Browsing by Author "Tang, Shenglan"

Background

Methods

Results

Conclusion

Background

Human resources for health are crucial for health system strengthening and achieving sustainable development goals and universal health coverage, but the shortage and maldistribution of health workers have been critical concerns in the Asia Pacific region. This study aimed to identify the key interventions on attracting and retaining rural health workers, understand their management structure, examine the effectiveness and analyze the contexts in the Asia Pacific region.

Methods

This mixed-method study used systematic review and country case studies to synthesize and analyze the available data. A systematic review on attraction and retention of rural health workers in the Asia Pacific region was conducted. Thirty-five, fourteen and nineteen studies were included for the interventions and their management structure, effectiveness and contexts, respectively. In-depth interviews of twenty-two key informants and gray literature recommended from the key informants in China, Vietnam and Cambodia were used to gather information for the country case studies. Narrative synthesis was applied to review and synthesize the extracted data from the systematic review and qualitative analysis using Nvivo 11 was conducted for the interviews.

Results

Five categories of interventions, involving education, regulation, financial incentives, personal and professional support and bundled interventions were implemented to attract and retain rural health workers in the Asia Pacific region. Regulatory interventions, such as MRBS, task shifting and compulsory rural services, were the key interventions reported in the systematic review. Although financial incentives were scarce in the systematic review, they were the key strategies in the country case studies of China, Vietnam and Cambodia. Asian Pacific countries also had their distinctive interventions, such as a system of compulsory rural services in Thailand, training on community health workers in Afghanistan, and a government midwifery incentive scheme in Cambodia. Geographically, the Pacific island countries were neglected.

Six categories of management structure of implementation were summarized. Decentralization from the central to the regional government was the dominant management structure. The regional government was responsible for program implementation in the decentralized programs, program development and implementation in the regional initiatives, which were more likely to be discovered in the countries and regions with strong economies. International donors were significant stakeholders for the low-income and post-conflict countries through providing financial and technical assistance. Several challenges emerged during implementation, including lack of rural eligible candidates, low and unsustainable financial incentives, complicated recruitment, poor management and deployment of HRH.

Although the majority of interventions lacked rigorous effectiveness evaluation or were without evaluation, most evaluated interventions demonstrated effectiveness in attracting and retaining rural health professionals. Some of the interventions also reported effectiveness in expanding health service coverage and improving health status. The regulatory interventions seemed to be more effective in attracting and retaining rural health workers through administrative and legislative enforcement. Bundled interventions were expected to be more effective and be more often recommended by the researchers and interviewees.

Various contexts, including political, economic and social factors and health system related issues, directly and indirectly impacted the attraction and retention of rural health workers. The political issues, economic development and social culture influenced rural HRH strengthening at the macro level while the health system reform pulled or pushed rural health workers. The promotion of rural health workers to be civil servants in Vietnam and Cambodia was a good motivation for rural health workers. The post mechanism in China, abolition of the referral system and increasing financial autonomy in the hospitals in Vietnam, the popular private sector, limited physical and human resources all served to push the health workers out of rural positions.

Conclusion

Due to great variation in economic development, Asian Pacific countries implemented three different patterns of interventions: 1) comprehensive packages in the high-income countries; 2) one or two categories of interventions in the low- and middle-income countries; and 3) training of community health workers in the post-conflict countries. Economic variation was also reflected in the differences of the management structure of implementation. The upper-middle- and high-income countries were likely to initiate regional interventions while the low-income countries partly relied on donations for HRH development and implementation, especially for the post-conflict countries. Although decentralization was widely applied to implementation, its implications were neglected and unclear. Based on the exclusive mechanism, effectiveness of each category of interventions varied. However, the regulatory interventions seemed be better. The socio-economic development significantly influenced interventions on attracting and retaining rural health workers. Rural HRH strengthening required strong economic support. Health financing reform for universal health coverage did impact the capacity building of rural health workforce. Further research was needed.

