The metric of ‘bed numbers’ is commonly used in hospital planning, but it fails to capture key aspects of how hospital services are delivered. Drawing on a study of innovative hospital projects in Europe, this article argues that hospital capacity planning should not be based on beds, but rather on the ability to deliver processes. It proposes using approaches that are based on manufacturing theory such as ‘lean thinking’ that focuses on the value that different processes add for the primary customer, i.e. the patient. It argues that it is beneficial to look at the hospital, not from the perspective of beds or specialties, but rather from the path taken by the patients who are treated in them, the respective processes delivered by health professionals and the facilities appropriate to those processes. Systematised care pathways seem to offer one avenue for achieving these goals. However, they need to be underpinned by a better understanding of the flows of patients, work and goods within a hospital, the bottlenecks that occur, and translation of this understanding into new capacity planning tools.
Equitable health services
This Briefing Note reviews the extent of emergency livelihoods responses during the most recent drought and resulting food crisis in the Horn of Africa. Drawing on secondary data and interviews with national and international actors in affected areas, it asks why accurate and timely early warning did not lead to a rapid and appropriate response to mitigate the drought’s effects, and highlights how inadequate contingency planning, limited capacity in livelihoods programming and inflexible funding mechanisms resulted in delays and deficiencies in livelihoods interventions, and the predominance of food assistance in the emergency response.
For many decades, the cornerstone of malaria management in Africa was to treat all febrile children with chloroquine. With high-level resistance to chloroquine and improved means of malaria diagnosis, recommendations for the management of malaria in Africa have changed in two important ways in the last few years. First, recommended therapy for uncomplicated falciparum malaria has moved to highly effective artemisinin-based combination therapies. Second, it is now recommended that the treatment of malaria be confined to parasitologically confirmed cases. This recommendation requires the availability of reliable diagnostic tests. The gold standard test for the diagnosis of malaria is microscopy. Evaluation of Giemsa-stained thick smears, when performed by expert microscopists, provides accurate diagnosis of malaria, although assuring expert slide preparation and reading can be difficult. Indeed, microscopy is often unavailable, especially in rural settings. In this regard, the advent of rapid diagnostic tests (RDTs) for malaria is an important advance. Multiple immunochromatographic tests, incorporating a number of different parasite antigens and produced by many different manufacturers, are now available. At best, these tests offer a simple, fairly inexpensive, and reliable means of diagnosis that can be performed by healthcare workers with limited training. However, concerns with RDTs include potential unreliability because of inconsistent manufacture or poor storage, uncertain supply, and potential misreading of results by unskilled health workers. An additional, generally unappreciated concern when considering RDTs is differences between available tests.
The objective of this paper was to measure the extent and causes of inequalities in the ownership and utilisation of bed nets (ITNs) across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania. A questionnaire was administered to heads of 1,603 households from rural and urban areas and focus group discussions were used to explore community perspectives on the causes of inequalities. Use of ITNs remained appallingly low compared to the RBM target of 80% coverage. The results highlight the need for mass distribution of free ITNs, a community-wide programme to treat all untreated nets and to promote the use of long-lasting insecticidal nets (LLINs) or longer-lasting treatment of nets, targeting the rural population and under-fives.
Antenatal care (ANC) is a widely used strategy to improve the health of pregnant women and to encourage skilled care during childbirth. In 2002, the Ministry of Health of the United Republic of Tanzania developed a national adaptation plan based on the new model of the World Health Organisation (WHO). This study assesses the time health workers currently spent on providing ANC services and compare it to the requirements anticipated for the new ANC model in order to identify the implications of Focused ANC on health care providers’ workload.
Antenatal care (ANC) is a widely used strategy to improve the health of pregnant women and to encourage skilled care during childbirth. In 2002, the Ministry of Health of the United Republic of Tanzania developed a national adaptation plan based on the new model of the World Health Organisation (WHO). In this study we assess the time health workers currently spent on providing ANC services and compare it to the requirements anticipated for the new ANC model in order to identify the implications of Focused ANC on health care providers workload.
Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here the authors share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff. The study aims to describe experiences implementing EQUIP’s QI approach at the community level. A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. The authors outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce. Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.
Despite growing support for integration of frontline services, a lack of information about the pre-conditions necessary to integrate such services hampers the ability of policy makers and implementers to assess how feasible or worthwhile integration may be, especially in low- and middle-income countries (LMICs). The authors adopted a modified systematic review with aspects of realist review of quantitative and qualitative studies that incorporated assessment of health system preparedness for and capacity to implement integrated services. From an initial list of 10 550 articles, 206 were selected for full-text review by two reviewers who independently reviewed articles and inductively extracted and synthesized themes related to health system preparedness. Five ‘context’ related categories and four health system ‘capability’ themes were searched. The contextual enabling and constraining factors for frontline service integration were: the organizational framework of frontline services, health care worker preparedness, community and client preparedness, upstream logistics and policy and governance issues. The intersecting health system capabilities identified were the need for: sufficiently functional frontline health services, sufficiently trained and motivated health care workers, availability of technical tools and equipment suitable to facilitate integrated frontline services and appropriately devolved authority and decision-making processes to enable frontline managers and staff to adapt integration to local circumstances. This review demonstrates that synthesis is possible. It presents a common set of contextual factors and health system capabilities necessary for successful service integration which may be considered indicators of preparedness and could form the basis for an ‘integration preparedness tool’.
This study aimed to synthesise recent evidence on how to scale up the delivery of malaria interventions in endemic regions through a systematic review of the available literature. A total of 39 papers were selected, which related to delivery at scale of intermittent preventive treatment in pregnancy, artemisinin combination therapy (ACT) or insecticide treated nets (ITNs). In terms of coverage and equity, the review found that the evidence to link changes in coverage to any specific strategy is weak: only 3 of 24 studies reporting coverage had a concurrent comparison group, and only one was classified as high-level evidence using the GRADE criteria. For ACT, an associated increase in treatment among children (73% to 88%) was reported with delivery through accredited drug dispensing outlets and health facilities in Tanzania. For ITN programmes, instances where household ownership or use of nets reached targets of 80% were associated with free delivery of nets through campaigns. The study identifies barriers and facilitators to interventions, notably cost as a barrier. The study cautions that, to prioritise strengthening of health system elements for scale up, systematic reviews alone are not sufficient and additional research methods are needed.
The aim of this study was to synthesise recent evidence on how to scale up the delivery of malaria interventions in endemic regions through a systematic review of the available literature. The researchers included 39 papers, including 19 African countries, related to scaling up the delivery of intermittent preventive treatment in pregnancy (IPTp), artemisinin combination therapy (ACT) or insecticide-treated nets (ITNs). They found that relatively few strategies for scaling up have been reported in published literature and acute knowledge gaps exist for scale up of diagnostics and treatment. In terms of coverage and equity, the evidence to link changes in coverage to any specific strategy was found to be weak. IPTp coverage was low, while a 15% increase in ACT among children was reported with delivery through accredited drug dispensing outlets and health facilities in Tanzania. For ITN programmes, reaching programme targets was associated with free delivery through campaigns. There was a shortage of information on facilitators and barriers to scale up and what little was available was setting-specific. The researchers conclude that, to prioritise strengthening of health system elements for scale up, additional research methods and new studies are needed to fill the knowledge gap.