| 论文题名(中文)： | 苏丹疟疾防治工作中国内和国际卫生行动者之间协调与碎片化情况的探索性分析 |
| 作者： | |
| 学号： | 2111210671 |
| 论文语种： | eng |
| 学科名称： | 医学 - 公共卫生硕士 |
| 学生类型： | 硕士 |
| 学校： | 北京大学医学部 |
| 院系： | |
| 专业： | |
| 第一导师姓名： | |
| 论文完成日期： | 2024-05-23 |
| 论文答辩日期： | 2024-05-07 |
| 论文题名(外文)： | An Explorative Analysis of Coordination and Fragmentation Among Domestic and International Health Actors on Malaria Control in Sudan |
| 关键词(中文)： | |
| 关键词(外文)： | Malaria ; coordination ; service delivery ; fragmentation ; health system ; Sudan ; barriers. |
| 论文文摘（中文）： |
背景 卫生体系的碎片化对卫生部门活动的有效运作以及卫生体系的长期可持续性构成重大挑战。决策机构协调不力可能导致难以确定优先事项，它导致医疗保健服务的重复，严重稀释和扭曲了各级医疗保健机构有限的人力和财力资源。同时，卫生体系的碎片化可能会妨碍有效地调动分配给服务层面的有限资源。它阻碍了全面初级保健的提供。此外，卫生体系的碎片化还导致诊断和治疗的延误，使临床状况恶化，导致晚期诊断，最终加重经济负担。 研究目的 本研究旨在探讨和解释苏丹国家卫生体系与从事疟疾控制项目的国际合作伙伴之间的分裂问题。具体目标包括：描绘苏丹疟疾控制的现有行政结构和服务分工，这包括揭示不同行为者所扮演的不同角色，并阐明相互联系的协调机制。此外，一个重要的方面是界定国内卫生体系行为者和参与疟疾防治工作的国际伙伴内部/之间现有的碎片化性的形式和后果。另一个重要组成部分是详细分析造成参与疟疾控制计划的这些实体内部/之间碎片化的根本原因。最后，重点讨论了旨在促进医疗保健提供者、政府机构和在领导层和服务提供层面开展工作的国际合作伙伴之间协同增效的潜在解决方案。 方法 本研究采用了定性研究方法。将卫生体系的组成部分（治理和领导、医疗产品、卫生筹资、卫生信息系统、人力资源和服务提供）作为制定分析框架的关键模型。 研究内容包括查阅政策文件和报告，以及进行半结构化访谈，以便深入了解疟疾控制计划中协调和碎片化的不同方面。在Khartoum、Gezzera和White Nile State三个州对卫生工作者、行政人员、卫生专家和顾问进行了访谈。共有 29 名受访者参加了访谈，他们分别代表政府机构，包括联邦卫生部、州卫生部、卫生机构、国家医疗供应基金和国家疟疾控制计划。此外，国际合作伙伴包括全球基金、世界卫生组织和联合国儿童基金会。数据分析采用了主题分析法，并借鉴了框架方法。 结果 苏丹的疟疾控制活动涉及病媒和病例管理、卫生工作者的能力建设和社区活动。由于疟疾控制的服务提供和决策结构复杂，病媒控制、病例管理和社区活动较为碎片化，导致协调不力，疟疾传播干预措施执行不力。此外，州/地方一级缺乏协调也对医疗保健服务的提供产生了负面影响。 我们发现了一些导致缺乏协调的结构性因素。政治不稳定影响了疟疾控制活动的有效协调，导致计划实施的延误。当地资金有限，对外部合作伙伴的严重依赖限制了财务独立性，导致审批延误，阻碍了活动的及时执行，从而影响了整体成果。医疗服务中心缺乏基础设施准备，员工培训不足，导致患者对初级卫生服务中心服务质量的信任度降低。 沟通中存在的挑战、对反应及时性的不满和无效的信息传送渠道加重了协调的困难。缺乏中央数据共享系统和疟疾控制计划定期联合评估机制、报告不一致、数据收集问题等，都构成了服务提供层面的协调障碍。受访者强调，免费药品供应不足导致药品短缺。由于纵向项目提供更好的薪酬奖励，并吸引工人离开公共部门，对医疗卫生劳动力的竞争造成了与国际捐助者之间的协调差距，这导致了医护人员的短缺。此外，尽管卫生部批准了协议，但医疗机构的药物处方指南各不相同，导致各医疗机构的处方各异。 协调疟疾防治活动的关键因素包括国际合作伙伴的政策与国家卫生体系的需求相一致，以及对当地卫生体系长期投资的关注。多种协调机制的存在缺乏协同作用，给协调工作带来了挑战。此外，缺乏循证数据和研究也阻碍了根据事实信息、评估和评价疟疾方案执行情况形成明确的国家观点。 全球基金项目与政府规划周期之间的活动规划周期不一致，影响了评估进程，并在不同层面造成了挑战。卫生部在项目层面缺乏强有力的领导，造成了与国际机构之间的不一致，给国家议程的实施带来了挑战。由于缺乏明确的角色和职责，导致卫生部内部以及与国际合作伙伴之间的协调出现严重漏洞，造成职责模糊或重要任务被忽视。捐助方缺乏灵活性以及财务管理方面的挑战导致延误和效率低下，影响了疟疾防治活动。疟疾防治计划的资源分配存在巨大缺口。疟疾防治计划的性质包括在更广泛的卫生体系中采用半垂直结构，这导致了协调方面的挑战，并通过在计划内不同层面建立平行系统来加强垂直运作。 卫生信息系统各自为政，导致报告不一致、监测存在差距、准确预测应对疟疾等公共卫生挑战的药物需求存在障碍，同时对计划评估产生影响。此外，由于缺乏长期的卫生商品采购协议，导致采购过程出现延误，特别是在紧急情况下。 结论 这项研究对国际援助和国家卫生体系之间的协调和碎片化提供了宝贵的见解，突出了疟疾控制计划在各个层面碎片化的因素和驱动因素。研究强调了碎片化性对医疗服务质量造成的后果，并提供了加强协调的潜在途径。苏丹医疗保健部门各自为政导致效率低下、成本增加、公共卫生项目不一致以及社区对预防措施的不确定性。缺乏协调也阻碍了地方社区的有效参与。各种促进因素和障碍影响了苏丹疟疾控制工作的协调，对服务提供和政策制定过程都产生了影响。 加强责任制和政府领导、纳入国家政策、加强卫生工作者的能力建设以及增加对国内卫生体系的投资，对于解决各自为政和效率低下的问题至关重要。捐助方的灵活性、优先考虑研究投资、改善交流平台和建立强大的卫生信息系统，对于加强协调以有效防治苏丹疟疾至关重要。 |
| 文摘（外文）： |
