Factors affecting private sector engagement in achieving universal health coverage: a scoping review.

BACKGROUND: Universal Health Coverage (UHC) is one of the most important strategies adopted by countries in achieving goals of sustainable development. To achieve UHC, the governments need the engagement of the private sector. OBJECTIVE: The aim of this study was to identify factors affecting private sector engagement in achieving universal health coverage. METHODS: The study is a scoping review that utilizes Arkesy & O'Malley frameworks. Data collection was conducted in MEDLINE, Web of Sciences, Embase, ProQuest, SID, and MagIran databases and the Google Scholar search engine. Also, manual searches of journals and websites, reference checks, and grey literature searches were done using specific keywords. To manage and screen the studies, EndNote X8 software was used. Data extraction and analysis was done by two members of the research team, independently and using content analysis. RESULTS: According to the results, 43 studies out of 588 studies were included. Most of the studies were international (18 studies). Extracted data were divided into four main categories: challenges, barriers, facilitators, goals, and reasons for engagement. After exclusion and integration of identified data, these categories were classified in the following manner: barriers and challenges with 59 items and in 13 categories, facilitators in 50 items and 9 categories, reasons with 30 items, and in 5 categories and goals with 24 items and 6 categories. CONCLUSION: Utilizing the experience of different countries, challenges and barriers, facilitators, reasons, and goals were analyzed and classified. This investigation can be used to develop the engagement of the private sector and organizational synergy in achieving UHC by policymakers and planners.

Main findings: Governments are key in healthcare provision, but the private sector's involvement is increasingly vital for universal health coverage.Added knowledge: This paper explores the evolving role of the private sector in universal health coverage, analysing barriers, challenges, facilitators, reasons, and goals for engagement while suggesting areas for further exploration.Global health impact for policy and action: The private sector's contributions to achieving Universal Health Coverage necessitate comprehensive policy frameworks and targeted actions to ensure equitable and sustainable health outcomes worldwide.

Litigation in access to universal health coverage for children and adolescents in Brazil.

Background: Brazil's Unified Health System (SUS) ensures universal, equitable, and excellent quality health coverage for all. The broad right to health, supported by the Constitution, has led to excessive litigation in the public sector. This has negatively impacted the financial stability of SUS, created inequality in children and adolescents' access to healthcare, and affected communication between the healthcare system and the judiciary. The enactment of Law Number 13.655 on 25 April 2018, proposed significant changes in judicial decisions. This study aimed to investigate decision-making changes in health litigation involving children and adolescents following the implementation of the new normative model. Methods: The study is cross-sectional, analyzing 3753 national judgment documents from all State Courts of Brazil, available on their respective websites from 2014 to 2020. It compares regional legal decisions before and after the promulgation of Law Number 13.655/2018. Data tabulation, statistical analysis, textual analysis, coding, and counting of significant units in the collected documents were performed. The results of data cross-referencing are presented in tables and diagrams. Results: The majority (96.86%) of legal claims (3635 cases) received partial or total provision of what was prescribed by the physician. The Judiciary predominantly handled these cases individually. The analysis indicates that the decisions made did not adhere to the norms established in 2018. Conclusion: Regional heterogeneity in health litigation was observed, and there was no significant variability in decisions during the studied period, even after the implementation of the new normative paradigm in 2018. Technical-scientific support was undervalued by the magistrates. Prioritizing litigants undermines equity in access to Universal Health Coverage for children and adolescents.

Exploring unmet healthcare needs and associated inequalities among middle-aged and older adults in Eastern China during the progression toward universal health coverage.

