Department of International Health, Bloomberg School of Public Health Johns Hopkins University, 615 N Wolfe Street, E8140, Baltimore, MD, 21205, USA.
Department of Epidemiology, Human Genetics and Environmental Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA.
BMC Public Health. 2022 Jun 30;22(1):1271. doi: 10.1186/s12889-022-13681-0.
Improving service delivery is a key strategy for achieving service coverage, one of the two components of universal health coverage (UHC). As one of the largest global public health initiatives, individuals involved with the Global Polio Eradication Initiative (GPEI) have learned many important lessons about service delivery. We identified contributors and challenges to delivering health services at national and subnational levels using experiences from the GPEI. We described strategies used to strengthen service delivery and draw lessons that could be applicable to achieving UHC.
Online cross-sectional surveys based on the Consolidated Framework for Implementation Research (CFIR) domains and socioecological model were conducted from 2018-2019. Data were analyzed using an embedded mixed methods approach. Frequencies of the contributors and challenges to service delivery by levels of involvement were estimated. Chi-square tests of independence were used to assess unadjusted associations among categorical outcome variables. Logistic regressions were used to examine the association between respondent characteristics and contributors to successful implementation or implementation challenges. Horizontal analysis of free text responses by CFIR domain was done to contextualize the quantitative results.
Three thousand nine hundred fifty-five people responded to the online survey which generated 3,659 valid responses. Among these, 887 (24.2%) reported involvement in service delivery at the global, national, or subnational level with more than 90% involved at subnational levels. The main internal contributor of strengthened service delivery was the process of conducting activities (48%); working in frontline role had higher odds of identifying the process of conducting activities as the main internal contributor (AOR: 1.22, p = 0.687). The main external contributor was the social environment (42.5%); having 10-14 years of polio program implementation was significantly associated with identifying the social environment as the main external contributor to strengthened service delivery (AOR: 1.61, p = 0.038). The most frequent implementation challenge was the external environment (56%); working in Eastern Mediterranean region was almost 4 times more likely to identify the external environment as the major challenge in service delivery strengthening (AOR:3.59, p < 0.001).
Priority actions to improve service delivery include: adopt strategies to systematically reach hard-to-reach populations, expand disease-focused programs to support broader primary healthcare priorities, maximize community outreach strategies to reach broader age groups, build community trust in health workers and develop multisectoral leadership for collaboration. Achieving UHC is contingent on strengthened subnational service delivery.
提高服务提供能力是实现服务覆盖的关键策略之一，而服务覆盖是全民健康覆盖（UHC）的两个组成部分之一。作为全球最大的公共卫生倡议之一，参与全球根除脊髓灰质炎行动（GPEI）的人员从该行动中汲取了许多有关服务提供的重要经验。我们利用 GPEI 的经验，确定了在国家和国家以下各级提供卫生服务的促成因素和挑战。我们描述了用于加强服务提供的策略，并从中汲取了可能适用于实现 UHC 的经验教训。
2018-2019 年，我们基于实施研究综合框架（CFIR）域和社会生态模型进行了在线横断面调查。使用嵌入式混合方法分析数据。按参与程度估计服务提供的促成因素和挑战的频率。使用独立性卡方检验评估分类结果变量之间的无调整关联。使用逻辑回归检查受访者特征与成功实施或实施挑战之间的关联。通过 CFIR 域对自由文本回复进行水平分析，以对定量结果进行背景化。
3955 人对在线调查做出了回应，共产生 3659 份有效回复。其中，887 人（24.2%）报告在全球、国家或国家以下各级参与服务提供，超过 90%的人在国家以下各级参与。服务提供加强的主要内部促成因素是开展活动的过程（48%）；处于一线角色的人更有可能将开展活动的过程确定为主要内部促成因素（优势比：1.22，p=0.687）。主要的外部促成因素是社会环境（42.5%）；有 10-14 年脊髓灰质炎项目实施经验与将社会环境确定为服务提供加强的主要外部促成因素显著相关（优势比：1.61，p=0.038）。最常见的实施挑战是外部环境（56%）；在东地中海区域工作的人几乎有 4 倍的可能性将外部环境确定为服务提供强化的主要挑战（优势比：3.59，p<0.001）。
优先行动包括：采取策略以系统地覆盖难以到达的人群，扩大以疾病为重点的项目以支持更广泛的初级卫生保健优先事项，最大限度地扩大社区外联战略以覆盖更广泛的年龄组，建立社区对卫生工作者的信任，并为合作建立多部门领导。实现 UHC 取决于加强国家以下各级的服务提供。
