Context in Development, 16 Manor Park, Maids Moreton, Buckingham, UK.
Independent Consultant, 63, Epsom Road, Guildford, UK.
Health Policy Plan. 2019 Nov 1;34(Supplement_2):ii28-ii35. doi: 10.1093/heapol/czz103.
Universal Health Coverage, to meet the Sustainable Development Goal of 'Health for All', aims to increase the access of preventative and curative care services, particularly to the poor and vulnerable. However, the very provision of curative services by health providers in the primary care setting in low-income countries is considered one of the major drivers of antimicrobial resistance. The Zanzibar Ministry of Health introduced performance-based financing (PBF) in 2 of 10 Health Districts in July 2013. Payments to health facilities and staff were on a fee-for-service basis using 'direct quality indicators'. Results of an evaluation of secondary data of two indicators, 'treatment according to guidelines' and 'antibiotics prescribed according to guidelines' from 31 Primary Health Care Units in the two PBF pilot districts are compared with 28 in non-PBF districts. The proportion of patients treated with an antibiotic not in accordance with treatment guidelines after the introduction of PBF fell to 2%, 6% and 5% in 2014, 2015 and 2016, respectively, compared with an increase from 25% (2013) to 31% (2014) and 22% (2015, 2016) in non-PBF facilities. The key take-home messages from this evaluation are firstly that 'direct quality indicators' to improve the use of treatment guidelines, introduced into a national PBF reform that includes financial incentives and rigorous verification of register entries, have the potential to significantly reduce inappropriate use of antibiotics in high population density settings in Africa. Secondly, for a sustained reduction in the overall proportion of unnecessary antibiotic prescriptions rigorous monitoring of health worker behaviour is required to address changes in prescribing practice. A well-designed and monitored PBF with 'direct quality indicators' has the potential to ensure that 'Health for All', in terms of increased access to primary health services is not synonymous with 'antibiotics for all'.
全民健康覆盖旨在满足“人人享有健康”的可持续发展目标，旨在增加预防和治疗服务的可及性，特别是为贫困和弱势群体提供服务。然而，在低收入国家的初级保健环境中，卫生提供者提供治疗服务被认为是导致抗微生物药物耐药性的主要驱动因素之一。2013 年 7 月，桑给巴尔卫生部在 10 个卫生区中的 2 个区引入了基于绩效的融资（PBF）。对卫生设施和工作人员的付款是按服务收费的，使用“直接质量指标”。对两个指标的二次数据进行评估的结果，来自两个 PBF 试点区的 31 个初级保健单位的“根据指南进行治疗”和“根据指南开具抗生素”与 28 个非 PBF 区的进行了比较。与非 PBF 设施相比，引入 PBF 后，不符合治疗指南的抗生素治疗患者比例在 2014 年、2015 年和 2016 年分别降至 2%、6%和 5%，而在 2013 年至 2014 年和 2015 年至 2016 年期间，非 PBF 设施的这一比例从 25%增加到 31%和 22%。从这次评估中得出的关键信息是，首先，在包括财政激励和严格核实登记条目在内的国家 PBF 改革中引入的“直接质量指标”，以改善治疗指南的使用，有可能在非洲人口密度较高的地区显著减少抗生素的不合理使用。其次，为了持续减少不必要的抗生素处方的总体比例，需要严格监测卫生工作者的行为，以解决处方实践的变化。精心设计和监测的 PBF 与“直接质量指标”相结合，有可能确保“全民健康覆盖”，即增加获得初级保健服务的机会，与“全民使用抗生素”并不相同。
