Project description:BackgroundPoverty is a major barrier to healthcare access in low-income countries. The degree of equitable access for noncommunicable disease (NCD) patients is not known in rural Haiti.ObjectivesWe evaluated the poverty distribution among patients receiving care in an NCD clinic in rural Haiti compared with the community and assessed associations of poverty with sex and distance from the health facility.MethodsWe performed a cross-sectional study of patients with NCDs attending a public-sector health center in rural Haiti 2013-2016, and compared poverty among patients with poverty among a weighted community sample from the Haiti 2012 Demographic and Health Survey. We adapted the multidimensional poverty index: people deprived ≥44% of indicators are among the poorest billion people worldwide. We assessed hardship financing: borrowing money or selling belongings to pay for healthcare. We examined the association between facility distance and poverty adjusted for age and sex using linear regression.ResultsOf 379 adults, 72% were women and the mean age was 52.5 years. 17.7% had hypertension, 19.3% had diabetes, 3.1% had heart failure, and 33.8% had multiple conditions. Among patients with available data, 197/296 (66.6%) experienced hardship financing. The proportions of people who are among the poorest billion people for women and men were similar (23.3% vs. 20.3%, p > 0.05). Fewer of the clinic patients were among the poorest billion people compared with the community (22.4% vs. 63.1%, p < 0.001). Patients who were most poor were more likely to live closer to the clinic (p = 0.002).ConclusionAmong patients with NCD conditions in rural Haiti, poverty and hardship financing are highly prevalent. However, clinic patients were less poor compared with the community population. These data suggest barriers to care access particularly affect the poorest. Socioeconomic data must be collected at health facilities and during community-level surveillance studies to monitor equitable healthcare access.HighlightsPoverty and hardship financing are highly prevalent among NCD patients in rural Haiti.Patients attending clinic are less poor than expected from the community.People travelling farther to clinic are less poor.Socioeconomic data should be collected to monitor healthcare access equity.

Project description:BackgroundEvidence-based treatments (EBTs) are critical to effectively address mental health problems among children and adolescents, but costly for mental health service agencies to implement and sustain. Financing strategies help agencies overcome cost-related barriers by obtaining financial resources to support EBT implementation and/or sustainment.AimsWe sought to (i) understand how youth mental health system decision-makers involved with EBT implementation and sustainment view key features (e.g., relevance, feasibility) that inform financing strategy selection and (ii) compare service agency, funding agency, and intermediary representative perspectives.MethodTwo surveys were disseminated to 48 representatives across U.S. youth mental health service agencies, funding agencies, and intermediaries who were participating in a larger study of financing strategies. Quantitative and qualitative data were gathered on 23 financing strategies through quantitative ratings and open-ended responses. Data were analyzed using descriptive statistics and rapid content analysis.ResultsThe financing strategies rated as most relevant include braided funding streams, contracts for EBTs, credentialing/rostering providers, fee-for-service reimbursement (regular and increased), and grant funding. All other strategies were unfamiliar to 1/3 to 1/2 of participants. The six strategies were rated between somewhat and quite available, feasible, and effective for EBT sustainment. For sustaining different EBT components (e.g., delivery, materials), the mix of financing strategies was rated as somewhat adequate. Qualitative analysis revealed challenges with strategies being non-recurring or unavailable in representatives' regions. Ratings were largely similar across participant roles, though funding agency representatives were the most familiar with financing strategies.DiscussionDespite the breadth of innovative financing strategies, expert representatives within the youth mental health services ecosystem had limited knowledge of most options. Experts relied on strategies that were familiar but often did not adequately support EBT implementation or sustainment. These findings underscore more fundamental issues with under-resourced mental health systems in the U.S.; financing strategies can help agencies navigate EBT use but must be accompanied by larger-scale system reforms. Limitations include difficulties generalizing results due to using a small sample familiar with EBTs, high agreement as a potential function of snowball recruiting, and limited responses to the open-ended survey questions.Implications for health care provision and useAlthough EBTs have been found to effectively address mental health problems in children and adolescents, available strategies for financing their implementation and sustainment in mental health systems are insufficient. This constraint prevents many children and adolescents from receiving high-quality services.Implications for health policiesFinancing strategies alone cannot solve systematic issues that prevent youth mental health service agencies from providing EBTs. Policy changes may be required, such as increased financial investment from the U.S. government into mental health services to support basic infrastructure (e.g., facility operations, measuring outcomes).Implications for further researchFuture work should examine expert perspectives on EBT financing strategies in different contexts (e.g., substance use services), gathering targeted feedback on financing strategies that are less well known, and exploring topics such as strategic planning, funding stability, and collaborative decision-making as they relate to EBT implementation and sustainment.

