Priority setting for health in the context of devolution in Kenya: implications for health equity and community-based primary care

Devolution changes the locus of power within a country from central to sub-national levels. In 2013, Kenya devolved health and other services from central government to 47 new sub-national governments (known as counties). This transition seeks to strengthen democracy and accountability, increase community participation, improve efficiency and reduce inequities. With changing responsibilities and power following devolution reforms, comes the need for priority-setting at the new county level. Priority-setting arises as a consequence of the needs and demand for healthcare resources exceeding the resources available, resulting in the need for some means of choosing between competing demands. We sought to explore the impact of devolution on priority-setting for health equity and community health services. We conducted key informant and in-depth interviews with health policymakers, health providers and politicians from 10 counties (n = 269 individuals) and 14 focus group discussions with community members based in 2 counties (n = 146 individuals). Qualitative data were analysed using the framework approach. We found Kenya’s devolution reforms were driven by the need to demonstrate responsiveness to county contexts, with positive ramifications for health equity in previously neglected counties. The rapidity of the process, however, combined with limited technical capacity and guidance has meant that decision-making and prioritization have been captured and distorted for political and power interests. Less visible community health services that focus on health promotion, disease prevention and referral have been neglected within the prioritization process in favour of more tangible curative health services. The rapid transition in power carries a degree of risk of not meeting stated objectives. As Kenya moves forward, decision-makers need to address the community health gap and lay down institutional structures, processes and norms which promote health equity for all Kenyans

Homeward bound or bound for a home? Assessing the capacity of dementia patients to make decisions about hospital discharge: Comparing practice with legal standards

Background This article stems from a larger project which considers ways of improving assessments of capacity and judgements about best interests in connection with people with dementia admitted to acute hospitals with respect to decisions about place of residence. Aims Our aim is to comment on how assessments of residence capacity are actually performed on general hospital wards compared with legal standards for the assessment of capacity set out in the Mental Capacity Act, 2005 (MCA). Method Our findings are grounded in ethnographic ward-based observations and in-depth interviews conducted in three hospital wards, in two hospitals (acute and rehabilitation), within two NHS healthcare trusts in the North of England over a period of nine months between 2008 and 2009. Twenty-nine patient cases were recruited to the study. We also draw from broader conceptions of capacity found in domestic and international legal, medical, ethical and social science literature. Results Our findings suggest that whilst professionals profess to be familiar with broad legal standards governing the assessment of capacity under the MCA, these standards are not routinely applied in practice in general hospital settings when assessing capacity to decide place of residence on discharge from hospital. We discuss whether the criteria set out in the MCA and the guidance in its Code of Practice are sufficient when assessing residence capacity, given the particular ambiguities and complexities of this capacity. Conclusions We conclude by suggesting that more specific legal standards are required when assessing capacity in this particular context

Explaining the decline in coronary heart disease mortality in Turkey between 1995 and 2008.

BACKGROUND: Coronary heart disease (CHD) mortality rates have been decreasing in Turkey since the early 1990s. Our study aimed to determine how much of the CHD mortality decrease in Turkey between 1995 and 2008 could be attributed to temporal trends in major risk factors and how much to advances in medical and surgical treatments. METHODS: The validated IMPACT CHD mortality model was used to combine and analyse data on uptake and effectiveness of CHD treatments and risk factor trends in Turkey in adults aged 35-84 years between 1995 and 2008.Data sources were identified, searched and appraised on population, mortality and major CHD risk factors for adults those aged 35-84 years. Official statistics, electronic databases, national registers, surveys and published trials were screened from 1995 onwards. RESULTS: Between 1995 and 2008, coronary heart disease mortality rates in Turkey decreased by 34% in men and 28% in women 35 years and over. This resulted in 35,720 fewer deaths in 2008.Approximately 47% of this mortality decrease was attributed to treatments in individuals (including approximately 16% to secondary prevention, 3% angina treatments, 9% to heart failure treatments, 5% to initial treatments of acute myocardial infarction, and 5% to hypertension treatments) and approximately 42% was attributable to population risk factor reductions (notably blood pressure 29%; smoking 27%; and cholesterol 1%). Adverse trends were seen for obesity and diabetes (potentially increasing mortality by approximately 11% and 14% respectively). The model explained almost 90% of the mortality fall. CONCLUSION: Reduction in major cardiovascular risk factors explained approximately 42% and improvements in medical and surgical treatments explained some 47% of the CHD mortality fall. These findings emphasize the complimentary value of primary prevention and evidence-based medical treatments in controlling coronary heart disease

Association between wasting and food insecurity among children under five years: findings from Nepal demographic health survey 2016

Background Wasting is a consequence of food insecurity, inappropriate dietary practices, and inadequate caring and feeding practices. The present study assessed association between wasting and household food insecurity among under 5 years old children, along with other socio-demographic characteristics. Methods This study is a secondary analysis of the Nepal Demographic and Health Survey 2016. The survey is cross-sectional in design with use of standardized tools. The sampling frame used is an updated version of the frame from the 2011 National Population and Housing Census. The participants were children under 5 years of age (n = 2414). Logistic regression was carried out to identify the odds of being wasted for children belonging to different levels of food insecure households using odds ratio and 95% confidence intervals. Results The prevalence of wasting increased with the level of food insecurity, from mild (9.4%) to moderate (10.8%) and to severe (11.3%). The highest proportions of wasted children were in Province 2 (14.3%), from rural areas (10.1%), born to mothers with no education (12.4%) and from a richer quintile (11.3%). Children belonging to severe food insecure households had 1.36 (95%CI 0.72–2.57) adjusted odds of being wasted and those belonging to mild food insecure and moderately food insecure households had 0.98 (95%CI 0.64-1.49) and 1.13 (95%CI 0.65–1.97) odds of being wasted respectively. Province 1 (AOR 2.06, 95%CI 1.01–4.19) and Province 2 (AOR 2.45, 95%CI 1.22–4.95) were significantly associated with wasting. Conclusion Considering the increment in childhood wasting as per level of food insecurity, an integrated intervention should be developed in Nepal that, 1. addresses improving knowledge and behavior of community people with respect to diet and nutrition; 2. reduce the problem of food insecurity through agricultural interventions

