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Publications

Filtering by Category: JHSPH

Stakeholder Analysis for a Maternal and Newborn Health Project in Eastern Uganda

Future Health Systems

Based on the realization that Uganda is not on track to achieving Millennium Development Goals 4 and 5, Makerere University School of Public Health in collaboration with other partners proposed to conduct two community based maternal/newborn care interventions aimed at increasing access to health facility care through transport vouchers and use of community health workers to promote ideal family care practices. Prior to the implementation, a stakeholder analysis was undertaken to assess and map stakeholders’ interests, influence/power and position in relation to the interventions; their views regarding the success and sustainability; and how this research can influence policy formulation in the country.
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10 best resources on … mixed methods research in health systems

Future Health Systems

Mixed methods research has become increasingly popular in health systems. Qualitative approaches are often used to explain quantitative results and help to develop interventions or survey instruments. Mixed methods research is especially important in low- and middle-income country (LMIC) settings, where understanding social, economic and cultural contexts are essential to assess health systems performance. To provide researchers and programme managers with a guide to mixed methods research in health systems, we review the best resources with a focus on LMICs.
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Health care: Order health systems in developing world

Future Health Systems

In this correspondence, the authors note that governments and policy-makers are aiming to improve health markets in developing countries as they take up the challenge of last year's United Nations resolution to move towards universal health coverage. We caution that they must do more than simply legislate their way to a more orderly health system.
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Essential drugs policy in three rural counties in China: What does a complexity lens add?

Future Health Systems

In 2009 the government of China identified an essential drugs policy as one of five priority areas for health system reform. Since then, a national essential drugs policy has been defined, along with plans to implement it. As a large scale social intervention, the policy will have a significant impact on various local health actors. This paper uses the lens of complex adaptive systems to examine how the policy has been implemented in three rural Chinese counties. Using material gathered from interviews with key actors in county health bureaus and township health centers, we illustrate how a single policy can lead to multiple unanticipated outcomes. The complexity lens applied to the material gathered in interviews helps to identify relevant actors, their different relationships and policy responses and a new framework to better understand heterogeneous pathways and outcomes. Decision-makers and policy implementers are advised to embrace the complex and dynamic realities of policy implementation. This involves developing mechanisms to monitor different behaviors of key actors as well as the intended outcomes and unintended consequences of the policy.
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Future Health Markets: A meeting statement from Bellagio

Future Health Systems

Policy-makers, entrepreneurs, academics and funders convened at the Rockefeller Foundation Bellagio Center from 10th-14th December 2012 to discuss the changing face of health markets, and in particular to consider future trends in such markets. Their aim was to promote a greater shared understanding and analysis of health market systems, and to consider how markets can better serve the needs of the poor in low- and middle-income countries (LMICs). This report is an attempt to capture the rich discussions held during the meeting, which reviewed the evolution of health markets, identified key drivers of and gaps resulting from their rapid development, and highlighted critical issues that must be tackled to ensure the poorest have access to safe, affordable, effective and equitable health services. The report concludes with recommendations for shaping future health markets as agreed during the meeting.
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Sector-wide approaches (SWAps) in health: what have we learned?

Future Health Systems

Sector-wide approaches (SWAps) in health were developed in the early 1990s in response to widespread dissatisfaction with fragmented donor-sponsored projects and prescriptive adjustment lending. SWAps were intended to provide a more coherent way to articulate and manage government-led sectoral policies and expenditure frameworks and build local institutional capacity as well as offer a means to more effective relationships between governments and donor agencies. The global health landscape has changed dramatically since then. Although many countries have undertaken SWAps, the experience deviated considerably from the early vision, and many of the problems in national health systems persist. The future of SWAps will depend on stronger government oversight and innovative institutional arrangements to support health strategies that address the need for both targeted initiatives and stronger health systems to provide a wide range of public health and clinical services. For development assistance to be more effective, it will also depend on better discipline by donors to support national governments through transparent negotiation.
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Expecting the unexpected: applying the Develop-Distort Dilemma to maximize positive market impacts in health

Future Health Systems

Although health interventions start with good intentions to develop services for disadvantaged populations, they often distort the health market, making the delivery or financing of services difficult once the intervention is over: a condition called the ‘Develop-Distort Dilemma’ (DDD). In this paper, we describe how to examine whether a proposed intervention may develop or distort the health market. Our goal is to produce a tool that facilitates meaningful and systematic dialogue for practitioners and researchers to ensure that well-intentioned health interventions lead to productive health systems while reducing the undesirable distortions of such efforts.
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Evaluating health systems strengthening interventions in low-income and middle-income countries: are we asking the right questions?

Future Health Systems

In recent years, there have been several calls for rigorous health policy and systems research to inform efforts to strengthen health systems (HS) in low- and middle-income countries (LMICs), including the use of systems thinking concepts in designing and evaluating HS strengthening interventions. The objectives of this paper are to assess recentevaluations of HS strengthening interventions to examine the extent to which they ask a broader set of questions, and provide an appropriately comprehensive assessment of the effects of these interventions across the health system.
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Transforming Health Markets in Asia and Africa: Improving quality and access for the poor

