Health Policy and Planning - current issue

A systematic review of the evidence on integration of targeted health interventions into health systems

Atun, R., de Jongh, T., Secci, F., Ohiri, K., Adeyi, O. — Thu, 24 Dec 2009 05:10:54 PST

A longstanding debate on health systems organization relates to benefits of integrating health programmes that emphasize specific interventions into mainstream health systems to increase access and improve health outcomes. This debate has long been characterized by polarization of views and ideologies, with protagonists for and against integration arguing the relative merits of each approach. However, all too frequently these arguments have not been based on hard evidence. The presence of both integrated and non-integrated programmes in many countries suggests there may be benefits to either approach, but the relative merits of integration in various contexts and for different interventions have not been systematically analysed and documented.

In this paper we present findings of a systematic review that explores a broad range of evidence on: (i) the extent and nature of the integration of targeted health programmes that emphasize specific interventions into critical health systems functions, (ii) how the integration or non-integration of health programmes into critical health systems functions in different contexts has influenced programme success, (iii) how contextual factors have affected the extent to which these programmes were integrated into critical health systems functions.

Our analysis shows few instances where there is full integration of a health intervention or where an intervention is completely non-integrated. Instead, there exists a highly heterogeneous picture both for the nature and also for the extent of integration. Health systems combine both non-integrated and integrated interventions, but the balance of these interventions varies considerably.

Eliciting policymakers' and stakeholders' opinions to help shape health system research priorities in the Middle East and North Africa region

Thu, 24 Dec 2009 05:10:54 PST

Evidence-informed decisions can strengthen health systems. Literature suggests that engaging policymakers and other stakeholders in research priority-setting exercises increases the likelihood of the utilization of research evidence by policymakers. To our knowledge, there has been no previous priority-setting exercise in health policy and systems research in countries of the Middle East and North Africa (MENA) region. This paper presents the results of a recent research priority-setting exercise that identified regional policy concerns and research priorities related to health financing, human resources and the non-state sector, based on stakeholders in nine low and middle income countries (LMICs) of the MENA region. The countries included in this study were Algeria, Egypt, Jordan, Lebanon, Morocco, Palestine, Syria, Tunisia and Yemen.

This multi-phased study used a combination of qualitative and quantitative research techniques. The overall approach was guided by the listening priority-setting approach, adapted slightly to accommodate the context of the nine countries. The study was conducted in four key phases: preparatory work, country-specific work, data analysis and synthesis, and validation and ranking. The study identified the top five policy-relevant health systems research priorities for each of the three thematic areas for the next 3–5 years.

Study findings can help inform and direct future plans to generate, disseminate and use research evidence for LMICs in the MENA region. Our study process and results could help reduce the great chasm between the policy and research worlds in the MENA region. It is hoped that funding agencies and countries will support and align financial and human resources towards addressing the research priorities that have been identified.

Comparative cost analysis of insecticide-treated net delivery strategies: sales supported by social marketing and free distribution through antenatal care

Thu, 24 Dec 2009 05:10:54 PST

Insecticide-treated nets (ITNs) are effective in substantially reducing malaria transmission. Still, ITN coverage in sub-Saharan Africa (SSA) remains extremely low. Policy makers are concerned with identifying the most suitable delivery mechanism to achieve rapid yet sustainable increases in ITN coverage. Little is known, however, on the comparative costs of alternative ITN distribution strategies. This paper aimed to fill this gap in knowledge by developing such a comparative cost analysis, looking at the cost per ITN distributed for two alternative interventions: subsidized sales supported by social marketing and free distribution to pregnant women through antenatal care (ANC). The study was conducted in rural Burkina Faso, where the two interventions were carried out alongside one another in 2006/07. Cost information was collected prospectively to derive both a financial analysis adopting a provider's perspective and an economic analysis adopting a societal perspective. The average financial cost per ITN distributed was US$8.08 and US$7.21 for sales supported by social marketing and free distribution through ANC, respectively. The average economic cost per ITN distributed was US$4.81 for both interventions. Contrary to common belief, costs did not differ substantially between the two interventions. Due to the district's ability to rely fully on the use of existing resources, financial costs associated with free ITN distribution through ANC were in fact even lower than those associated with the social marketing campaign. This represents an encouraging finding for SSA governments and points to the possibility to invest in programmes to favour free ITN distribution through existing health facilities. Given restricted budgets, however, free distribution programmes are unlikely to be feasible.

Learning from international policies on trans fatty acids to reduce cardiovascular disease in low- and middle-income countries, using Mexico as a case study

Perez-Ferrer, C., Lock, K., Rivera, J. A — Thu, 24 Dec 2009 05:10:54 PST

Trans fatty acids (TFA) are a major risk factor for cardiovascular disease (CVD), and are consumed in large quantities in low- and middle-income countries as they are used to produce low cost, commonly eaten processed food products. International organizations agree that evidence linking TFA and CVD is strong enough to warrant public health action.

This study investigates barriers and opportunities that exist for TFA policy development in low- and middle-income countries, through a literature review of international TFA policy and stakeholder analysis. Previous national policy responses have mostly been in developed countries. Voluntary reduction of TFA by the food industry, following food labelling and/or consumer lobbying, has been the approach in several countries but with varying levels of success, and resulting in major differences in formulation of products between countries. Canada and New York have now moved from voluntary to mandatory approaches. Only three countries have regulated the TFA content of food. Common factors for successful TFA reduction include increased consumer and political awareness of the health impacts of TFA and the need for champion consumer organizations.