Background Health system fragmentation poses significant challenges to the effective functioning and coherence of health sector’s activities, as well as the long-term sustainability of health systems. Poor coordination of decision-making bodies may lead to difficulties with priority setting. It leads to duplication of health care services, seriously diluting and distorting the limited human and financial resources available at different levels of care. Fragmentation of health systems potentially hinders effective mobilization of limited resources allocated to the service level. It impedes the delivery of comprehensive primary health care. Moreover, fragmentation of the health system results in delays in diagnosis and treatment, which exacerbates clinical conditions and ultimately leads to late-stage diagnoses and increased financial burden.
Objective The study aims to explore and explain fragmentation between national health system and international partners working on malaria control programs in Sudan. The specific objectives involve mapping the current administrative structure and service provision landscape for malaria control in Sudan, including understanding the diverse roles played by various actors and elucidating coordination mechanisms. Moreover, it includes delineating existing forms and consequences of fragmentation within domestic health system actors and international partners involved in malaria control efforts. In addition to analyzing factors contributing to fragmentation within entities involved in the malaria control program and proposing solutions for fostering synergy among healthcare providers, government bodies, and international partners.
Methods The study has implemented a qualitative research method. Using health system building blocks (governance and leadership, medical product, health finance, health information system, human resources and service delivery) as a key model for developing analytical framework. The study has included review of policy documents and reports, and semi-structured interviews in order to give in-depth information about different aspect of coordination and fragmentation in malaria control program. Interviews with health workers, administrators, health expert and consultants have been conducted at three states, namely, Khartoum, Gezzera and White Nile State. A total of 29 interviewees participated, representing governmental institutions including federal ministry of health, state ministries of health, health facilities, national medical supply fund and national malaria control program. In addition to international partners including, the Global Fund, the World Health Organization and UNICEF. The data was analyzed using manual thematic analysis drawing from the Framework approach.
