Tim Ensor

Background: Due to rapid urbanization, in many low- and middle-income countries (LMICs), urban primary healthcare (PHC) systems are not compatible with meeting the growing need for healthcare services. However, limited research exists on what patients consider important when seeking PHC services from various types of providers in LMICs like Bangladesh. This study aimed to identify and prioritise attributes to develop a discrete choice experiment (DCE) intended to elicit PHC preferences among people living in the slums of Dhaka, Bangladesh. Methods: To identify and prioritise key attributes for developing choice sets for DCE in a local context, we followed a two-phase process. In the first phase, attributes were identified through: (a) a systematic review of relevant literature, (b) four focus group discussions with community members who had and had not utilised PHC services in the past year, and (c) eight key informant interviews with supply-side stakeholders. In the second phase, the attributes were reduced and refined through (d) a ranking exercise with 15 community participants, (e) one-to-one consultations with four urban health experts, and (f) pretesting the draft DCE instrument. Results: The systematic review, FGDs, and KIIs together yielded a long list of 25 attributes, which was reduced to 12 for the community ranking exercise. Six attributes were finally selected for the DCE: travel time to reach a healthcare centre, waiting time, type of healthcare provider, recommendation from neighbours/relatives, consultation fee, and medicine expenditure. Attribute levels reflected the range of experiences identified in the qualitative data analysis and were refined through expert consultation and pretesting. During pretesting, comprehension of attributes and levels was found to be difficult for people with low literacy and these difficulties were addressed through revising the wording and introducing graphical Q-cards. Conclusions: This study contributes to the existing literature on the development of attributes and levels for a DCE. By documenting a transparent, replicable process, this study offers researchers a practical worked example of developing DCE attributes in understudied low-income urban settings.

Introduction In Bangladesh, government provision of primary care in rural areas has seen the development of services for non-communicable diseases, particularly hypertension and diabetes (given their substantial rise in recent decades). However, in the context of cities, which are characterised by a plurality of providers that have sprung up to meet the demands of a rapidly growing urban population, such provision is very limited. Methods and analysis We will conduct a mixed-methods study, based on the RE-AIM framework, to understand the (1) reach, (2) effectiveness, (3) adoption, (4) implementation and (5) maintenance (the five RE-AIM domains) of a health systems intervention to strengthen management processes for hypertension and diabetes within government and non-governmental organisation (NGO-run) primary care facilities. To evaluate the effectiveness of the intervention, we will use a quasi-experimental, difference-in-differences design. We will recruit 20 purposively selected urban government-run and NGO-run primary care facilities across Dhaka North and South City Corporation areas. Ten facilities will be purposively allocated to an intervention group and receive training and guidance materials on diabetes and hypertension care, based on the WHO Package of Essential Non-communicable (PEN) Disease Intervention for Primary Care, and the use of an e-health application for patient records. The remaining facilities will be allocated to the existing care group and receive no intervention inputs, with identical data collection processes carried out in both groups. We aim to collect data on 50 patients visiting each facility during a baseline period and at 6 and 12 months after implementing the intervention. We will estimate the average treatment effect on the treated (ATT) for the intervention at 6 and 12 months after implementing the intervention on a primary outcome that measures how many of eight key management processes are appropriately carried out for each patient visit at a study facility (with the appropriateness of each management process determined by assessing criteria based on how patients should be managed according to the intervention guidelines). We will also estimate the ATT for the intervention at 6 and 12 months after implementing the intervention on each of the appropriate management processes making up the primary outcome as separate secondary outcomes. Alongside this design, we will collect a range of additional quantitative and qualitative data to evaluate the other RE-AIM domains, using sequential mixed methods approaches, focusing on understanding potential facilitators and barriers in relation to these domains. Ethics and dissemination Ethics approval has been received from the Research Governance Committee at the University of Leeds, UK (MREC 21-008) and from the Bangladesh Medical Research Council (BMRCAIREC/20 I 9-2022/485). We will use a variety of channels to share our findings with policy makers, service providers, academicians and relevant stakeholders.

