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1.
Global Health ; 18(1): 81, 2022 09 19.
Article in English | MEDLINE | ID: covidwho-2038823

ABSTRACT

BACKGROUND: The use of telemedicine, or the provision of healthcare and communication services through distance-based technologies, has increased substantially since the 2019 novel coronavirus (COVID-19) pandemic. However, it is still unclear what are the innovative features of the widespread use of such modality, its forms of employment and the context in which it is used across pluralist health systems, particularly in low- and middle-income settings. We have sought to provide empirical evidence on the above issues by analysing the responses of medical doctors in a representative cross-sectional survey in two states in Brazil: São Paulo and Maranhão. METHODS: We analysed the responses of 1,183 physicians to a survey on the impact of COVID-19 on their livelihood and working practice. Two independent samples per state were calculated based on a total of 152,511 active medical registries in São Paulo and Maranhão. Proportional stratified sampling was performed and the distributions for gender, age, state and location of address (capital or countryside) were preserved. The survey contained questions on the frequency of physicians' employment of telemedicine services; the specific activities where these were employed, and; the forms in which the pandemic had influenced the adoption or consolidation of this technology. We performed descriptive and univariate analysis based on the chi-square test or Fisher's exact test for the qualitative data, and the Mann-Whitney test in the quantitative cases. Data were shown as absolute frequency and proportion with a 95% confidence interval. RESULTS: In our sample of physicians, telemedicine was employed as a form of clinical collaboration by most doctors (76.0%, 95 CI 73.6-78.5), but only less than a third of them (30.6%, 95 CI 28.0-33.3) used it as a modality to provide healthcare services. During the pandemic, telemedicine was used predominantly in COVID-19-related areas, particularly for hospital-based in-patient services, and in private clinics and ambulatory settings. Male, younger doctors used it the most. Doctors in São Paulo employed telemedicine more frequently than in Maranhão (p < 0.001), in urban settings more than in rural areas (p < 0.001). Approximately three-quarters of doctors in large hospitals reported using telemedicine services (78.3%, 95 CI 75.9-80.6), followed by doctors working for smaller private clinics (66.4%, 95 CI 63.7-69.1), and by a smaller proportion of primary care doctors (58.4%, 95 CI 55.6-61.2). CONCLUSIONS: Our study suggests that telemedicine may have helped ensure and expand the range of communication and healthcare services in low- and middle-income settings during the COVID-19 pandemic. However, the modality appears to lend itself to be disproportionally used by doctors working in specific, priviledged sections of pluralistic health systems, and presumably by patients seeking care there. Regulation and incentives will be required to support the use of the technology across health systems in low- and middle-income countries in order to increase access to services for less disadvantaged populations.


Subject(s)
COVID-19 , Physicians , Telemedicine , Brazil/epidemiology , COVID-19/epidemiology , Cross-Sectional Studies , Humans , Male , Pandemics
2.
Int J Environ Res Public Health ; 19(16)2022 08 15.
Article in English | MEDLINE | ID: covidwho-2023649

ABSTRACT

Evidence exists on the health impacts of the current COVID-19 pandemic on health workers, but less is known about its impact on their work dynamics and livelihoods. This matters, as health workers-and physicians in particular-are a scarce and expensive resource in low- and middle-income countries (LMICs). Our cross-sectional survey set out to explore changes in working hours and earnings during the second year of the pandemic in a representative sample of 1183 physicians in Brazil's São Paulo (SP) and Maranhão (MA) states. Descriptive analysis and inferential statistics were employed to explore differences in working hours and earnings among public and private sector physicians across the two locations. The workloads and earnings of doctors working exclusively in the public sector increased the most in the second year of the epidemic, particularly in MA. Conversely, the largest proportion of private-only doctors in our sample saw a decrease in their working hours (48.4%, 95% CI 41.8-55.0), whereas the largest proportion of public-only doctors in MA saw an increase in their working hours (44.4%, 95% CI 38.0-50.8). Although earnings remained broadly stable in the public sector, a third of public sector-only physicians in MA saw an increase in their earnings (95% CI 24.4-36.2). More than half of private-only doctors across both states saw a decrease in their earnings (52.2%, 95% CI 45.6-58.8). The largest proportion of dual practitioners (the majority in Brazil and in our sample) maintained their pre-pandemic levels of income (38.8%, 95% CI 35.3-42.3). As public-sector doctors have been key in the fight against the pandemic, it is critical to invest in these cadres in order to develop epidemic preparedness in LMICs, and to find new ways to harness for-profit actors to deliver social benefits.


