Effective Coverage: A Metric for Monitoring Universal Health Coverage

A major challenge in monitoring universal health coverage (UHC) is identifying an indicator that can adequately capture the multiple components underlying the UHC initiative. Effective coverage, which unites individual and intervention characteristics into a single metric, offers a direct and flexible means to measure health system performance at different levels. We view effective coverage as a relevant and actionable metric for tracking progress towards achieving UHC. In this paper, we review the concept of effective coverage and delineate the three components of the metric — need, use, and quality — using several examples. Further, we explain how the metric can be used for monitoring interventions at both local and global levels. We also discuss the ways that current health information systems can support generating estimates of effective coverage. We conclude by recognizing some of the challenges associated with producing estimates of effective coverage. Despite these challenges, effective coverage is a powerful metric that can provide a more nuanced understanding of whether, and how well, a health system is delivering services to its populations.

This paper is part of the PLOS Universal Health Coverage Collection.

Summary Points

• Effective coverage unites intervention need, use, and quality into a simple but data-rich metric, reflecting the core components of UHC.
• Effective coverage can be applied to understand the health gains delivered by interventions at a range of levels, from individual benefits to national impact.
• Effective coverage can be measured and used across resource settings. Lower-income countries can harness data from existing survey data to feed into effective coverage estimations.
• The broader use of effective coverage remains hindered by the availability and quality of health data, especially at subnational levels.

     

Psychosocial interventions and the demoralization of humanitarianism

This paper critically analyses from a political sociology standpoint the international conceptualization of war-affected populations as traumatized and in need of therapeutic interventions. It argues for the importance of looking beyond the epidemiological literature to understand trauma responses globally. The paper explores how the imperative for international psychosocial programmes lies in developments within donor countries and debates in their humanitarian sectors over the efficacy of traditional aid responses. The aim of the paper is threefold. First, it discusses the emotional norms of donor states, highlighting the psychologizing of social issues and the cultural expectations of individual vulnerability. Second it examines the demoralization of humanitarianism in the 1990s and how this facilitated the rise of international psychosocial work and the psychologizing of war. Third, it draws attention to the limitations of a mental health model in Croatia, a country which has been receptive to international psychosocial programmes. Finally it concludes that the prevalent trauma approaches may inhibit recovery and argues for the need to re-moralize resilience.     

Eliminating onchocerciasis within the Meme River Basin of Cameroon: A social-ecological approach to understanding everyday realities and health systems

BackgroundOnchocerciasis affects some of the world’s most marginalized people, perpetuating poverty and inequalities. Mass Drug Administration (MDA) with Ivermectin has taken place within the Meme River basin region in Cameroon for over 15 years. Despite this, onchocerciasis is still prevalent in the region due to existing and emerging contextual challenges. Using a social-ecological approach we explore the everyday realities of communities, highlighting the challenges and potential solutions that could support Neglected Tropical Disease (NTD) programmes when transitioning from control to elimination of onchocerciasis in this highly endemic area and other similar communities.Methodology/Principal findingIn-depth interviews (71) with community members and Community Drug Distributors (CDDs) were conducted to understand current knowledge, attitudes, and behaviours in relation to transmission, prevention and treatment of onchocerciasis. Through application of the social-ecological model, four key themes were identified: 1. Contextual factors on health promotion interventions (Onchocerciasis history and understanding of the disease, prevention and mitigation strategies and MDA experience); 2. Social determinants (poverty and livelihoods, economic and social impacts on CDD volunteers and stigma); 3. Environmental determinants (exposure, housing, occupation and poverty); and 4. health seeking pathways and decision making for treatment (access, cost and preferable treatment routes).We discuss these core and cross cutting themes (gender differences and community participation/ownership) in relation to intersectoral collaboration, gender equity and health systems support, making recommendations for NTD programmes within the context of integrated and interdisciplinary approaches. These include the need for; intersectional and gender analysis at the local level, addressing environmental dimensions of onchocerciasis through integrated and regular health promotion, vector control strategies and access to safe water sources; reflection and action that embeds responses to social and economic barriers to MDA; integrated case detection and management that is responsive to onchocerciasis symptoms and related stigma and a fair and just support network for CDDs.Conclusion/SignificanceNTD programmes need to respond to diverse community circumstances and behaviours. Communities are not a homogeneous risk group and treating them in this way will delay elimination. A deeper understanding of individual needs and their capacity to seek prevention and treatment must be considered if onchocerciasis is to be eliminated and the remaining impacts managed.     