BACKGROUND: Given the rapid population aging in China, achieving universal health coverage (UHC) presents a primary challenge in addressing unmet healthcare needs and associated inequalities among middle-aged and older adults. Several studies have focused on healthcare utilization and its inequalities, but little attention has been paid to the inequality in unmet healthcare needs. This study aimed to analyze the inequalities in unmet the healthcare needs of middle-aged and older adults in eastern China during the progression toward UHC. METHODS: Data were obtained from the fourth, fifth, and sixth National Health Service Survey (NHSS) of Jiangsu Province, located in eastern China, during the years 2008, 2013, and 2018, respectively. Logistic regression models were used to assess the associated factors of unmet healthcare needs. The inequality was measured according to the concentration index (CI) and its decomposition. RESULTS: In this study, we found that 12.86%, 2.22%, and 48.89% of middle-aged and older adults reported unmet needs for outpatient and inpatient services and physical examinations, respectively. The prevalence of unmet outpatient needs increased from 2008 to 2018, while the prevalence of unmet inpatient services was lower but maintained. The prevalence of unmet needs for physical examinations among middle-aged and older adults markedly decreased since 2008. Rural areas had a higher prevalence of unmet needs for inpatient services and physical examinations than urban areas. Unmet healthcare needs were more prevalent among the poor. The pro-poor inequalities of unmet healthcare needs have been mitigated during the progression toward UHC; however, they remain predominant among rural middle-aged and older adults for outpatient and inpatient services. Socioeconomic factors significantly influenced unmet healthcare needs and contributed to their inequalities. CONCLUSIONS: The findings characterize the prevalence and inequality of unmet healthcare need among middle-aged and older adults in eastern China during the progression toward UHC. Policy interventions should be actively advocated to effectively mitigate the unmet healthcare needs and address the associated inequalities.

Perioperative capacity and contextual challenges in teaching hospitals of southern Ethiopia: explanatory sequential mixed-methods research.

BACKGROUND: Previous Ethiopian literature on surgical capacity and challenges has focused on quantitative investigations, lacking contextual understanding. This explanatory sequential mixed-methods research (MMR) aimed to assess perioperative capacity and contextual challenges at three teaching hospitals in southern Ethiopia. METHODS: A quantitative survey assessed workforce, infrastructure, service delivery, financing, and information systems. The survey findings were explained by qualitative semi-structured interviews of twenty perioperative providers. Descriptive statistics were integrated with qualitative thematic analysis findings using the narrative waving approach. Key findings from both datasets were linked using a joint display table. RESULTS: The survey revealed shortages in the specialist workforce (with a ratio of 0.58 per 100,000 population), surgical volume (at 115 surgeries per 100,000 population), equipment, supplies, financing, and perioperative data tracking. Hospitals' radiology services and blood products were only available 25-50% of the time, while anesthetic agents and essential laboratory services were often available 51-75% of the time. Perioperative management protocols were used rarely (1-25% of the time). Over 90% of patients lack health insurance coverage. Qualitative data also revealed scarcity of perioperative resources and equipment; unaffordable perioperative costs, lack of health insurance coverage, and unforeseen expenses; poor patient safety culture and communication barriers across the perioperative continuum of care; workforce shortages, job dissatisfaction, and concerns of competence; and weak national governance, and sociopolitical turmoil, and global market volatility exacerbating local challenges. These challenges are linked to risks in quality of care and patient safety, according to clinicians. CONCLUSION: The study identifies deficiencies in the health system and sociopolitical landscape affecting safe surgery conduct. It highlights the need for comprehensive health system strengthening to expand workforce, upgrade facilities, improve safety culture, resilience, and leadership to ensure timely access to essential surgery. Exploring external factors, such as the impact of national governance and sociopolitical stability on reform efforts is also essential.

Optimization of the emergency obstetric and neonatal care network in Benin through expert-based sub-national prioritizations.

Introduction: To reduce maternal mortality by 2030, Benin needs to implement strategies for improving access to high quality emergency obstetric and neonatal care (EmONC). This study applies an expert-based approach using sub-national travel specificities to identify and prioritize a network of EmONC maternities that maximizes both population coverage and functionality. Methods: We conducted a series of workshops involving international, national, and department experts in maternal health to prioritize a set of EmONC facilities that meet international standards. Geographical accessibility modeling was used together with EmONC availability to inform the process. For women in need of EmONC, experts provided insights into travel characteristics (i.e., modes and speeds of travel) specific to each department, enabling more realistic travel times estimates modelled with the AccessMod software. Results: The prioritization approach resulted in the selection of 109 EmONC maternities from an initial group of 125 designated maternities. The national coverage of the population living within an hour's drive of the nearest EmONC maternity increased slightly from 92.6% to 94.1% after prioritization. This increase in coverage was achieved by selecting maternities with sufficient obstetrical activities to be upgraded to EmONC maternities in the Plateau and Atlantique departments. Conclusion: The prioritization approach enabled Benin to achieve the minimum EmONC availability, while ensuring very good geographical accessibility to the prioritized network. Limited human and financial resources can now be targetted towards a smaller number of EmONC facilities to make them fully functioning in the medium-term. By implementing this strategy, Benin aims to reduce maternal mortality rates and deliver effective, high-quality obstetric and neonatal care, especially during emergencies.