Subject(s)
COVID-19 , Physicians , Brazil/epidemiology , COVID-19/epidemiology , Cross-Sectional Studies , Humans , Pandemics
3.
Int J Health Policy Manag ; 2021 Nov 07.
Article in English | MEDLINE | ID: covidwho-1539130

ABSTRACT

BACKGROUND: The aim of this research was to synthetise the existing evidence on the impact of epidemic-related lockdown measures on women and children's health in low- and lower-middle-income countries (LLMICs). METHODS: A mixed-methods systematic review was conducted of qualitative, quantitative and mixed-methods evidence. Between 1st and 10th of November 2021, seven scientific databases were searched. The inclusion criteria were that the paper provided evidence on the impact of lockdown and related measures, focused on LLMICs, addressed impacts on women and child's health, addressed epidemics from 2000-2020, was peer-reviewed, provided original evidence, and was published in English. The Joanne Briggs Institute's critical appraisal tools were used to assess the quality of the studies, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting. The evidence from the papers was grouped by type of lockdown measure and categories of impact, using a narrative data-based convergent synthesis design. RESULTS: The review process identified 46 papers meeting the inclusion criteria from 17 countries that focussed on the coronavirus disease 2019 (COVID-19) and Ebola epidemics. The evidence on the decrease of utilisation of health services showed plummeting immunisation rates and faltering use of maternal and perinatal services, which was linked to a growth of premature deaths. Impacts on the mental health of children and women were convincingly established, with lockdowns associated with surges in depression, anxiety and low life satisfaction. Vulnerability may be compounded by lockdowns, as livelihoods were disrupted, and poverty levels increased. CONCLUSION: Limitations included that searches were conducted in late-2020 as new research was being published, and that some evidence not published in English may have been excluded. Epidemic-related lockdown measures carry consequences for the health of women and children in lower-income settings. Governments will need to weigh the trade-offs of introducing such measures and consider policies to mitigate their impacts on the most vulnerable.

5.
Health Policy Plan ; 36(4): 542-551, 2021 May 17.
Article in English | MEDLINE | ID: covidwho-1008823

ABSTRACT

Economic crises carry a substantial impact on population health and health systems, but little is known on how these transmit to health workers (HWs). Addressing such a gap is timely as HWs are pivotal resources, particularly during pandemics or the ensuing recessions. Drawing from the empirical literature, we aimed to provide a framework for understanding the impact of recessions on HWs and their reactions. We use a systematic review and best-fit framework synthesis approach to identify the relevant qualitative, quantitative and mixed-methods evidence, and refine an a priori, theory-based conceptual framework. Eight relevant databases were searched, and four reviewers employed to independently review full texts, extract data and appraise the quality of the evidence retrieved. A total of 57 peer-reviewed publications were included, referring to six economic recessions. The 2010-15 Great Recession in Europe was the subject of most (52%) of the papers. Our consolidated framework suggests that recessions transmit to HWs through three channels: (1) an increase in the demand for services; (2) the impacts of austerity measures; and (3) changes in the health labour market. Some of the evidence appeared specific to the context of crises; demand for health services and employment increased during economic recessions in North America and Oceania, but stagnated or declined in Europe in connection with the austerity measures adopted. Burn-out, lay-offs, migration and multiple jobholding were the reactions observed in Europe, but job opportunities never dwindled for physicians during recessions in North America, with nurses re-entering labour markets during such crises. Loss of motivation, absenteeism and abuse of health systems were documented during recessions in low-income countries. Although the impacts of recessions may vary across economic events, health systems, labour markets and policy responses, our review and framework provide an evidence base for policies to mitigate the effects on HWs.


Subject(s)
Economic Recession , Health Workforce , Europe , Health Personnel , Humans , Motivation
6.
PLoS One ; 15(10): e0241017, 2020.
Article in English | MEDLINE | ID: covidwho-892383

ABSTRACT

BACKGROUND: Economic recessions carry an impact on population health and access to care; less is known on how health systems adapt to the conditions brought by a downturn. This particularly matters now that the COVID-19 epidemic is putting health systems under stress. Brazil is one of the world's most affected countries, and its health system was already experiencing the aftermath of the 2015 recession. METHODS: Between 2018 and 2019 we conducted 46 semi-structured interviews with health practitioners, managers and policy-makers to explore the impact of the 2015 recession on public and private providers in prosperous (São Paulo) and impoverished (Maranhão) states in Brazil. Thematic analysis was employed to identify drivers and consequences of system adaptation and coping strategies. Nvivo software was used to aid data collection and analysis. We followed the Standards for Reporting Qualitative Research to provide an account of the findings. RESULTS: We found the concept of 'health sector crisis' to be politically charged among healthcare providers in São Paulo and Maranhão. Contrary to expectations, the public sector was reported to have found ways to compensate for diminishing federal funding, having outsourced services and adopted flexible-if insecure-working arrangements. Following a drop in employment and health plans, private health insurance companies have streamlined their offer, at times at the expenses of coverage. Low-cost walk-in clinics were hit hard by the recession, but were also credited for having moved to cater for higher-income customers in Maranhão. CONCLUSIONS: The 'plates' of a health system may shift and adjust in unexpected ways in response to recessions, and some of these changes might outlast the crisis. As low-income countries enter post-COVID economic recessions, it will be important to monitor the adjustments taking place in health systems, to ensure that past gains in access to care and job security are not eroded.


Subject(s)
Administrative Personnel/psychology , Betacoronavirus , Coronavirus Infections , Economic Recession , Health Care Sector/economics , Health Facility Administrators/psychology , Health Personnel/psychology , Pandemics , Pneumonia, Viral , Private Sector/economics , Public Sector/economics , Ambulatory Care Facilities/economics , Attitude of Health Personnel , Brazil , COVID-19 , Community Health Services/economics , Developing Countries , Humans , Insurance, Health, Reimbursement , Interviews as Topic , Physicians/psychology , Qualitative Research , SARS-CoV-2 , Telemedicine , Unemployment
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