A stakeholder analysis, using the Mexican policy context as a case study, explored contextual issues influencing implementation of TFA regulation in low- or middle-income countries. Although the public health context seemed to be appropriate to promote TFA policy, the issue is not on the political agenda because it lacks legitimacy and support as a health or regulatory issue. The food industry and government resist the need for regulation, and there is no organized health or consumer lobby to counter this. This is likely to be the case in other middle- and low-income countries.

Child immunization coverage in urban slums of Bangladesh: impact of an intervention package

Uddin, M. J., Larson, C. P, Oliveras, E., Khan, A I, Quaiyum, M A, Saha, N. C. — Thu, 24 Dec 2009 05:10:54 PST

The study assessed the impact of an EPI (Expanded Programme on Immunization) intervention package, implemented within the existing service-delivery system, to improve the child immunization coverage in urban slums of Dhaka, Bangladesh. This intervention trial used a pre- and post-test design. An intervention package was tested from September 2006 to August 2007 in two urban slums. The intervention package included: (a) an extended EPI service schedule; (b) training for service providers on valid doses and management of side-effects; (c) a screening tool to identify immunization needs among clinic attendants; and (d) an EPI support group for social mobilization. Data were obtained from random sample surveys, service statistics and qualitative interviews. Analysis of quantitative data was based on a ‘before and after’ assessment of selected immunization-coverage indicators. Qualitative data were analysed using content analysis. Ninety-nine per cent of the children were fully immunized after implementation of the interventions compared with only 43% before implementation. Antigen-wise coverage after implementation was also significantly higher compared with before implementation. Only 1% drop-out was observed after implementation of the interventions while it was 33% before implementation. At baseline, a significantly higher proportion of children of non-working mothers (75%) were fully immunized compared with children of working mothers (14%). Although the proportion of fully immunized children of both non-working and working mothers was significantly higher at endline, fully immunized children of working mothers dramatically improved at endline (99%) compared with baseline (14%). The findings suggest the effectiveness of a ‘package of interventions’ in improving child immunization coverage in urban slums. However, further research is needed to fully assess the effectiveness of the package, to assess the individual components in order to identify those that make the biggest contribution to coverage, and to assess the sustainability of this package within the existing service delivery system, particularly on a wider scale.

"This body does not want free medicines": South African consumer perceptions of drug quality

Patel, A., Gauld, R., Norris, P., Rades, T. — Thu, 24 Dec 2009 05:10:54 PST

Objectives Like many other developing countries, South Africa provides free medicines through its public health care facilities. Recent policies encourage generic substitution in the private sector. This study explored South African consumer perceptions of drug quality and whether these perceptions influenced how people procured and used their medicines.

Methods The study was undertaken in Durban, Cape Town and Johannesburg in South Africa between December 2005 and January 2006. A combination of purposive and snowball sampling was used to recruit participants from low and middle socio-economic groups as well as the elderly and teenagers. Data were collected through 12 focus group discussions involving a total of 73 participants. Interviews were tape-recorded. Thematic analysis was performed on the transcripts.

Results Irrespective of socio-economic status, respondents described medicine quality in terms of the effect the medicine produced on felt symptoms. Generic medicines, as well as medicines supplied without charge by the state, were considered to be poor quality and treated with suspicion. Respondents obtained medicines from three sources: public sector hospitals and/or clinics, dispensing doctors and community pharmacies. Cost, avoidance of feeling ‘second-class’, receiving individualized care and choice in drug selection were the main determinants influencing their procurement behaviour. Selection of over-the-counter medicines was influenced by prior knowledge of products, through advertising and previous use. Participants perceived that they had limited influence on selection of prescription medicines. Generic substitution would be supported if the doctor, rather than the pharmacist, recommended it.

Conclusions Our findings emphasize the importance of meaningful consumer involvement in the development of national medicines policies, and strategic campaigns targeting consumers and prescribers regarding the quality of generic and essential medicines. Where consumers perceive free or generic medicines as inferior, this could significantly undermine attempts to implement national medicines policies aimed to improve access to medicines.

Medicine prices in urban Mozambique: a public health and economic study of pharmaceutical markets and price determinants in low-income settings

Russo, G., McPake, B. — Thu, 24 Dec 2009 05:10:55 PST

It has been suggested that medicines are unaffordable in low-income countries and that world manufacturing and trade policies are responsible for high prices. This research investigates medicine prices in urban Mozambique with the objective of understanding how prices are formed and with what public health implications. The study adopts an economic framework and uses a combination of quantitative and qualitative methods to analyse local pharmaceutical prices and markets. The research findings suggest that: (a) local mark-ups are responsible for up to two-thirds of drugs’ final prices in private pharmacies; (b) statutory profit and cost ceilings are applied unevenly, due to lack of government control and collusion among suppliers; and (c) the local market appears to respond effectively to the urban population's diverse needs through its low-cost and high-cost segments, although uncertainty around the quality of generics may be inducing consumers to purchase less affordable drugs. We conclude that local markets play a larger than expected role in the determination of prices in Mozambique, and that more research is needed to address the complex issue of affordability of medicines in low-income countries. We also argue that price controls may not be the most effective way to influence access to medicines in low-income countries, and managing demand and supply towards cheaper effective drugs appears a more suitable policy option.