Cost-effectiveness of health care service delivery interventions in low and middle income countries:a systematic review

Background:Low and middle income countries(LMICs)face severe resource limitations but the highest burden of disease.There is a growing evidence base on effective and cost-effective interventions for these diseases.However,questions remain about the most cost-effective method of delivery for these interventions.We aimed to review the scope,quality,and findings of economic evaluations of service delivery interventions in LMICs.Methods:We searched PUBMED,MEDLINE,EconLit,and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions.We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio.Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions.Quality was judged by the Drummond checklist.Results:Overall,3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review.Thirty-seven studies were included in the final review.Twenty-three studies reported on interventions we classed as“changing by whom and where care was provided”,specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community.Evidence suggests this type of intervention is likely to be cost-effective or cost-saving.Nine studies reported on quality improvement initiatives,which were generally found to be cost-effective.Quality and methods differed widely limiting comparability of the studies and findings.Conclusions:There is significant heterogeneity in the literature,both methodologically and in quality.This renders further comparisons difficult and limits the utility of the available evidence to decision makers.

Participatory approach to design social accountability interventions to improve maternal health services:a case study from the Democratic Republic of the Congo

Background:Social accountability(SA)comprises a set of mechanisms aiming to,on the one hand,enable users to raise their concerns about the health services provided to them(voice),and to hold health providers(HPs)accountable for actions and decisions related to the health service provision.On the other hand,they aim to facilitate HPs to take into account users’needs and expectations in providing care.This article describes the development of a SA intervention that aims to improve health services responsiveness in two health zones in the Democratic Republic of the Congo.Methods:Beneficiaries including men,women,community health workers(CHWs),representatives of the health sector and local authorities were purposively selected and involved in an advisory process using the Dialogue Model in the two health zones:(1)Eight focus group discussions(FGDs)were organized separately during consultation aimed at sharing and discussing results from the situation analysis,and collecting suggestions for improvement,(2)Representatives of participants in previous FGDs were involved in dialogue meetings for prioritizing and integrating suggestions from FGDs,and(3)the integrated suggestions were discussed by research partners and set as intervention components.All the processes were audio-taped,transcribed and analysed using inductive content analysis.Results:Overall there were 121 participants involved in the process,51 were female.They provided 48 suggestions.Their suggestions were integrated into six intervention components during dialogue meetings:(1)use CHWs and a health committee for collecting and transmitting community concerns about health services,(2)build the capacity of the community in terms of knowledge and information,(3)involve community leaders through dialogue meetings,(4)improve the attitude of HPs towards voice and the management of voice at health facility level,(5)involve the health service supervisors in community participation and;(6)use other existing interventions.These components were then articulated into three intervention components during programming to:create a formal voice system,introduce dialogue meetings improving enforceability and answerability,and enhance the health providers’responsiveness.Conclusions:The use of the Dialogue Model,a participatory process,allowed beneficiaries to be involved with other community stakeholders having different perspectives and types of knowledge in an advisory process and to articulate their suggestions on a combination of SA intervention components,specific for the two health zones contexts.

Outcome of treatment seeking rural gamblers attending a nurse-led cognitive-behaviour therapy service:A pilot study

Objectives:Little is known about the differences between urban and rural gamblers in Australia,in terms of comorbidity and treatment outcome.Health disparities exist between urban and rural areas in terms of accessibility,availability,and acceptability of treatment programs for problem gamblers.However,evidence supporting cognitivebehaviour therapy as the main treatment for problem gamblers is strong.This pilot study aimed to assess the outcome of a Cognitive-Behavioural Therapy(CBT)treatment program offered to urban and rural treatment-seeking gamblers.Methods:People who presented for treatment at a nurse-led Cognitive-Behavioural Therapy(CBT)gambling treatment service were invited to take part in this study.A standardised clinical assessment and treatment service was provided to all participants.A series of validated questionnaires were given to all participants at(a)assessment,(b)discharge,(c)at a one-month,and(d)at a 3-month follow-up visit.Results:Differences emerged between urban and rural treatment-seeking gamblers.While overall treatment outcomes were much the same at three months after treatment,rural gamblers appeared to respond more rapidly and to have sustained improvements over time.Conclusion:This study suggests that rural problem gamblers experience different levels of co-morbid anxiety and depression from their urban counterparts,but once in treatment appear to respond quicker.ACBT approach was found to be effective in treating rural gamblers and outcomes were maintained.Ensuring better availability and access to such treatment in rural areas is important.Nurses are in a position as the majority health professional in rural areas to provide such help.

Patient-centered medical home and integrated care in the United States: An opportunity to maximize delivery of primary care

The reciprocal relationship between mental and physical health is well established.Undiagnosed,untreated,and poorly managed mental health conditions are associated with numerous physical health complications,poor treatment adherence,and decreased quality of life.Despite growing evidence regarding the importance of effectively addressing these conditions in primary care,the rates of identification remain low and follow-up and management by primary care providers has been criticized.The objective of this review was to demonstrate the role of Patient-Centered Medical Home(PCMH)and mental health integration in addressing comprehensive health care needs in primary care patients,and to describe common barriers and facilitators to the implementation of these types of programs.

The impact of the COVID-19 pandemic on nasopharyngeal carcinoma patients-a national cancer centre experience

Purpose or objective The COVID-19 pandemic has resulted in significant healthcare implications,with care for can-cer patients compromised due to resource diversion towards battling the pandemic.We aim to investigate the impact of the peak wave of the pandemic in 2020 on the delivery of cancer care in Singapore,specifically via our nasopharyn-geal carcinoma(NPC)treatment data.This study applies real world numbers to the impact of COVID-19 on cancer care delivery in Singapore.The choice of nasopharyngeal cancer allows a good direct estimate of common treatment measures such as time to biopsy,time to staging scans,time to treatment commencement,due to its clear protocol and algorithms for staging and treatment;thus serving as an excellent surrogate for the effectiveness and timeliness of the different aspects of cancer care delivery.Materials and methods In this retrospective study,we included all patients with newly diagnosed NPC from 1st January to 31st May from 2017 to 2020 at our centre.This time period was chosen as it coincided with the period in 2020 during the COVID-19 pandemic where there was the most strain on healthcare resources and the most restrictions on population movement within Singapore,which may impact on healthcare seeking behaviour.Narrowing down the time period to the first 5 months of the 4 respective years also allowed us to reduce the effect of annual seasonal variation in patient numbers seen as a result of holidays and festive periods such as the Lunar New Year and scheduled school holidays.Electronic medical records(EMR)were accessed.Only newly diagnosed NPC cases were included in our analysis.Patients with second synchronous primary malignancies or NPC disease recurrence were excluded.Data analysis was carried out using a combination of SPSS and Microsoft Excel.Results Significantly,there was a reduction of 37-46.3%in newly diagnosed NPC cases during the peak of the COVID-19 pandemic from January to end May 2020 compared to the preceding three years.Despite the reduction in numbers of newly diagnosed NPC,there was no statistically significant differences in delay from biopsy to the first radiation oncology visit and from biopsy to the first day of treatment in 2020 compared to the preceding years.All the patients treated in our centre also received the standard NPC treatment for their disease stage as per international guidelines.Conclusion We recommend a heightened awareness of the dangers of delaying cancer presentation and care in healthcare policies and resource allocation and at the same time,encourage patient’s confidence in their ability to seek care.With the resurgence of new COVID-19 variants and case numbers worldwide and in Singapore,this study focuses upon the need to be aware of the exigencies of other clinical groups in resource utilization.It would be instructive to compare this study with future long term follow up to investigate the trajectory of our cancer care delivery,as well as survival outcomes.