Results Malaria control activities in Sudan have involved vector and case management, capacity building for health workers and community-based activities. With a complex structure of service delivery and policy-making for malaria control, fragmentation has been identified in vector control, case management, and community-based activities, leading to poor coordination and inadequate implementation of interventions on malaria transmission. Additionally, lack of coordination at the state/locality level has had a negative impact on delivery of health care services. We have identified arrange of structural factors contributing to lack of coordination including, political instability, limited local funding and heavy reliance on external partners. In addition, inadequate infrastructure preparedness at healthcare centers and insufficient staff training. These have resulted in delays in program implementation and approval processes, ultimately impacting overall outcomes and reducing patients' trust in the quality of services provided by Primary Healthcare Centers PHCs. Communication challenges, response timeliness dissatisfaction, and ineffective information dissemination channels have worsened coordination issues. The lack of centralized data sharing system, reporting inconsistencies, and inadequate pharmaceutical provision were identified as barriers for coordination at the service delivery level. Competition for health workforce has led to shortages in healthcare workers due to better pay incentives offered by vertical projects. Furthermore, medication prescription guidelines in health facilities varied despite approved protocols from the FMOH, resulting in prescriptions variations across health facilities. Key factors for coordination of activities to control malaria included alignment of international partners' policy with national health system needs and concerns about long term investment in local health systems. Presence of multiple coordination mechanisms that work without synergy present a challenge in coordinating efforts and collaboration. In addition, absence of evidence-based data and research has hindered the formation of clear national perspectives based on factual information, assessment and evaluation of malaria program performance. There are misalignments in activities planning cycles between Global Fund programs and government planning cycles, impacting assessment processes and creating administrative challenges. The lack of strong leadership at the program level caused misalignment between domestic and international agencies, leading to challenges in implementing national agendas. The absence of clear roles and responsibilities resulted in coordination gaps both internally within FMOH and with international partners. Inflexibility from donors has resulted in delays and inefficiencies impacting malaria control activities, including significant resource allocation gaps for malaria programs. This inflexibility has also led to a semi-vertical structure within the broader health system for the malaria control program, reinforcing vertical operations through established parallel systems at different levels within the programs. Fragmentation exists in health information systems, resulting in discrepancies in reporting, surveillance gaps, accurate forecasting hurdles for medication requirements addressing public health challenges such as malaria, along with impacts on program assessment. Additionally, the absence of long-term agreement for procurement of health commodities results in delays in procurement process specially during emergency.
Conclusion The study provides valuable insights into coordination and fragmentation between international aid provision and national health systems, highlighting factors and drivers of fragmentation in malaria control programs at various levels. It underscores the consequences of fragmentation on healthcare service quality and offers potential pathways to enhance coordination. Fragmentation within Sudan's healthcare sector leads to inefficiencies, increased costs, inconsistent public health programs, as well as uncertainty within communities regarding preventive measures. The absence of coordination also hampers effective community engagement at the local level. Various facilitators and barriers influenced coordination in malaria control efforts in Sudan, impacting both service delivery and policy-making process. Enhancing accountability and government leadership, integration within national policy, enhancing capacity building for health workers and enhance investment in domestic health system are crucial for addressing fragmentation and inefficiency. Donors’ flexibility, prioritizing research investment, improving communication platforms and establishing a robust health information system are essential to enhance coordination to effectively combat malaria in Sudan. |
