From January 2015 to December 2016, the health authorities in Burundi piloted the inclusion of child nutrition services into the pre-existing performance-based financing free health care policy ...(PBF-FHC). An impact evaluation, focused on health centres, found positive effects both in terms of volume of services and quality of care. To some extent, this result is puzzling given the harshness of the contextual constraints related to the fragile setting.
With a multi-methods approach, we explored how contextual and implementation constraints interacted with the pre-identified tracks of effect transmission embodied in the intervention. For our analysis, we used a hypothetical Theory of Change (ToC) that mapped a set of seven tracks through which the intervention might develop positive effects for children suffering from malnutrition. We built our analysis on (1) findings from the facility surveys and (2) extra qualitative data (logbooks, interviews and operational document reviews).
Our results suggest that six constraints have weighted upon the intervention: (1) initial low skills of health workers; (2) unavailability of resources (including nutritional dietary inputs and equipment); (3) payment delays; (4) suboptimal information; (5) restrictions on autonomy; and (6) low intensity of supervision. Together, they have affected the intensity of the intervention, especially during its first year. From our analysis of the ToC, we noted that the positive effects largely occurred as a result of the incentive and information tracks. Qualitative data suggests that health centres have circumvented the many constraints by relying on a community-based recruitment strategy and a better management of inputs at the level of the facility and the patient himself.
Frontline actors have agency: when incentives are right, they take the initiative and find solutions. However, they cannot perform miracles: Burundi needs a holistic societal strategy to resolve the structural problem of child malnutrition.
Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).
Malnutrition is a huge problem in Burundi. In order to improve the health system response, the Ministry of Health piloted the introduction of malnutrition prevention and care indicators within its ...performance-based financing (PBF) scheme. Paying for units of services and for qualitative indicators is expected to enhance provision and quality of these nutrition services. The objective of this study is to assess the impacts of this intervention, on both child acute malnutrition recovery rates at health centre level and prevalence of chronic and acute malnutrition among children at community level. This study follows a cluster-randomized controlled evaluation design: 90 health centres (HC) were randomly selected for the study, 45 of them were randomly assigned to the intervention and received payment related to their performance in malnutrition activities, while the other 45 constituted the control group and got a simple budget allocation. Data were collected from baseline and follow-up surveys of the 90 health centres and 6,480 households with children aged 6 to 23 months. From the respectively 1,067 and 1,402 moderate and severe acute malnutrition transcribed files and registers, findings suggest that the intervention had a positive impact on moderate acute malnutrition recovery rates (OR: 5.59, p = 0.039 -at the endline, 78% in the control group and 97% in the intervention group) but not on uncomplicated severe acute malnutrition recovery rate (OR: 1.16, p = 0.751 -at the endline, 93% in the control group and 92% in the intervention group). The intervention also had a significant increasing impact on the number of children treated for acute malnutrition. Analyses from the anthropometric data collected among 12,679 children aged 6-23 months suggest improvements at health centre level did not translate into better results at community level: prevalence of both acute and chronic malnutrition remained high, precisely at the endline, acute and chronic malnutrition prevalence were resp. 8.80% and 49.90% in the control group and 8.70% and 52.0% in the intervention group, the differences being non-significant. PBF can contribute to a better management of malnutrition at HC level; yet, to address the huge problem of child malnutrition in Burundi, additional strategies are urgently required.
Despite the current global and national momentum, universal health coverage could remain an empty promise unless it is focused on the provision of quality essential services to everyone. And this, in ...turn, will not happen without strengthening local health systems. A quarter of a century later, it is clear that African health systems, particularly in rural areas, have been shaped by these efforts. The district strategy is the backbone of nearly every national health system in Africa; countries are covered by health facilities -- organized in a tier system -- whose activity packages focus on priority services. Profound changes at the global level have also affected Africa. One was the adoption of the Millennium Development Goals.