The burden of non-communicable diseases (NCDs) continues to grow in Vietnam. Recently, Vietnam government initiated a new national plan with a strong focus on NCD prevention and control in the community. This study is intended to investigate the current role of Vietnamese village health workers (VHWs) in preventive and NCD-related care, and to explore the barriers and facilitators to expand the role by including routine community-based NCD prevention and control services. From June to July 2016, four focus group discussions with VHWs (n=24) and thirteen in-depth interviews (n=13) with public health administrators (n=13) were conducted in Chi Lin District, Hai Duong Province, Vietnam. A thematic analysis was conducted to identify themes in the data. The participants identified health education, program outreach, and case management as the current responsibilities of VHW. In NCD programs, VHWs provide these services mostly to hypertension and diabetes patients. Majority of the participants endorsed the idea of incorporating NCD early detection and risk reduction into VHW role and thought their close connection with community justified their strength in conducting these services. Currently perceived barriers included aging VHW, insufficient NCD-related knowledge, poor training quality, imbalanced workload and remuneration, lack of resource, and policy-driven guideline. While, participants believed that upon empowering through training, guidance, and proper incentive, VHWs would serve as effective NCD risk detector and healthy behavior promoter in their communities. The study indicates that, with interpersonal, organizational and policy support, VHWs may have the potential to conduct routine community-based NCD early detection and risk reduction activities in Vietnam.

Background: To control and minimize the spread of COVID-19, vaccination among the population to achieve herd immunity is important. However, optimizing the vaccination capacity for facility-based vaccination sites and mass vaccination sites is challenging. Additionally, evaluating the impacts of different patient flow arrangements for mass vaccination sites is hard in practice. A study to answer those questions is needed to improve the operation of COVID-19 vaccination sites and reduce the waiting time for patients and cost. Methods: Initially, the time-motion method was used to evaluate the real-world health facilities’ COVID-19 vaccination capacity in China. Then, optimization models were built to determine the optimal capacity levels for different vaccination sites based on the time-motion data. Furthermore, the impacts of different patient flow arrangements were investigated in mass vaccination sites through a discrete event simulation approach. Results: The optimization models established in this study provide tools for policymakers to optimize the capacity level of walk-in COVID-19 vaccination sites for different vaccination targets while considering the cross-infectious risk. Compared to facility-based vaccination sites, a single mass vaccination site will require fewer service desks than using multiple facility-based vaccination sites. The mass vaccination site arranged with an optimal capacity level using a pooled queue tends to be more flexible compared to real-world arrangements. Conclusions: This research developed a modeling framework that can help to optimize the service capacity level, identify the trade-off points for vaccination planning, and reduce the cost of operating the vaccination sites to aid in the planning of the COVID-19 vaccination site.

Due to a high burden of disease of pneumonia in Vietnam, the country not including the pneumococcal conjugate vaccine (PCV) in its National Expanded Programme of Immunization (EPI), and the scarce data on PCV vaccine coverage or caregivers’ behavior within the country, it is imperative to assess the Knowledge, Attitude and Practice (KAP) of the caregivers’ community, to further explore ways to increase PCV uptake. The purpose of this study is to understand the KAP of caregivers towards PCV inoculation for children in Hanoi, VietnamMethodology: 338 respondents fulfilled the Qualtrics questionnaire and 26 respondents (16 caregivers and 10 health workers) were interviewed in Hanoi, Vietnam, using semi-structured interviews in June-December 2023. Materials and data were transcribed between Vietnamese and English, and analyzed according to selected themes. Discussion/Conclusions: Although the findings suggest that caregivers in Hanoi have limited knowledge on PCV, support for attitude and practice on accepting PCV exists, especially from caregivers with high socio-economic status. This study wished to contribute to a better understanding of the KAP factors regarding childhood vaccines, which may support decision-making about vaccine policies, and be utilized for creating suitable vaccine promotion materials for child caregivers.

Objective: This study aims to investigate the cancer epidemiology and impact of healthcare system reform on patient out-of-pocket expense, presence of catastrophic health expenditures (CHE), healthcare utilization, and inpatient/outpatient medical expenditure in China after 2009 from the perspective of health system reforms.

Methods: This study is a mixed-methods study, includes an analysis of quantitative data and key informant interviews with major stakeholders. Quantitative analysis was performed on data collected from the China Health and Retirement Longitudinal Study (CHARLS) in 2011 and 2018 to investigate the correlation between cancer prevalence, CHE incidence (households that spend 40% of their non-food incomes on healthcare), and socioeconomic characteristics. This analysis explored the healthcare utilization and out-of-pocket expenses (OOPE) of cancer patients across different socioeconomic status groups and in urban and rural areas, as well as in the eastern, central, and western regions. Key informant interviews were conducted with major stakeholders including physicians, scholars, and disease control leaders/managers. The transcripts of the interviews were coded and analyzed for themes on the results of the quantitative study, inequalities in healthcare service utilization, and inequalities in healthcare insurance finance.