Background: Strengthening urban primary healthcare (PHC) systems in low- and middle-income countries (LMICs) is essential to effectively serve the growing urban poor. Such reforms should incorporate patient opinions to ensure accessible and affordable services. However, there is limited evidence on patient preferences for PHC providers in these settings. We aimed to conduct a systematic review of the evidence on the attributes reported by patients when choosing PHC providers in urban LMICs. Methods: A search was performed across MEDLINE, Embase, Global Health, Web of Science, PsycINFO, and Scopus bibliographic databases, as well as grey literature sources, from their earliest entries until March 30, 2024. Studies examining the revealed or stated preferences of populations for PHC providers in urban LMIC settings were included. We descriptively analysed and compared these studies, assessing their methodological quality using checklists for Conjoint Analysis studies and the Mixed Methods Appraisal Tool. Results: Our findings are reported according to PRISMA guidelines. The search yielded 5,089 citations, of which 28 met the eligibility criteria for this review. We identified 203 attributes across selected studies. The most frequently reported attributes were cost of services ( n = 25) and distance/proximity ( n = 24), followed by provider behaviour/attitude ( n = 19) and quality of care ( n = 17). Most studies identified the availability of medicine/equipment, distance/proximity, healthcare provider type, and quality of care as the most valued attributes. Eighteen studies examined preference heterogeneity, considering socioeconomic factors such as education, gender, age, severity of illness, and income, with severity of illness being the most significant factor. Conclusions: Prioritising patient preferences in health system reforms is essential for equitable and sustainable healthcare in rapidly urbanising LMICs. Our review highlights the most valued attributes in preference studies, which will help policymakers and researchers tailor better PHC interventions to meet urban community needs and guide future studies on PHC preferences in similar settings.

Objectives: We explored how key sociodemographic characteristics were associated with correct knowledge about antibiotics and antibiotic resistance (ABR) and appropriate usage of antibiotics from a One Health perspective among rural community members in Bangladesh. Design: Cross-sectional single-period survey. Setting: Rural villages in Cumilla district, Bangladesh. Participants: Eligibility criteria: aged ≥18. Across 50 clusters of villages, we approached 2160 community members and 2187 (98.8%) agreed to participate. Primary and secondary outcome measures: Primary outcomes: we collected two knowledge outcomes measuring the number of correctly answered binary/multiple-choice questions about (1) antibiotics and ABR and appropriate usage of antibiotics in relation to human illness and (2) antibiotics and ABR and appropriate usage of antibiotics in relation to animal health and the environment. Secondary outcomes: self-reported awareness of (1) antibiotics and (2) ABR. Results: Several sociodemographic characteristics were associated with variation in both knowledge outcomes. Education showed the strongest associations, with higher education levels associated with higher knowledge scores. For example, compared with having no formal/incomplete primary education, having higher education was associated with 10 percentage points (95% CI 8 to 12) and 6 percentage points (95% CI 3 to 8) higher mean knowledge scores for the knowledge outcomes 1 and 2, respectively. Having worked in the last month compared with not having worked was also weakly positively associated with both knowledge outcomes, and being female compared with being male was also weakly negatively associated with both knowledge outcomes. Conclusions: Better public education is required to tackle ABR in Bangladesh but correct knowledge about antibiotics and ABR and appropriate usage of antibiotics in relation to humans, animals and the environment varies in relation to individuals’ education level, sex and working status. To maximise their effectiveness, interventions to tackle ABR must be flexible given recipients’ sociodemographic characteristics and pre-existing knowledge levels.

Background: Kazakhstan implemented a diagnosis-related group (DRG)-based payment system in 2012, transitioning from a fee-for-service remuneration model for public hospitals. The reform aimed to enhance hospital efficiency and cost control. A national rollout was preceded by a pilot phase involving 21 hospitals in 2011. While DRG systems are increasingly adopted and adapted globally, evidence on their effects remains limited in low- and middle-income countries. Objective: To assess whether the introduction of the DRG-based system is associated with changes in hospital activity and the quality of care. Design and methods: A controlled interrupted time series design was employed, using matched control hospitals to estimate the causal impact of the payment reform. The analysis was based on weekly hospital discharge data from the 2011/2012 to 2012/2013 fiscal years, obtained from the Ministry of Health. Result: Findings suggest that the impact of the reform on hospital activity varied by hospital levels, with pilot hospitals showing a quicker response to nationwide implementation. No significant effects were observed on quality of care, as measured by standardised in-hospital mortality rates. Conclusions: The introduction of the DRG-based payment system was associated with heterogenous effects on hospital activity but did not yield measurable short-term improvements in care quality. These findings underscore the importance of implementation context and highlight the need for further research to assess long-term and system-wide effects. JEL classification: H51, I1, P36