Collaborations and Networks Within Communities for Improved Utilization of Primary Healthcare Centers: On the Road to Universal Health Coverage.

Objectives: Community involvement depends on the level of linked and targeted activities for health by community members. This study examines the collaborations employed within communities to ensure sustainable access and improved use of healthcare in the community. Methods: This study was conducted in rural and urban local government areas in Anambra, Kano, and Akwa-Ibom, Nigeria. About 90 in-depth interviews and 12 focus group discussions were conducted with community stakeholders and service users. The findings were transcribed and coded via thematic analysis, guided by the Expanded Health Systems framework. Results: Various horizontal collaborations in communities foster increased use of PHC services; promoting community health. Major horizontal collaborations in these communities were community-led, primary health facility-led, and Individual-led collaborations. Their actions revolved around advocacy, building and renovating PHC centers, equipping facilities, and sensitization to educate community members on the need to utilize services at PHC centers. Conclusion: Strategic involvements and collaborations of local actors within communities give rise to improvements in the utilization of primary healthcare centres, reportedly resulting in improved access to PHC healthcare services for community members.

Reduced burden on urban hospitals by strengthening rural health facilities: Perspective from India.

In India, rural-urban health disparities have been persisting over a period. Migration of patients from rural to urban is an integral part of population dynamics thereby creating an additional burden on urban hospitals. Over the decade, India has made significant advances in health in reducing the rural-urban gap. The article highlights how the strengthening of rural healthcare facilities has reduced the burden of urban hospitals. Secondary data on the usage of public and private healthcare facilities from two rounds of the National Family Health Survey (NFHS) conducted in 2016 and 2021 and the Rural Health Statistics 2021-2022 were analyzed. The proportion of beneficiaries seeking care from public health facilities has increased from 41.9% to 45.7% in rural areas and 31% to 35.3% in urban areas between 2014 to 2017. The institutional deliveries have increased from 56% to 69.2% in rural areas and from 42% to 48.3% in urban areas. The State and local level interventions such as the upgradation of existing physical infrastructure, human resources, regular supply of medicines and consumables, development of referral linkages, patient transportation, and enhancing community participation have strengthened the rural healthcare system. Adequate utilization of the resources is crucial to addressing the lag and alleviating the rural-urban divide.

Improving access to primary health care through financial innovation in rural China: a quasi-experimental synthetic difference-in-differences approach.

BACKGROUND: Inadequate financing constrains primary healthcare (PHC) capacity in many low- and middle-income countries, particularly in rural areas. This study evaluates an innovative PHC financing reform in rural China that aimed to improve access to healthcare services through supply-side integration and the establishment of a designated PHC fund. METHODS: We employed a quasi-experimental synthetic difference-in-differences (SDID) approach to analyze county-level panel data from Chongqing Province, China, spanning from 2009 to 2018. The study compared the impact of the reform on PHC access and per capita health expenditures in Pengshui County with 37 other control counties (districts). We assessed the reform's impact on two key outcomes: the share of outpatient visits at PHC facilities and per capita total PHC expenditure. RESULTS: The reform led to a significant increase in the share of outpatient visits at PHC facilities (14.92% points; 95% CI: 6.59-23.24) and an increase in per capita total PHC expenditure (87.30 CNY; 95% CI: 3.71-170.88) in Pengshui County compared to the synthetic control. These effects were robust across alternative model specifications and increased in magnitude over time, highlighting the effectiveness of the integrated financing model in enhancing PHC capacity and access in rural China. CONCLUSIONS: This research presents compelling evidence demonstrating that horizontal integration in PHC financing significantly improved utilization and resource allocation in rural primary care settings in China. This reform serves as a pivotal model for resource-limited environments, demonstrating how supply-side financing integration can bolster PHC and facilitate progress toward universal health coverage. The findings underscore the importance of sustainable financing mechanisms and the need for policy commitment to achieve equitable healthcare access.