Results: The self-reported prevalence rate of cancer increased from 0.93% in 2011 to 1.02% in 2018. The incidence of CHE of cancer patients increased from 45.40% in 2011 to 58.50% in 2018. Urban-Rural Resident Basic Medical Insurance (URRBMI) beneficiaries are more likely to experience CHE than Urban Employee Basic Medical Insurance (UEBMI) beneficiaries. In 2018, the incidence of CHE was significantly lower in the group with the highest socioeconomic status compared to other groups. Compared to 2008 and 2011, the outpatient visit rate for cancer patients decreased by 7% in 2018, while the hospitalization rate significantly increased by nearly 30%. Urban residents have a higher hospitalization rate, which may be related to the concentration of hospitals providing cancer treatment services in cities, and urban employees enjoy a more comprehensive health insurance benefit package. In groups with higher socioeconomic status, cancer patients tend to have higher rates of outpatient visits and hospitalizations. This may be due to their greater ability to afford the expenses associated with cancer treatment.Both the average outpatient visits expenditure and the average inpatient care expenditure have increased significantly (outpatient visits expenditure per time increased by ¥500, and inpatient per time increased by ¥7000 from 2011 to 2018). While healthcare expenditure has significantly increased, the percentage of out-of-pocket expenses (OOPE) has decreased. Reasons for the decrease include more cancer drugs being included in the reimbursement list, a reduction in the medical insurance deductible, and an increase in the reimbursement ratio.

Conclusions: The health system reforms have improved access to healthcare services, especially inpatient care, and improved drug accessibility. However, inequality in healthcare service utilization and healthcare insurance financing still exists. Inequality is mainly reflected in urban-rural differences and different socioeconomic statuses. To address inequalities within the country, China needs to take a series of coordinated actions. Include improving mechanisms used to mobilize the health insurance funds in China, and making comprehensive changes to health insurance benefit packages and healthcare resource contributions.

Background. Since the late 2000s, universal health coverage (UHC) has been identified as an important goal, which is to ensure people’s access to needed health services without suffering from financial hardships. Many countries have adopted health insurance reform as an important approach to meet the goal of UHC. China and Vietnam are two countries that have made great progress through this approach. China covered more than 97% of entire population in 2011, while Vietnam just reached 80% in 2017. Compared with the universal service package in Vietnam, the health insurance in China has been criticized for its limited benefit package and failure to protect patients from financial risks. To compare the development of health insurance and its influence on the attainment of UHC, a mix-method study was conducted in China and Vietnam.

Methods. A policy review was included to compare the important health insurance policies in these two countries. Guided by the WHO UHC model, national-level data on health financing, population coverage, health service use and financial protection were quantitatively analyzed. The quantitative result was present with qualitative data extracted from 16 interviews with UHC scholars, policymakers, and local government agency officers to provide a comprehensive comparison of the health insurance development in China and Vietnam.

Result. Along with the great political efforts to develop the health insurance, a large amount of financial resource for health and health insurance has also been devoted to health insurance. A trend toward health financing through social security fund has been observed in both countries. Regarding the health insurance policy development, China has prioritized the population coverage rate at an early stage. Through extensive subsidies for enrollees of the New Rural Medical Insurance Scheme (NCMS) and Urban Resident Medical Insurance Scheme (URBMI), 97% of China’s total population has been covered since 2011. However, the insurance benefit design is very shallow and has a clear focus on inpatient services. As a result, although an increased use of inpatient services was observed, the real financial burden actually rose. The government has started to increase the benefits package since 2009. A greatly increased government budget and improved benefit package have been observed with a decrease of the financial burden. Meanwhile, there are still gaps between the policy and real implementation, the disparities between benefit packages, health services use and, financial risks still exist among different schemes.

The development of health insurance in Vietnam depends on the expansion of the compulsory scheme. Since 2003, the Vietnamese government has started to increase the number of compulsory groups and gradually introduce a government subsidy for the vulnerable people, including the poor, children, the old and the near poor. A high population coverage rate has been achieved among all the subsidized groups. The service coverage is wide in scope and the reimbursement rate has a pro-poor design. Compared with China, there is no obvious trend on service use. The health insurance in Vietnam also provides better financial protection and has achieved a better equity with protecting the vulnerable groups than in China.

Several important lessons were learned from this comparison between China and Vietnam. The government political and financial input are essential drivers for health insurance development. Government subsidy for premium is a common approach to financing the health insurance and encourage enrollment, which is also proved to be effective in both two countries. The service package design has a strong influence on the health service use pattern and the financial burden. The design of the insurance needs to focus more on equity. The vulnerable groups, especially the poor are still disproportionately suffering from the financial risk caused by using health services and this is still a common challenge facing both China and Vietnam.