Introduction In Bangladesh government provision of primary care in rural areas has seen the development of services for non-communicable diseases, particularly hypertension and diabetes (given their substantial rise in recent decades). However, in the context of cities, which are characterised by a plurality of providers that have sprung up to meet the demands of a rapidly growing urban population, such provision is very limited. Methods and analysis We will conduct a mixed-methods study, based on the RE-AIM framework, to understand the 1) reach, 2) effectiveness, 3) adoption, 4) implementation, and 5) maintenance (the five RE-AIM domains) of a health systems intervention to strengthen management processes for hypertension and diabetes within government and non-governmental (NGO-run) primary care facilities. To evaluate the effectiveness of the intervention we will use a quasi-experimental, difference-in-differences design. We will recruit 20 purposively selected urban government-run and NGO-run primary care facilities across Dhaka North and South City Corporation areas. Ten facilities will be purposively allocated to an intervention group and receive training and guidance materials on diabetes and hypertension care, based on the WHO Package of Essential Noncommunicable (PEN) Disease Intervention for Primary Care, and the use of an e-health application for patient records. The remaining facilities will be allocated to the existing care group and receive no intervention inputs, with identical data collection processes carried out in both groups. We aim to collect data on 50 patients visiting each facility during a baseline period and at 6- and 12-months after implementing the intervention. Using a standard linear-regression based approach, we will estimate the difference-in-differences effect of the intervention on a primary outcome measuring how many of eight key management processes were appropriately carried out for each patient visiting the facility at 6- and 12-months after implementing the intervention (with their appropriateness based on what should occur according to the intervention guidelines). We will also analyse the effect of the intervention on each management process separately as secondary outcomes. Alongside this design we will collect a range of additional quantitative and qualitative data to evaluate the other RE-AIM domains, using sequential mixed methods approaches, focusing on understanding potential facilitators and barriers in relation to these domains. Ethics and Dissemination Ethics approval has been received from the Research Governance Committee at the University of Leeds, UK (MREC 21-008) and from the Bangladesh Medical Research Council (BMRCAIREC/20 I 9 -2022 / 485). We will use a variety of channels to share our findings with policy makers, service providers, academicians, and relevant stakeholders. Strengths This will be the first study to use implementation research methods to understand the delivery of diabetes and hypertension management in the context of the pluralistic urban primary care services of Bangladesh. The use of the RE-AIM framework to structure and plan evaluation will help assess multiple dimensions of implementation under real-world conditions therefore providing detailed insights for decision-making on the potential future scale-up of the National Protocol and Simple App within PHC facilities in urban Bangladesh. Limitations Conducting a randomised trial design for effectiveness evaluation will not be possible due to lack of resources Planning an evaluation for a longer time scale will be difficult due to project funding timelines

Background: Surgical services are scarce with persisting inequalities in access across populations and regions globally. As the world’s most populous county, India’s surgical need is high and delivery rates estimated to be sub-par to meet need. There is a dearth of evidence, particularly sub-regional data, on surgical provisioning which is needed to aid planning. Aim and method: This mixed-methods study examines the state of surgical care in Northeast India, specifically health care system capacity and barriers to surgical delivery. It involved a facility-based census and semi-structured interviews with surgeons and patients across four states in the region. Results: Abdominal conditions constituted a large portion of the overall surgeries across public and private facilities in the region. Workloads varied among surgical providers across facilities. Task-shifting occurred, involving non-specialist nursing staff assisting doctors with surgical procedures or surgeons taking on anaesthetic tasks. Structural factors dis-incentivised facility-level investment in suitable infrastructure. Facility functionality was on average higher in private providers compared to public providers and private facilities offer a wider range of surgical procedures. Facilities in general had adequate laboratory testing capability, infrastructure and equipment. Public facilities often do not have surgeon available around the clock while both public and private facilities frequently lack adequate blood banking. Patients’ care pathways were shaped by facility-level shortages as well as personal preferences influenced by cost and distance to facilities. Discussion and conclusion: Skewed workloads across facilities and regions indicate uneven surgical delivery, with potentially variable care quality and provider efficiency. The need for a more system-wide and inter-linked approach to referral coordination and human resource management is evident in the results. Existing task-shifting practices, along with incapacities induced by structural factors, signal the directions for possible policy action.