Future Health Systems

There has been a dramatic spread of health markets in much of Asia and Africa over the past couple of decades. This has substantially increased the availability of health-related goods and services in all but the most remote localities, but it has created problems with safety, efficiency and cost. The effort to bring order to these chaotic markets is almost certain to become one of the greatest challenges in global health. This book documents the problems associated with unregulated health markets and presents innovative approaches that have emerged to address them. It outlines a framework that researchers, policy makers and social entrepreneurs can use to analyse health market systems and assess the likely outcome of alternative interventions. The book presents a new way of understanding highly marketised health systems, applies this understanding to an analysis of health markets in countries across Asia and Africa and identifies some of the major new developments for making these markets perform better in meeting the needs of the poor. It argues that it is time to move beyond ideological debates about the roles of public and private sectors in an ideal health system and focus more on understanding the operation of these markets and developing practical strategies for improving their performance. This book is ideal reading for researchers and students in public health, development studies, public policy and administration, health economics, medical anthropology, and science and technology studies. It is also a valuable resource for policy makers, social entrepreneurs, and planners and managers in public and private sector health systems, including pharmaceutical companies, aid agencies, NGOs and international organisations.
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Exploring the Ethics of Long-Term Research Engagement With Communities in Low- and Middle-Income Countries

Future Health Systems

Over the past few decades, there has been increasing attention focused on the ethics of health research, particularly in low- and middle-income countries. Despite the increasing focus on the literature addressing human protection, community engagement, appropriate consent procedures and ways to mitigate concerns around exploitation, there has been little discussion about how the duration of the research engagement may affect the ethical design and implementation of studies. In other words, what are the unique ethical challenges when researchers engage with host communities for longer periods (10 years or more), and what special considerations does this time commitment generate when applying ethical principles to these kinds of studies? This article begins to outline key areas of ethical concern that arise during long-term, sustained research activities with communities in low-resource settings. Through a review of the literature and consultations with experts in health systems, we identified the following key themes: fair benefits and long-term beneficence; community autonomy, consultation and consent; impacts on local health systems; economic impacts of research participation; ethical review processes; and institutional processes and oversight within research organizations. We hope that this preliminary exploration will stimulate further dialogue and help inform ethical guidance around long-term research engagements in the developing world.
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Bring order to unregulated health markets

Future Health Systems

In this commentary in Nature, the authors argue that the rapid expansion of health markets in Asia and Africa has made medicines, information and primary-care services available in all but the most remote areas. But it also creates problems with drug safety and efficiency, equity of treatment and the cost of care. Poorly trained practitioners often prescribe unnecessary pills or injections, with patients bearing the expense and the costs to their health. Counterfeit drugs are rife and drug resistance is growing. Bringing order to unruly health markets is a major challenge.
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Do we have the right models for scaling up health services to achieve the Millennium Development Goals?

Future Health Systems

There is widespread agreement on the need for scaling up in the health sector to achieve the Millennium Development Goals (MDGs). But many countries are not on track to reach the MDG targets. The dominant approach used by global health initiatives promotes uniform interventions and targets, assuming that specific technical interventions tested in one country can be replicated across countries to rapidly expand coverage. Yet countries scale up health services and progress against the MDGs at very different rates. Global health initiatives need to take advantage of what has been learned about scaling up.
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Better Guidance Is Welcome, but without Blinders

Future Health Systems

The three-paper series on guidance for evidence-informed decisions about health systems, published in PLoS Medicine, and produced by members of the World Health Organization (WHO) Task Force on Developing Health Systems Guidance, offers important contributions to improving the quality of evidence-informed decision-making in health systems [1]–[3]. We recognize the importance of engendering greater structure and systematization in processes that collate and evaluate evidence, and bring it to bear on policy. However, there are significant challenges in doing this for policies related to health systems, and we caution against the adoption of rigid approaches to the development of guidance and to the application of evidence to policy.
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FHS Podcast 2: A visit to Kabul

Future Health Systems

In the second podcast from Future Health Systems, Jeff Knezovich visits the FHS Afghanistan team in Kabul to find out what sort of research they're currently undertaking, what challenges they face in attempting research in an insecure environment, and what it's like living and working in difficult security situations. He interviews Kojo, Melissa Roach and Anubhav Agarwal, who tell him about the community scorecard that FHS is in the process of piloting in several provinces in Afghanistan.
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Building Informed Trust: Injection Practices in Cambodia

Future Health Systems

Dr Sachiko Ozawa from JHSPH presents recent findings from a study on trust in health systems and injection rates in Cambodia to the Health System Reform in Asia conference in Hong Kong in December 2012. She notes that the average Cambodian receives six injections/year, and that trained medical practitioners often feel pressure to give shots and IVs as patients will often turn to informal providers if they don't.
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Understanding informal markets: The roles and perspectives of RMPs in West Bengal and Karnataka, India

Future Health Systems

Dr Asha George of JHSPH presents work on the role of informal health care providers in India at the Health System Reform in Asia conference held in December 2011 in Hong Kong. She compares West Bengal and Karnataka -- two states with very different health profiles -- providing both qualitative and quantitative insights into how and why the poor use poorly trained rural medical practitioners as their first port of call when accessing health services.
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Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan

Future Health Systems

User fees for primary care tend to suppress utilization, and many countries are experimenting with fee removal. Studies show that additional inputs are needed after removing fees, although well-documented experiences are lacking. This study presents data on the effects of fee removal on facility quality and utilization in Afghanistan, based on a pilot experiment and subsequent nationwide ban on fees.
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Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan

Future Health Systems

User fees are a known common barrier to using health services, particularly among the poor. When fees are present, many facilities have waiver systems for poor patients to exempt them from paying. Targeting waivers to patients who need them most has been a challenge, especially in fragile states, where relevant data are limited and trust in institutions is low. An analysis of the asset index of beneficiaries indicated that although targeting was progressive, significant leakage and high levels of under-coverage occurred; 42% of cards were used by people in the wealthiest three quintiles, and only 19% of people in the poorest quintile received a card. Households with waiver cards reported higher rates of care-seeking for recent illnesses compared to those without cards (p = 0.02).
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