Beyond reducing direct medical cost: examining health outcomes in tuberculosis through a difference-in-differences analysis of South Korea's out-of-pocket payment exception policy.

Background: Universal health coverage and social protection are major global goals for tuberculosis. This study aimed to investigate the effects of an expanded policy to guarantee out-of-pocket costs on the treatment outcomes of patients with tuberculosis. Methods: By linking the national tuberculosis report and health insurance data and performing covariate-adjusted propensity-score matching, we constructed data on health insurance beneficiaries (treatment group) who benefited from the out-of-pocket payment exemption policy and medical aid beneficiaries as the control group. Using difference-in-differences analysis, we analyzed tuberculosis treatment completion rates and mortality in the treatment and control groups. Results: A total of 41,219 persons (10,305 and 30,914 medical aid and health insurance beneficiaries, respectively) were included in the final analysis (men 59.6%, women 40.4%). Following the implementation of out-of-pocket payment exemption policy, treatment completion rates increased in both the treatment and control groups; however, there was no significant difference between the groups (coefficient, -0.01; standard error, 0.01). After the policy change, the difference in mortality between the groups increased, with mortality decreasing by approximately 3% more in the treatment group compared with in the control group (coefficient: -0.03, standard error, 0.01). Conclusion: There are limitations to improving treatment outcomes for tuberculosis with an out-of-pocket payment exemption policy alone. To improve treatment outcomes for tuberculosis and protect patients from financial distress due to the loss of income during treatment, it is essential to proactively implement complementary social protection policies.

Genesis of People's Medicine Centre (PMC) for popularisation of generic medicine: A critical qualitative inquiry.

Introduction: The concerns of inaccessibility to essential medicines in India are well-studied and documented. Pradhan Mantri Bhartiya Janaushadhi Priyojana (PMBJP) is one of the policy initiatives to address the inaccessibility of essential medicine. Janaushadhi Kendra (People's Medicine Centre), which is part of PMBJP is being enquired in a limited way to understand its effectiveness. The province of Odisha has been chosen as the study area for the evaluation of People's Medicine Centres. Objective: The present study intends to inquire into the nature of People's Medicine Centre ownership, pharmacists' motivations and incentives to engage in business, perceived customers' trust and satisfaction, scheme beneficiaries, and challenges. Methods: A qualitative research approach has been adopted to evaluate the broader subjective accounts of the pharmacists and People's Medicine Centre. An open-ended interview guide was used. The topics of ownership, motivation, incentives, trust, satisfaction, perceived benefits, and challenges has been recorded from the participants. A total of seventeen in-depth interviews were conducted in the province of Odisha, India. Results: The study found that the ownership of People's Medicine Centre was of two types in the province of Odisha: public-NGO-owned People's Medicine Centres and public-private-owned People's Medicine Centres. The financial incentive provisions in the scheme attracted the private pharmacists. Pharmacists highlighted about the lower price of generic medicines compared to branded medicines, which is very popular among patients. They also pointed out that there is no difference in the efficacy of both medicines. The attitude of physicians, especially private physicians, were considered problematic for popularity and acceptance. Conclusion: The People's Medicine Centres in Odisha established themselves as trusted outlets despite physicians' unfavourable attitudes. Although the centres have not reached the required geographical coverage, economically developed regions have large number of centres, while backward regions have minimal presence. The scheme needs to be more conducive to the welfare of the masses living in remote and rural areas.

Determinants of HIV/AIDS treatment and care service quality in Woliso Town, Oromia, Ethiopia: in the case of HIV prevention and control project.