Background Surgical services are scarce with persisting inequalities in access across populations and regions globally. As the world’s most populous county, India’s surgical need is high and delivery rates estimated to be sub-par to meet need. There is a dearth of evidence particularly sub-regional data on surgical provisioning and need to aid planning. Aim and method This mixed methods study examines the state of surgical care in Northeast India, specifically health care system capacity and barriers to surgical delivery. It involved a facility based census and semi-structured interviews with surgeons and patients across four states in the region. Results Abdominal conditions constituted a large portion of the overall surgeries across public and private facilities in the region. Workloads varied among surgical providers across facilities. Task-shifting occurred, involving non-specialist nursing staff assisting doctors on surgical procedures or surgeons’ taking on anaesthetic tasks. Structural factors dis-incentivised facility level investment in suitable infrastructure. Patients’ care pathways were shaped by facility level shortages as well as personal preferences influenced by cost and distance to facilities. Discussion and conclusion skewed workloads across facilities and regions indicate uneven surgical delivery, with potentially variable care quality and provider efficiency. A systemic approach to referral coordination and human resource management are evident. Existing task shifting practices, along with incapacities induced by structural factors signal the direction of possible policy action.

Objective To identify the approaches and strategies used for ensuring cultural appropriateness, intervention functions and theoretical constructs of the effective and ineffective school-based smoking prevention interventions that were implemented in low-income and middle-income countries (LMICs). Data sources Included MEDLINE, EMBASE, Global Health, PsycINFO, Web of Science and grey literature which were searched through August 2022 with no date limitations. Eligibility criteria We included randomised controlled trials (RCTs) with ≥6 months follow-up assessing the effect of school-based interventions on keeping pupils never-smokers in LMICs; published in English or Arabic. Data extraction and synthesis Intervention data were coded according to the Theoretical Domains Framework, intervention functions of Behaviour Change Wheel and cultural appropriateness features. Using narrative synthesis we identified which cultural-adaptation features, theoretical constructs and intervention functions were associated with effectiveness. Findings were mapped against the capability-motivation and opportunity model to formulate the conclusion. Risk of bias was assessed using the Cochrane risk of bias tool. Results We identified 11 RCTs (n=7712 never-smokers aged 11–15); of which five arms were effective and eight (four of the effective) arms had a low risk of bias in all criteria. Methodological heterogeneity in defining, measuring, assessing and presenting outcomes prohibited quantitative data synthesis. We identified nine components that characterised interventions that were effective in preventing pupils from smoking uptake. These include deep cultural adaptation; raising awareness of various smoking consequences; improving refusal skills of smoking offers and using never-smokers as role models and peer educators. Conclusion Interventions that had used deep cultural adaptation which incorporated cultural, environmental, psychological and social factors, were more likely to be effective. Effective interventions considered improving pupils’ psychological capability to remain never-smokers and reducing their social and physical opportunities and reflective and automatic motivations to smoke. Future trials should use standardised measurements of smoking to allow meta-analysis in future reviews.

Laparoscopic surgery, a minimally invasive technique to treat abdominal conditions, has been shown to produce equivalent safety and efficacy with quicker return to normal function compared to open surgery. As such, it is widely accepted as a cost-effective alternative to open surgery for many abdominal conditions. However, access to laparoscopic surgery in rural North-East India is limited, in part due to limited equipment, unreliable supplies of CO₂gas, lack of surgical expertise and a shortage of anaesthetists. We evaluate the cost-effectiveness of gasless laparoscopy as a means to increase provision of minimally invasive surgery (MIS) for abdominal conditions in rural North-East India. A decision tree model was developed to compare costs, evaluated from a patient perspective, and health outcomes, disability adjusted life years (DALYs), associated with gasless laparoscopy, conventional laparoscopy or open abdominal surgery in rural North-East India. Results indicate that MIS (performed by conventional or gasless laparoscopy) is less costly and produces better outcomes, fewer DALYs, than open surgery. These results were consistent even when gasless laparoscopy was analysed using least favourable data from the literature. Scaling up provision of MIS through increased access to gasless laparoscopy would reduce the cost burden to patients and increase DALYs averted. Based on a sample of 12 facilities in the North-East region, if scale up was achieved so that all essential surgeries amenable to laparoscopic surgery were performed as such (using conventional or gasless laparoscopy), 64% of DALYS related to these surgeries could be averted, equating to an additional 454.8 DALYs averted in these facilities alone. The results indicate that gasless laparoscopy is likely to be a cost-effective alternative to open surgery for abdominal conditions in rural North-East India and provides a possible bridge to the adoption of full laparoscopic services.