works to improve and sustain health workforce performance. Most frameworks on health workforce planning and policymaking are high-level and conceptual, and do not provide a structure for synthesizing the growing body of empirical literature on the effectiveness of strategies to strengthen human resources for health (HRH). Our aim is to create a detailed, interactive logic model to map HRH evidence and inform policy development and decision-making. Methods: We reviewed existing conceptual frameworks and models on health workforce planning and policymaking. We included frameworks that were: (1) visual, (2) comprehensive (not concentrated on specific outcomes or strategies), and (3) designed to support decision-making. We compared and synthesized the frameworks to develop a detailed logic model and interactive evidence visualization tool. Results: Ten frameworks met our inclusion criteria. The resulting logic model, available at hrhvisualizer.org , allows for visualization of high-level linkages as well as a detailed understanding of the factors that affect health workforce outcomes. HRH data and governance systems interact with the context to affect how human resource policies are formulated and implemented. These policies affect HRH processes and strategies that influence health workforce outcomes and contribute to the overarching health systems goals of clinical quality, responsiveness, efficiency, and coverage. Unlike existing conceptual frameworks, this logic model has been operationalized in a highly visual, interactive platform that can be used to map the research informing policies and illuminating their underlying mechanisms. Conclusions: The interactive logic model presented in this paper will allow for comprehensive mapping of literature around effective strategies to strengthen HRH. It can aid researchers in communicating with policymakers about the evidence behind policy questions, thus supporting the translation of evidence to policy.Other UBCNon UBCPublic Policy and Global Affairs, School ofArts, Faculty ofReviewedFacult