Correction: Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review. Copy to clipboard Provided by the ...Springer Nature SharedIt content-sharing initiative Correction Open access Published:22 February 2024 Correction: Health seeking behaviours and private sector delivery of care for non-communicable diseases in low- and middle-income countries: a systematic review Callum Brindley 1,2, Nilmini Wijemunige1,3, Charlotte Dieteren1,2, Judith Bom1,2, Bruno Meessen4 & … Igna Bonfrer1,2 Show authors BMC Health Services Research volume 24, Article number: 233 (2024) Cite this article 159 Accesses Metrics details The Original Article was published on 23 January 2024 Correction to: BMC Health Services Research (2024) 24:127 https://doi.org/10.1186/s12913-023-10464-0 In this article, the third author, Charlotte Dieteren, was omitted from the author group due to a typesetting mistake.
Globally, non-communicable diseases (NCDs) are the leading cause of mortality and morbidity placing a huge burden on individuals, families and health systems, especially in low- and middle-income ...countries (LMICs). This rising disease burden calls for policy responses that engage the entire health care system. This study aims to synthesize evidence on how people with NCDs choose their healthcare providers in LMICs, and the outcomes of these choices, with a focus on private sector delivery.
A systematic search for literature following PRISMA guidelines was conducted. We extracted and synthesised data on the determinants and outcomes of private health care utilisation for NCDs in LMICs. A quality and risk of bias assessment was performed using the Mixed Methods Appraisal Tool (MMAT).
We identified 115 studies for inclusion. Findings on determinants and outcomes were heterogenous, often based on a particular country context, disease, and provider. The most reported determinants of seeking private NCD care were patients having a higher socioeconomic status; greater availability of services, staff and medicines; convenience including proximity and opening hours; shorter waiting times and perceived quality. Transitioning between public and private facilities is common. Costs to patients were usually far higher in the private sector for both inpatient and outpatient settings. The quality of NCD care seems mixed depending on the disease, facility size and location, as well as the aspect of quality assessed.
Given the limited, mixed and context specific evidence currently available, adapting health service delivery models to respond to NCDs remains a challenge in LMICs. More robust research on health seeking behaviours and outcomes, especially through large multi-country surveys, is needed to inform the effective design of mixed health care systems that effectively engage both public and private providers.
PROSPERO registration number CRD42022340059 .
•Growing pluralism characterizing our societies calls for more attention to the contribution of different health system stakeholders to policy processes.•This study documents the roles of eighteen ...national hospital associations before and during the COVID-19 pandemic.National authorities should grant a role to national hospital associations in the rebuilding of health systems post pandemic.
Building on the premise that health authorities should govern their health systems in partnership with the full community of stakeholders, we document the contribution of national hospital associations to health policy processes, before and during the COVID-19 crisis.
This research followed a rapid cross-sectional comparative design. Data were collected through an online survey targeting hospital associations. Eighteen of them shared information on their institutional profile, their areas of activity, their position and participation as policy actors before and during the COVID-19 crisis, the barriers and enablers affecting their participation and the impact of the crisis on their own financial situation.
We have documented a spectrum of situations both for national policy platforms and hospital associations. In some countries, there is the ideal match of well-established associations and national participatory health policy platforms. In others, hospital associations have modest staffing and may struggle to get access to policy platforms of importance. Being a well-established and respected contributor seems to have been an enabling factor for the contribution of the hospital associations to the COVID-19 response. For most associations, the crisis has led to an increased effort to be present in the policy arena; an issue they follow closely is the negative impact of the lockdown on the hospitals’ revenue.
The growing pluralism characterizing our societies calls for the establishment of health policy platforms allowing for broader participation. Encouraging hospitals to set up their association for the latter to represent them in decision processes could be one of the components of the rebuilding of national health systems post pandemic.
Several low- and middle-income countries have exempted patients from user fees in certain categories of population or of services. These exemptions are very effective in lifting part of the financial ...barrier to access to services, but they have been organized within unstable health systems where there are sometimes numerous dysfunctions. The objective of this article is to bring to light the disruptions triggered by exemption policies in health systems of low- and middle-income countries.
Scoping review of 23 scientific articles. The data were synthesized according to the six essential functions of health systems.
The disruptions included specifically: 1) immediate and significant increases in service utilization; 2) perceived heavier workloads for health workers, feelings of being exploited and overworked, and decline in morale; 3) lack of information about free services provided and their reimbursement; 4) unavailability of drugs and delays in the distribution of consumables; 5) unpredictable and insufficient funding, revenue losses for health centres, reimbursement delays; 6) the multiplicity of actors and the difficulty of identifying who is responsible ('no blame' game), and deficiencies in planning and communication.