Background: Universal healthcare has been promoted by organizations including the World Health Organization and United Nations as a means of ensuring healthcare access for vulnerable populations. Despite momentum towards universal healthcare, especially among Southeast Asian nations, little research has been conducted to understand healthcare equity in nations that have already implemented universal healthcare. This paper assesses equity in healthcare access in Brunei Darussalam using results from the Brunei Darussalam Health System Survey (HSS).

Methods: Data were gathered using a nationally-representative survey of 1,197 households across four districts in Brunei Darussalam. The Health System Survey aimed to measure individual's expectations and utilization of the Brunei national healthcare system. Data were analyzed using descriptive statistics and multinomial logistic regression to identify respondent- and household-level characteristics that affect healthcare utilization and expenditures.

Results: HSS data suggest that healthcare utilization in Brunei varies by ethnicity, district of residence, health status, and income. When compared to other ethnic groups, Chinese households were significantly less likely to utilize public healthcare and significantly more likely to utilize private healthcare services. Indigenous groups also demonstrated significantly lower rates of private healthcare utilization compared to other ethnicities. Temburong district had the lowest rates of both private and public healthcare utilization and was associated with a 2.67 decreased likelihood of using public healthcare in the past six months. When stratifying for health status, data indicate that healthcare utilization in Brunei is proportional to healthcare need, with 93 percent of respondents in poor health reporting using government hospitals 12 or more times in the past six months compared to 76 percent of respondents in excellent health reporting using healthcare only once in the past six months. Income was also found to be positively associated with increased healthcare expenditures and private healthcare use.

Conclusion: This study highlights an example of a universal healthcare system in Southeast Asia and indicates that a well-funded universal healthcare system can reduce significant utilization disparities. Substantial financial resources do not, however, guarantee equity among rural and minority populations and universal healthcare efforts should incorporate measures to understand and address barriers to healthcare among these groups.

Abstract

Background: As the country with the third largest TB epidemic, China has a major responsibility to control the prevalence of TB. A standardized health information system is required to monitor the TB epidemic and the performance of the national TB control program. However, the capacity of the health information systems to detect infectious diseases in China need further enhancement. It is widely perceived that the problems of underreporting exist in China’s infectious diseases reporting systems, but little is known about the extent of underreporting as no rigorous empirical research has been conducted. Therefore, the aim of this study is to empirically analyze the issues of TB underreporting, identify weaknesses in the health information systems, and make suggestions for improvement.

Methods: This study utilized a mixed method approach to evaluate China’s health information system by identifying the problems of TB underreporting in Zhenjiang, China. Using the data of 2,136 TB cases from the hospital information and TB information management systems, we analyzed the extent to which TB cases are underreported through chi-square test and multivariable logit regression. We subsequently conducted policy document review and evaluated the transcripts from 19 interviews to investigate the key factors causing TB underreporting.

Results: Our study indicates that approximately 29.3% of TB cases in Zhenjiang city are unreported. The unreported rates of outpatients are higher than the unreported rates of inpatients except the cases in Jurong Hospital. Generally, inpatients who did not reside in their jurisdiction had higher unreported rates than those inpatients living in their jurisdiction for a long period. Moreover, patients without a personal ID card had higher unreported rates than those with ID cards. Additionally, underreporting among inpatient was significantly higher than non-in-hospital referrals.

Through in-depth interviews, we discovered the potential factors causing TB underreporting are poor system design and some human resource related issues. More specifically, for the former one, hospitals use different electronic systems to record patient information, which often causes confusion when TB reporters search the records for a TB diagnosis. The lack of a self-check function reduces the accuracy of data reported. Moreover, the health information systems lack interoperability among different health facilities, which slows the transfer of information and creates room for mistakes. For the latter one, clinicians and hospital statisticians reflected that the heavy workload and low financial incentives made them reluctant to report TB cases timely and accurately. What’s more, the absence of specific and unified standards for health workers from different cities, counties, and facilities with which to comply is also evident. The limited requirements of government intensified the chaos generated during the establishment of information systems at the local level. The political context of inadequate incentive policies and low degree of supervision aggravated the quality of implementation.

Conclusion: We found that the lack of self-check function, lack of data standardization, lack of system interoperability and accessibility, heavy workload for healthcare workers, lack of awareness of reporting, lack of financial incentives, absence of surveillance, and lack of guidance and role clarity are associated with TB underreporting. Our study reveals the important role of system design, government leadership, and qualified, dedicated, and well- paid health personnel play in ensuring the accuracy of data.