| 论文目录： |
摘要 I
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Abstract I 目录Table of contents I 第一章 引言Chapter 1. Introduction 1 1.1 立题依据Rationale 1 1.1.1 卫生体系碎片化的概念Concept of health system fragmentation 1 1.1.2 文献综述摘要Summary of literature review 2 1.2研究案例国的背景Context of study case country 7 1.2.1 苏丹人口概况Demographic profile of Sudan 7 1.2.2 苏丹卫生体系的组织Organization of Sudan’s health system 8 1.2.3 苏丹的卫生筹资Health financing in Sudan 9 1.2.4 苏丹卫生体系面临的挑战Health system challenges in Sudan 11 1.2.5 疟疾造成的疾病负担The disease burden of malaria 12 1.2.6 苏丹参与的卫生部门发展援助Sudan’s engagement with development aid in health sector 13 1.2.7抗击艾滋病、结核病和疟疾全球基金The Global Fund to Fight AIDS, TB and Malaria 14 1.3 研究问题和意义Research questions and significance 14 1.4 研究目的、目标和内容Research aim, objectives and content 16 1.4.1 研究目的Aim of the study 16 1.4.2 研究目标Research objectives 16 1.4.3 研究内容Research content 16 第二章 研究方法 Chapter 2. Research methods 18 2.1 数据收集方法Methods for data collection 18 2.2 数据收集Data collection 18 2.2.1文件与文献综述 Document and literature review 18 2.2.2关键知情人访谈 Key informants’ interviews 19 2.2.3 样本与抽样Sampling design 20 2.2.4 访谈提纲Topic guides 22 2.3 数据分析Data analysis 23 2.3.1 文件分析Document analysis 23 2.3.2 主题分析Thematic analysis 23 2.4 质量控制Quality control 25 2.5 伦理Ethics 25 第三章 结果Chapter 3. Results 27 3.1 苏丹的国内和国际疟疾防控行动者Domestic and international actors in malaria control in Sudan 27 3.1.1 涉及疟疾防控的国内卫生部门行政结构Administrative structure of domestic health departments related to malaria control 28 3.1.2 国际合作International partners 31 3.1.3 苏丹国内卫生体系与国际合作伙伴之间的协调机制Coordination mechanisms between domestic health system and international partners in Sudan 33 3.2 服务水平碎片化的形式和后果Forms and consequences of fragmentation related to malaria control 34 3.2.1病媒控制的碎片化Fragmentation in vector control 34 3.2.2个案管理碎片化 Fragmentation in case management 37 3.2.3 社区活动碎片化 Fragmentation in community-based activities 38 3.3 疟疾防治活动的协调和碎片化因素 Factors for coordination and fragmentation of malaria control activities 39 3.3.1 结构因素Structural factors 40 3.3.2 服务层面的协调差距 Gaps in coordination at service level 44 3.3.3 协调疟疾防治活动的关键因素 Key factors for coordination of activities to control Malaria 49 3.3.4 决策和行政层面的协调差距Gaps in coordination at policy-making and administrative level 54 第四章 讨论Chapter 4. Discussion 66 4.1调查结果摘要 Summary of findings 66 4.2 与以往研究结果比较Comparison with previous findings 68 4.3解释和影响 Interpretation and implication 70 4.4 优势与不足Strengths and limitations 74 4.5 政策建议Recommendation 75 4.5.1 责任机制Accountability 75 4.5.2 政府责任与参与 Government commitment and engagement 75 4.5.3 国内卫生体系整合Integration within national health system 76 4.5.4 初级保健中心和卫生工作者的能力建设Capacity building of PHCs and health workforce 76 4.5.5 投资国内卫生体系，而不是创建独立的服务Invest in domestic health system rather than creating parallel services 77 4.5.6 捐赠的灵活性Donor’s flexibility 77 4.5.7 研究中的投资 Investment in research 78 4.5.8 理顺协调平台Streamline platforms for coordination 78 4.5.9 卫生信息系统Health information system 79 第五章 结论Chapter 5. Conclusion 81 参考文献References 85 附录 文献综述Appendix A. Literature review 89 1. Introduction 89 2. Drivers and Factors of Fragmentation 89 3. Forms of health care fragmentation 90 4. Levels of Health system fragmentation 91 4.1 Health system fragmentation at Global Level 92 4.2 Health system fragmentation at national and sub-national Levels 92 4.3 Health system fragmentation between international donors and national health system 93 5. Consequences of health system fragmentation 94 6. Current Efforts to address health system fragmentation 96 7. Synergy and effective coordination in healthcare system 97 7.1 Coordination between health care providers 97 7.2 Harmonization of donor’s efforts and Paris declaration on aid effectiveness 98 8. Importance of integration with primary health care in disease control 99 References 101 致 谢Acknowledgements 104 原创性声明 Statement of Originality 105 个人简历、在学期间发表的学术论文与研究成果 Resume, published academic papers and research results during the graduate study 107 |
| 参考文献： |
18. World Bank Database 2018, 2018https://databank.worldbank.org/. 23. The United Nation (UN) Sudan Report 2018, 2019, and 2020. Published Online October 12, 2021. 25. World Health Organization 2015. Global Techincal Strategy for Malaria 2016–2030. 27. FMOH/ Sudan and the WHO. Malaria Programme Review, 2023 (Covering the Period 2018-2023 ). 30. The Global Fund to Fight AIDS, Tuberculosis and Malaria https://www.theglobalfund.org/en/ . 32. The WHO. Strengthening health system to improve health outcomes, The WHO. www.who.int 36. WHO. Monitoring the Building Blocks of Health System https://cdn.who.int/media/docs. 42. FMOH/ Sudan Malaria Strategic Plan (2021 - 2025) Khartoum, Sudan June 2020 |
| 分类号： | R19 |
| 开放日期： | 2024-10-11 |
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