Project description:The faltering of progress towards malaria elimination follows a plateauing in international financing since 2010. Despite calls for increased international financing, this will be hard to achieve. Both developed country donors and developing countries with malaria face severe fiscal constraints in expanding malaria funding in the next few years. Simply exhorting countries to spend more is unlikely to be successful, just as the Abuja declaration was not, and the developing countries with most malaria burden suffer from weaker economic growth and less capacity to increase domestic financing. One major prospect for substantial new financing is China, but this may depend on established funders yielding influence in the global financing architecture to China and other emerging economies. This argues for greater emphasis on spending available financing better, but improving the impact of international funding is not straightforward. It is associated with significant transaction costs for recipients, impairs the ability of the WHO to coordinate global efforts, and may pressure recipient countries to focus more on commodities and easy wins instead of investing in health systems and management capacity. While more should be done to mitigate these perverse effects, much of this is the unavoidable price of such generosity and the inevitable need for accountability to funders. Ultimately, countries must do more with their own spending, which is often under-counted, but usually far exceeds the international contribution. The experience of Sri Lanka, El Salvador, and China-three countries that eliminated malaria-provides two pointers. First, achieving early and widespread treatment of most malaria cases, which is not the case in much of high burden Africa, may be critical to sustain accelerated elimination. Second, such coverage requires health systems that prioritize access for all services and conditions. Public opinion surveys indicate that this is consistent with what much of the affected population wants, prioritizes, and is willing to finance through higher taxes, which points to weaknesses in accountability of policy to people. International funders could do better to heed what affected populations want and let local partners be responsive to their own public's preferences.

Project description:ObjectiveAccess to adequate mental health (MH) services is necessary for nearly half of Canadian youth (18-24 years) who enroll in post-secondary education given the relatively high risk of MH problems. Our objectives were to determine the status of MH services available to students in post-secondary institutions in Canada and to determine the extent to which these services are based on the principles of a high-quality youth MH (YMH) service.MethodInformation on MH services was collected from websites of a representative sample (N = 67) of post-secondary institutions across all provinces. Data were analysed descriptively according to four categories (universities with a Faculty of Medicine (FoM) n = 18, other large universities n = 15, small universities n = 16, and colleges n = 18).ResultsMost institutions provided 24-h crisis line support (84%) and indicated the availability of free counselling or psychotherapy (n = 62 of 67, 92.5%), while only a minority indicated provision of an initial clinical assessment (25%) and provision of multiple sessions of therapy (37%). Wait time for first contact was impressively low (<72 h) in the minority of institutions (40%) which provided this information. Access to either a prescribing physician or psychiatrist was infrequent, though several mentioned an unexplained model of "stepped care" and outside referrals. While relevant information was not uniformly easy to access, larger institutions both with and without a FoM appear to be better poised to provide MH services. None of the institutions appeared to follow all the principles of service delivery recommended for a high-quality YMH, with only two showing early identification activities.ConclusionsMH services in post-secondary institutions may need a transformation similar to YMH services, including a clear pathway to care, an initial clinical assessment, early identification of MHA disorders, and better utilization of institutional resources through greater collaboration and matching of timely interventions to the presenting problems.

Dataset Information

Characteristics and Financing of Institutions for Mental Diseases.

Publications

Characteristics and Financing of Institutions for Mental Diseases.

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