In Ethiopia, even though there is an effort to increase ART services, different challenges remain in the provision of HIV/AIDS treatment and care services, and little has been done to evaluate patient satisfaction levels. The purpose of this study is to assess the determinants of HIV/AIDS treatment and care service quality. A facility-based cross-sectional study was conducted during from October 2023 to November 2023 in Woliso Town. The total sample size was generated using a systematic random sampling method from the source population. The results of the study showed that client satisfaction with HIV/AIDS treatment and care service quality was 272 (81.4%) with 95% CI: 76.9-85.3%. Government employees were 67% less likely to be satisfied with HIV/AIDS treatment and care service quality (AOR = 0.33 95% CI: 0.11, 0.99) when compared to unemployed clients. The odds of client satisfaction were 6.72 times higher among study participants who do not have health insurance membership cards (AOR = 6.72 95% CI: 3.42, 13.91) compared to those who have health insurance membership cards. The odds of client satisfaction were 2.77 times higher among study participants who reported the availability of community referral for any social support (AOR = 2.77 95% CI: 1.12, 6.84) when compared to those who did not report. Those study participants for whom privacy was kept during the examination were 8.67 times higher to be satisfied (AOR = 8.67 95% CI: 2.53, 29.68) compared to those for whom privacy was not kept during the examination. In conclusion, the client satisfaction on HIV/AIDS treatment and care service quality was relatively high in the study area. Occupational status, health insurance membership cards, availability of community referral for any social support and keeping privacy during examination have significant associations with HIV/AIDS treatment and care service quality in terms of client satisfaction.

Engagement of private healthcare sector in addressing noncommunicable diseases at primary care level in the Eastern Mediterranean Region.

Background: The private healthcare sector is a critical stakeholder in the provision of health care services, including noncommunicable diseases (NCDs), and engagement with the sector is increasingly being advocated in efforts to achieve Universal Health Coverage. Aim: This study was conducted to explore the role of the private health sector in delivering NCD-related primary care services in selected countries of the WHO Eastern Mediterranean Region (EMR): Jordan, Oman, Pakistan, Sudan, and the Syrian Arab Republic. Methods: We adapted the analytical framework for this study from the "Framework for action to implement the United Nations political declaration on noncommunicable diseases". We conducted a desk review to gather evidence, identify gaps and provide direction for the subsequent stakeholder interviews. Key informant interview respondents were selected using the snowball sampling method. Data from the interviews were analysed using MAXQDA, version 2020. Results: We reviewed 26 documents and interviewed 19 stakeholders in Jordan, Oman, Pakistan, Sudan and the Syrian Arab Republic. Our results indicated increasing advocacy at the regional and national levels to align the private and public health sectors, just as there were efforts to reduce the risk factors for NCDs by implementing tobacco laws, introducing food labelling guidelines, increasing taxes on soft drinks, and promoting the healthy cities approach. NCDs health information systems varied widely among the countries, from being organized and developed to having poor recordkeeping. The private health sector is the predominant provider of care at primary level in most of the EMR countries. Conclusion: Increased collaboration between the public and private sectors is essential for better management of NCDs in the EMR. Governments need to strengthen regulation and defragment the private health sector and harness the sector's strengths as part of efforts to achieve national health targets, NCD goals and Universal Health Coverage.

Analyzing the impact of fiscal conditions on private health expenditures in OECD countries: a quantile ARDL investigation.

Organization for Economic Co-operation and Development (OECD) countries have embraced the aim of universal health coverage, as established in Sustainable Development Goal (SDG) 3.8. This goal guarantees access to quality healthcare services without financial hardship or poverty. Additionally, it requires correct and adequate financing sources. A country with weak protection for its population tends to spend less on healthcare and experiences a high share of out-of-pocket payments (OOPs), increasing the likelihood of people falling into poverty. This study aims to understand the relationship and causal effects between macroeconomic and public fiscal conditions and private health expenditure in OECD countries between 1995 and 2019. We retrieved OECD data for 26 OECD countries for the period 1995-2019. Panel AutoRegressive Distributed Lag (PARDL) and panel quantile AutoRegressive Distributed Lag (PQARDL) models were estimated to examine the relationship between private health expenditures and macroeconomic and public fiscal variables. Our results reveal a positive influence of government debt and economic freedom on private health expenditures. They also show a negative influence of the government budget balance, government health expenditures, and economic growth on private health expenditures. These results collectively suggest that public fiscal conditions will likely impact private health expenditures. The findings of this study raise concerns about the equity and financial protection objectives of universal health coverage in OECD countries.