Modelling the Incidence of Plasmodium vivax and Plasmodium falciparum Malaria in Afghanistan 2006–2009

Background

Identifying areas that support high malaria risks and where populations lack access to health care is central to reducing the burden in Afghanistan. This study investigated the incidence of Plasmodium vivax and Plasmodium falciparum using routine data to help focus malaria interventions.

Methods

To estimate incidence, the study modelled utilisation of the public health sector using fever treatment data from the 2012 national Malaria Indicator Survey. A probabilistic measure of attendance was applied to population density metrics to define the proportion of the population within catchment of a public health facility. Malaria data were used in a Bayesian spatio-temporal conditional-autoregressive model with ecological or environmental covariates, to examine the spatial and temporal variation of incidence.

Findings

From the analysis of healthcare utilisation, over 80% of the population was within 2 hours’ travel of the nearest public health facility, while 64.4% were within 30 minutes’ travel. The mean incidence of P. vivax in 2009 was 5.4 (95% Crl 3.2–9.2) cases per 1000 population compared to 1.2 (95% Crl 0.4–2.9) cases per 1000 population for P. falciparum. P. vivax peaked in August while P. falciparum peaked in November. 32% of the estimated 30.5 million people lived in regions where annual incidence was at least 1 case per 1,000 population of P. vivax; 23.7% of the population lived in areas where annual P. falciparum case incidence was at least 1 per 1000.

Conclusion

This study showed how routine data can be combined with household survey data to model malaria incidence. The incidence of both P. vivax and P. falciparum in Afghanistan remain low but the co-distribution of both parasites and the lag in their peak season provides challenges to malaria control in Afghanistan. Future improved case definition to determine levels of imported risks may be useful for the elimination ambitions in Afghanistan.     

Steps,challenges and lessons in developing community mental health care

This paper summarises our own accumulated experience from developing community-orientated mental health services in England and Italy over the last 20-30 years. From this we have provisionally concluded that the following issues are central to the development of balanced mental health services: a) services need to reflect the priorities of service users and carers; b) evidence supports the need for both hospital and community services; c) services need to be provided close to home; d) some services need to be mobile rather than static; e) interventions need to address both symptoms and disabilities; and f) treatment has to be specific to individual needs. In this paper we consider ten key challenges that often face those trying to develop community-based mental health services: a) dealing with anxiety and uncertainty; b) compensating for a possible lack of structure in community services; c) learning how to initiate new developments; d) managing opposition to change within the mental health system; e) responding to opposition from neighbours; f) negotiating financial obstacles; g) avoiding system rigidities; h) bridging boundaries and barriers; i) maintaining staff morale; and j) creating locally relevant ser- vices rather than seeking “the right answer” from elsewhere.     

What Does Public Health Ethics Tell (Or Not Tell) Us About Intervening in Non-Communicable Diseases?

Obesity has been described as pandemic and a public health crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of public health and public health ethics. I argue that the concept of an effective public health intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of public health and inclusion of a critical public health ethics perspective for an adequate account of the public health challenges posed by obesity.     

Uses and abuses of recovery: implementing recovery‐oriented practices in mental health systems

An understanding of recovery as a personal and subjective experience has emerged within mental health systems. This meaning of recovery now underpins mental health policy in many countries. Developing a focus on this type of recovery will involve transformation within mental health systems. Human systems do not easily transform. In this paper, we identify seven mis‐uses (“abuses”) of the concept of recovery: recovery is the latest model; recovery does not apply to “my” patients; services can make people recover through effective treatment; compulsory detention and treatment aid recovery; a recovery orientation means closing services; recovery is about making people independent and normal; and contributing to society happens only after the person is recovered. We then identify ten empirically‐validated interventions which support recovery, by targeting key recovery processes of connectedness, hope, identity, meaning and empowerment (the CHIME framework). The ten interventions are peer support workers, advance directives, wellness recovery action planning, illness management and recovery, REFOCUS, strengths model, recovery colleges or recovery education programs, individual placement and support, supported housing, and mental health trialogues. Finally, three scientific challenges are identified: broadening cultural understandings of recovery, implementing organizational transformation, and promoting citizenship.     