These disruptive elements give us an idea of what is to be expected if exemption policies do not put in place all the required conditions in terms of preparation, planning and complementary measures. There is a lack of knowledge on the effects of exemptions on all the functions of health systems because so few studies have been carried out from this perspective.
Burundi is one of the poorest countries and is among the four countries with the highest prevalence of stunting (58%) among children aged less than 5 years. This situation undermines the economic ...growth of the country as undernutrition is strongly associated with less schooling and reduced economic productivity. Identifying the determinants of stunting and severe stunting may help policy-makers to direct the limited Burundian resources to the most vulnerable segments of the population, and thus make it more cost effective. This study aimed to identify predictors of stunting and severe stunting among children aged less than two years in Burundi.
The sample is made up of 6199 children aged 6 to 23 months with complete anthropometric measurements from the baseline survey of an impact evaluation study of the Performance-Based financing (PBF) scheme applied to nutrition services in Burundi from 2015 to 2017. Binary and multivariable logistic regression analyses were used to examine stunting and severe stunting against a set of child, parental and household variables such as child's age or breastfeeding pattern, mother's age or knowledge of malnutrition, household size or socio-economic status.
The prevalence of stunting and severe stunting were 53% 95%CI: 51.8-54.3 and 20.9% 95%CI: 19.9-22.0 respectively. Compared to children from 6-11 months, children of 12-17 months and 18-23 months had a higher risk of stunting (AdjOR:2.1; 95% CI: 1.8-2.4 and 3.2; 95% CI: 2.8-3.7). Other predictors for stunting were small babies (AdjOR=1.5; 95% CI: 1.3-1.7 for medium-size babies at birth and AdjOR=2.9; 95% CI: 2.4-3.6 for small-size babies at birth) and male children (AdjOR=1.5, 95% CI: 1.4-1.8). In addition, having no education for mothers (AdjOR=1.6; 95% CI: 1.2-2.1), incorrect mothers' child nutrition status assessment (AdjOR=3.3; 95% CI: 2.8-4), delivering at home (AdjOR=1.4; 95% CI: 1.2-1.6) were found to be predictors for stunting. More than to 2 under five children in the household (AdjOR=1.45; 95% CI: 1.1-1.9 for stunting and AdjOR= 1.5; 95% CI: 1.2-1.9 for severe stunting) and wealth were found to be predictors for both stunting and severe stunting. The factors associated with stunting were found to be applicable for severe stunting as well.
Mother's education level, mother's knowledge about child nutrition status assessment and health facility delivery were predictors of child stunting. Our study confirms that stunting and severe stunting is in Burundi, as elsewhere, a multi-sectorial problem. Some determinants relate to the general development of Burundi: education of girls, poverty, and food security; will be addressed by a large array of actions. Some others relate to the health sector and its performance - we think in particular of the number of children under five in the household (birth spacing), the relationship with the health center and the knowledge of the mother on malnutrition. Our findings confirm that the Ministry of Health and its partners should strive for better performing and holistic nutrition services: they can contribute to better nutrition outcomes.
The burden of non-communicable diseases (NCDs) has increased substantially in low- and middle-income countries (LMICs), and adapting health service delivery models to address this remains a ...challenge. Many patients with NCD seek private care at different points in their encounters with the health system, but the determinants and outcomes of these choices are insufficiently understood. The proposed systematic review will help inform the governance of mixed health systems towards achieving the goal of universal health coverage. This protocol details our intended methodological and analytical approaches, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Following the PRISMA approach, this systematic review will develop a descriptive synthesis of the determinants and outcomes of private healthcare utilisation for NCDs in LMICs. The databases Embase, Medline, Web of Science Core Collection, EconLit, Global Index Medicus and Google Scholar will be searched for relevant studies published in English between period 1 January 2010 and 30 June 2022 with additional searching of reference lists. The study selection process will involve a title-abstract and full-text review, guided by clearly defined inclusion and exclusion criteria. A quality and risk of bias assessment will be done for each study using the Mixed Methods Appraisal Tool.
Ethical approval is not required because this review is based on data collected from publicly available materials. The results will be published in a peer-reviewed journal and presented at related scientific events.
CRD42022340059.
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