Background: Ending the global tuberculosis (TB) epidemic by 2035 will substantially depend on the effective control of the “lost to follow-up” (LTFU) from TB treatment. Myanmar is one of the 14 countries with high burden of TB, TB/HIV, and Multidrug-Resistant TB (MDR-TB). The aim of the study is to identify the factors associated with LTFU from TB treatment among migrant and mobile populations in Mon and Kayin States in Myanmar.

Methods: This was a prospective cohort study with a convergent mixed methods design. 146 new TB patients were surveyed and 14 “treatment after LTFU” patients were interviewed between June and September, 2016. Upon the treatment outcome data made available in February 2017, the survival analysis was conducted to measure the effect of potential predictors on time to LTFU during the full duration of treatment using Stata 14.0 version for Mac. Thematic networks analysis was applied to the qualitative data analysis by NVivo software 11.3.2 version for Mac.

Results: Of the 146 patients included, 10 (6.85%) new patients were LTFU from treatment. Having a family and/or community member support during the six to eight months’ treatment was a protective factor (Hazard Ratio (HR) 0.146; 95% CI 0.037 - 0.576; p = 0.0075), whereas the intention to stay for less than three months at the current place was a potential risk factor (HR 6.323; 95% CI 1.403 – 28.499; p = 0.0075) for getting LTFU from TB treatment. Having a lack of knowledge, but a positive attitude towards TB predisposed migrant TB patients to look for health education. However, financial constraint and social stigma of TB reinforced them to get LTFU from TB treatment. Poor provider-to-patient communication and barriers to accessibility of services were the enabling factors for the delay seeking care and treatment.

Conclusions: People on the move who are intended to stay in working area for less than 3 months are the high-risk group for TB treatment default. Having no family and/or community member support is a risk factor associated with tuberculosis treatment default among the migrant and mobile populations in Mon and Kayin States of Myanmar. National Tuberculosis Program should strengthen the existing multilateral community-based TB care with an integrated referral system inclusive of people on the move who are intended to stay in working area for less than three months. Fostering self-efficacy of TB patients by patient-centered communication and informed decision-making in the clinical setting as well as in the community will enable the better adherence to TB treatment among the migrant and mobile populations.

The human resources for health is one of the key building blocks in tuberculosis control. As the implementer of disease control policies and medical practices, physicians are at a core position for the health of tuberculosis patients. Unfortunately, while the tuberculosis control system is under the transition to the Trinity Model nationwide, little attention was paid to this particular workforce. This study filled the gap of little information about the challenges of tuberculosis physicians by researching on the gaps and challenges of tuberculosis physicians at prefecture-city and county level. A mixed method approach was used to collect both quantitative and qualitative data through survey and in-depth interview with physicians, directors of clinical departments and officials at disease control agencies. The shortage of physicians, difficulty in recruitment, insufficient and inappropriate use of protective equipment, unfair compensation, and insufficient training opportunities were found as major challenges of tuberculosis physicians. A collective effort from all levels of governments, CDCs, and hospitals should be made in increasing competence, ensuring health and safety, providing fair compensation, enhancing productivity, and strengthening supportive supervision of tuberculosis physicians.

AbstractBackground: Understanding the KAP of vaccinators towards non-NIP vaccines is crucial, especially in a country as populous and diverse as China. This study focuses on the 13-valent pneumococcal conjugate vaccine (PCV13), highlighting the importance of this vaccine in preventing diseases like pneumonia, which poses a significant health threat to children under five years of age. Methods: Conducted in four provinces—Yunnan, Liaoning, Hubei, and Guangdong—this mixed-methods study combines quantitative data from 419 healthcare professionals with qualitative insights from 13 in-depth interviews. Measures focused on assessing KAP related to PCV13, with analysis leveraging multivariate linear regression and thematic analysis. Results: The study revealed moderate levels of knowledge among vaccinators about the PCV13 vaccine, with variability in attitudes and practices observed across provinces. While a significant portion of healthcare professionals demonstrated a proactive stance in recommending vaccines in their professional capacity, a notable discrepancy was observed in their personal practices, particularly concerning the vaccination of their own children with PCV13. Conclusions: This investigation underscores the complexities surrounding the KAP of vaccinators towards non-NIP vaccines in China. Identifying systemic factors affecting PCV13 implementation and addressing discrepancies between professional recommendations and personal practices are crucial steps toward improving vaccination rates.