A Systematic Review of the Amount of Water per Person per Day Needed to Prevent Morbidity and Mortality in (Post-)Disaster Settings

BackgroundIn order to improve the effectiveness and efficiency of humanitarian efforts, minimum standards for humanitarian assistance and key indicators, showing whether a standard has been attained, have been developed. However, many of these standards and indicators are based on a consensus on best practices and experiences in humanitarian response, because relevant evidence on the impact of humanitarian interventions is often lacking.ObjectivesOne important example of a standard in humanitarian aid in a disaster setting is “water quantity.” The accompanying indicator states how many litres of water are needed per person per day in a disaster setting. It was our objective to determine the evidence base behind this indicator, in order to improve health outcomes such as morbidity (e.g., diarrhoea) and mortality.MethodsA systematic review was performed searching The Cochrane Library, Medline and Embase. We included studies performed during disasters and in refugee camps that reported a specific water amount and health-related outcomes related to water shortages, including diarrhoea, cholera, and mortality. We used GRADE to determine the quality of evidence.ResultsOut of 3,630 articles, 111 references relevant to our question were selected. Based on our selection criteria, we finally retained 6 observational studies, including 1 study that was performed during the disaster and 5 studies in a post-disaster phase. From two studies there is conclusive evidence on the relationship between the amount of water received and diarrhoea or mortality rates in refugee camps. However, overall, these studies do not contain enough data with relevance to a specific amount of water, and the level of evidence is very low.ConclusionsMore primary research on water amounts in a disaster setting is necessary, so that the humanitarian sector can further professionalise its water-related standards, indicators and interventions.     

Implementing shared decision making in routine mental health care

Shared decision making (SDM) in mental health care involves clinicians and patients working together to make decisions. The key elements of SDM have been identified, decision support tools have been developed, and SDM has been recommended in mental health at policy level. Yet implementation remains limited. Two justifications are typically advanced in support of SDM. The clinical justification is that SDM leads to improved outcome, yet the available empirical evidence base is inconclusive. The ethical justification is that SDM is a right, but clinicians need to balance the biomedical ethical principles of autonomy and justice with beneficence and non‐maleficence. It is argued that SDM is “polyvalent”, a sociological concept which describes an idea commanding superficial but not deep agreement between disparate stakeholders. Implementing SDM in routine mental health services is as much a cultural as a technical problem. Three challenges are identified: creating widespread access to high‐quality decision support tools; integrating SDM with other recovery‐supporting interventions; and responding to cultural changes as patients develop the normal expectations of citizenship. Two approaches which may inform responses in the mental health system to these cultural changes – social marketing and the hospitality industry – are identified.     

ETHICS BEYOND BORDERS: HOW HEALTH PROFESSIONALS EXPERIENCE ETHICS IN HUMANITARIAN ASSISTANCE AND DEVELOPMENT WORK

Health professionals are involved in humanitarian assistance and development work in many regions of the world. They participate in primary health care, immunization campaigns, clinic- and hospital-based care, rehabilitation and feeding programs. In the course of this work, clinicians are frequently exposed to complex ethical issues. This paper examines how health workers experience ethics in the course of humanitarian assistance and development work. A qualitative study was conducted to consider this question. Five core themes emerged from the data, including: tension between respecting local customs and imposing values; obstacles to providing adequate care; differing understandings of health and illness; questions of identity for health workers; and issues of trust and distrust. Recommendations are made for organizational strategies that could help aid agencies support and equip their staff as they respond to ethical issues.     

The Political Economy of ‘Trauma’ in Haiti in the Democratic Era of Insecurity

This article explores the challenges that emerge at the intersection of economies of compassion and terror: local, national, and international forms of humanitarian assistance; security practices in insecure social and institutional environments; questions of victimization and global reparations; and quests for justice, as revealed through an analysis of political violence and humanitarian interventions in Haiti during and after the 1991-94 coup period. Each domain is constrained by politics and history but can engender "occult economies" that challenge the intended consequences of restitution policies at international, national, and local levels of exchange. 'Trauma' and discourses about traumatic suffering are the hinge around which these economies pivot, generating new forms of political subjectivity for Haitian activists.     