Termination of the leprosy isolation policy in the US and Japan : Science, policy changes, and the garbage can model

BACKGROUND: In both the US and Japan, the patient isolation policy for leprosy /Hansen's disease (HD) was preserved along with the isolation facilities, long after it had been proven to be scientifically unnecessary. This delayed policy termination caused a deprivation of civil liberties of the involuntarily confined patients, the fostering of social stigmas attached to the disease, and an inefficient use of health resources. This article seeks to elucidate the political process which hindered timely policy changes congruent with scientific advances. METHODS: Examination of historical materials, supplemented by personal interviews. The role that science played in the process of policy making was scrutinized with particular reference to the Garbage Can model. RESULTS: From the vantage of history, science remained instrumental in all period in the sense that it was not the primary objective for which policy change was discussed or intended, nor was it the principal driving force for policy change. When the argument arose, scientific arguments were employed to justify the patient isolation policy. However, in the early post-WWII period, issues were foregrounded and agendas were set as the inadvertent result of administrative reforms. Subsequently, scientific developments were more or less ignored due to concern about adverse policy outcomes. Finally, in the 1980s and 1990s, scientific arguments were used instrumentally to argue against isolation and for the termination of residential care. CONCLUSION: Contrary to public expectations, health policy is not always rational and scientifically justified. In the process of policy making, the role of science can be limited and instrumental. Policy change may require the opening of policy windows, as a result of convergence of the problem, policy, and political streams, by effective exercise of leadership. Scientists and policymakers should be attentive enough to the political context of policies

Equity in the use of antithrombotic drugs, beta-blockers and statins among Finnish coronary patients

Background Earlier studies have mainly reported the use of antithrombotic drugs, beta-blockers and statins among hospital patient populations or MI patients. This study aimed to describe the use of these drugs among middle-aged Finnish coronary patients and to identify patient groups in risk of being prescribed inadequate medication for secondary prevention of coronary heart disease. Methods One-year follow-up survey data from a random sample of a cohort of coronary patients were used along with register data linked to the survey. The response rate was 54% (n = 2650). The main outcome measures were use of antithrombotic drugs, beta-blockers and statins and the data were analysed using logistic regression analysis. Results Among men and women, respectively, 82% and 81% used beta-blockers, 95% and 89% used antithrombotic drugs, and 62% and 59% used statins. Younger men and men from higher socioeconomic groups were more likely to use statins, even after controlling for disease severity and comorbidity. In women, the age trend was reversed and no socioeconomic differences were found. Drug use increased with increased disease severity, but diabetes had only a slight effect. Conclusion The use of antithrombotic drugs and beta-blockers among Finnish coronary patients seemed to be rather appropriate and, to some extent, prescription practices of preventive medication varied according to patients' risk of coronary events. However, statin use was remarkably low among men with low socio-economic status, and there is need to improve preventive drug treatment among diabetic coronary patients.BioMed Central Open acces

Avoidable costs of physical treatments for chronic back, neck and shoulder pain within the Spanish National Health Service: a cross-sectional study

<p>Abstract</p> <p>Background</p> <p>Back, neck and shoulder pain are the most common causes of occupational disability. They reduce health-related quality of life and have a significant economic impact. Many different forms of physical treatment are routinely used. The objective of this study was to estimate the cost of physical treatments which, despite the absence of evidence supporting their effectiveness, were used between 2004 and 2007 for chronic and non-specific neck pain (NP), back pain (BP) and shoulder pain (SP), within the Spanish National Health Service in the Canary Islands (SNHSCI).</p> <p>Methods</p> <p>Chronic patients referred from the SNHSCI to private physical therapy centres for NP, BP or SP, between 2004 and 2007, were identified. The cost of providing physical therapies to these patients was estimated. Systematic reviews (SRs) and clinical practice guidelines (CPGs) for NP, BP and SP available in the same period were searched for and rated according to the Oxman and AGREE criteria, respectively. Those rated positively for ≥70% of the criteria, were used to categorise physical therapies as Effective; Ineffective; Inconclusive; and Insufficiently Assessed. The main outcome was the cost of physical therapies included in each of these categories.</p> <p>Results</p> <p>8,308 chronic cases of NP, 4,693 of BP and 5,035 of SP, were included in this study. Among prescribed treatments, 39.88% were considered Effective (physical exercise and manual therapy with mobilization); 23.06% Ineffective; 13.38% Inconclusive, and 23.66% Insufficiently Assessed. The total cost of treatments was € 5,107,720. Effective therapies accounted for € 2,069,932.</p> <p>Conclusions</p> <p>Sixty percent of the resources allocated by the SNHSCI to fund physical treatment for NP, BP and SP in private practices are spent on forms of treatment proven to be ineffective, or for which there is no evidence of effectiveness.</p