Controlling soil-transmitted helminthiasis in pre-school-age children through preventive chemotherapy

Pre-school age children account for 10%-20% of the 2 billion people worldwide who are infected with soil-transmitted helminths (STHs): Ascaris lumbricoides (roundworm), Trichuris trichiura (whipworm), and Ancylostoma duodenale/Necator americanus (hookworms). Through a systematic review of the published literature and using information collated at World Health Organization headquarters, this paper summarizes the available evidence to support the recommendation that pre-school children should be included in regular deworming programmes. The first section describes the burden of STH disease in this age group, followed by a summary of how infection impacts iron status, growth, vitamin A status, and cognitive development and how STHs may exacerbate other high mortality infections. The second section explores the safety of the drugs themselves, given alone or co-administered, drug efficacy, and the importance of safe administration. The third section provides country-based evidence to demonstrate improved health outcomes after STH treatment. The final section provides country experiences in scaling up coverage of pre-school children by using other large scale public health interventions, including vitamin A programmes, immunization campaigns, and Child Health days. The paper concludes with a number of open research questions and a summary of some of the operational challenges that still need to be addressed.     

Public health ethics: asylum seekers and the case for political action

This paper is a case study in public health ethics. It considers whether there is a basis in ethics for political action by health professionals and their associations in response to inhumane treatment. The issue arises from Australia's treatment of asylum seekers and the charge that this treatment has been both immoral and inhumane. This judgement raises several questions of broader significance in bioethics and of significance to the emerging field of public health ethics. These questions relate to the role of health professionals in response to inhumane treatment of people in their charge; to the discipline of public health in light of a growing recognition of its ethical basis; and the role of public health and bioethical associations in response to ethical issues arising in a political context. It is argued that, in serious cases of humanitarian and human rights abuses affecting health and well-being, there is a case for political action by health professionals, academic and professional institutions, and associations of public health and ethics.     

Ethical dilemmas in malaria control.

Because the term "malaria control" specifies an anti-malaria activity rather than an outcome of that action, progress has been evaluated in terms of the effort expended. Plans that specify goals and time lines tend to lack irreversible endpoints. Anti-malaria interventions that are stimulated by economic considerations focus on sites in which the residents enjoy some employment advantage, while interventions based on humanitarian objectives serve the neediest residents of broad regions. Site-specific interventions are conducted by industrial or municipal agencies, while regional interventions are conducted by public agencies. Industry contributes an element of sustainability by injecting the possibility of gainful employment into the site. Efforts that distribute assets mainly to the richest-of-the-poor may fail to preserve lives that would otherwise have been preserved, while those that serve the poorest-of-the-poor may fail to create sustainable cycles of health and wealth. Progress in relieving the burden imposed by malaria requires economically motivated as well as humanitarian contributions, and both should specify realistically time-limited goals that ultimately permit deintensification.     

Diabetes research for developing countries

EAGLES investigations into the specific needs for diabetes research in developing countries, and Europe's potential to support that research [European Union and Diabetes http://ec.europa.eu/health/ph_information/dissemination/diseases/diabetes_en.htm, EU Research on Diabetes http://ec.europa.eu/research/leaflets/diabetes/index_en.html] reach nine major conclusions. In each case, they involve tuning European research to have the greatest impact in the shortest possible time, by understanding and respecting developing countries' conditions of health, politics and economics. Major recommendations arise from the lack of national population-based epidemiology to enable planning and convince political powers of the need for action; from countries' low healthcare budgets, entailing needs for the cheapest possible interventions; from the need to investigate interventions specifically tuned to national circumstances; and finally from the needs for specific local biomedical research, such as studies into the several unique African phenotypes of the disease. The details of our nine recommendations can be seen at the end of the report.     

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap­proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision‐making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low‐ and middle‐income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low‐resource settings may lead to wider learning from locally embedded strategies.     

The Ethics of Engaged Presence: A Framework for Health Professionals in Humanitarian Assistance and Development Work

In this article, we present an ethics framework for health practice in humanitarian and development work: the ethics of engaged presence. The ethics of engaged presence framework aims to articulate in a systematic fashion approaches and orientations that support the engagement of expatriate health care professionals in ways that align with diverse obligations and responsibilities, and promote respectful and effective action and relationships. Drawn from a range of sources, the framework provides a vocabulary and narrative structure for examining the moral dimensions of providing development or humanitarian health assistance to individuals and communities, and working with and alongside local and international actors. The elements also help minimize or avoid certain miscalculations and harms. Emphasis is placed on the shared humanity of those who provide and those who receive assistance, acknowledgement of limits and risks related to the contributions of expatriate health care professionals, and the importance of providing skillful and relevant assistance. These elements articulate a moral posture for expatriate health care professionals that contributes to orienting the practice of clinicians in ways that reflect respect, humility, and solidarity. Health care professionals whose understanding and actions are consistent with the ethics of engaged presence will be oriented toward introspection and reflective practice and toward developing, sustaining and promoting collaborative partnerships.