The Role of Supplementary Insurance in Achieving Universal Health Coverage: A Comprehensive Review.

Background: The gradual movement towards universal health coverage (UHC) is an important issue in many countries. The aim of this study is to identify the role of supplementary health insurance in achieving universal coverage. Methods: This comprehensive review study was conducted to identify the role of supplementary health insurance in achieving universal health coverage. 4894 articles were found in the search in databases (Scopus, PubMed, and Web Science), and finally42 articles were selected. Considering the criteria of titles and abstracts, the reviewed articles were assessed, and a thematic analysis approach was used to analyze the collected data. Results: The review showed 52 Sub dimensions in 7 dimensions. Policymakers can draw on international experiences to ensure that private health insurance contributes to achieving universal health coverage by Providing clarity within the national health financing policy framework regarding the role of private health insurance. Enhancing understanding of how supplementary health insurance impacts the performance of the healthcare system. They are improving oversight of private health insurance, regulating financial protection and consumer support, and implementing thorough market surveillance and proper allocation of health subsidies between the private and public sectors. Conclusion: Supplementary insurance holds promise as a complementary tool in achieving universal health coverage. Addressing gaps in primary insurance and providing additional financial protection can contribute to enhanced access, improved quality of care, and reduced financial barriers to healthcare services. However, careful attention must be given to affordability, equity, regulation, and coordination with primary insurance schemes to ensure its effective implementation and prevent unintended consequences.

The Scabbard of Excalibur: An Allegory on the Role of an Efficient and Effective Healthcare System under Universal Health Coverage during the Pandemic Response.

During the COVID-19 pandemic, while some countries succeeded in reducing their rate of death after SARS-CoV-2 infection via vaccination by the end of 2021, some of them also faced hospital capacity strain, leading to social anxiety about delays in the diagnosis and treatment of patients with other diseases. This essay presents an allegory to explain the situation during the COVID-19 pandemic. Through an allegory and Le Morte d'Arthur (Arthur's Death), this essay indicates that "the scabbard of Excalibur" that we are looking for is an efficient and effective healthcare system that can diagnose patients who might become severely ill due to COVID-19 and to treat them without hospital capacity strain. In Le Morte d'Arthur, the scabbard of Excalibur was lost, and we have not been able to find any alternatives to end the COVID-19 pandemic. We can choose a future in which "the scabbard of Excalibur" exists, providing a different ending for the next pandemic.

Inequalities in Out-of-Pocket Health Expenditure Measured Using Financing Incidence Analysis (FIA): A Systematic Review.

Government efforts and reforms in health financing systems in various countries are aimed at achieving universal health coverage. Household spending on healthcare plays a very important role in achieving this goal. The aim of this systematic review was to assess out-of-pocket health expenditure inequalities measured by the FIA across different territories, in the context of achieving UHC by 2030. A comprehensive systematic search was conducted in the PubMed, Scopus, and Web of Science databases to identify original quantitative and mixed-method studies published in the English language between 2016 and 2022. A total of 336 articles were initially identified, and after the screening process, 15 articles were included in the systematic review, following the removal of duplicates and articles not meeting the inclusion criteria. Despite the overall regressivity, insurance systems have generally improved population coverage and reduced inequality in out-of-pocket health expenditures among the employed population, but regional studies highlight the importance of examining the situation at a micro level. The results of the study provide further evidence supporting the notion that healthcare financing systems relying less on public funding and direct tax financing and more on private payments are associated with a higher prevalence of catastrophic health expenditures and demonstrate a more regressive pattern in terms of healthcare financing, highlighting the need for policy interventions to address these inequities. Governments face significant challenges in achieving universal health coverage due to inequalities experienced by financially vulnerable populations, including high out-of-pocket payments for pharmaceutical goods, informal charges, and regional disparities in healthcare financing administration.

Re-envisioning contributory health schemes to achieve equity in the design of financial protection mechanisms in low- and middle-income countries.

Universal health coverage has emerged as a global health priority, requiring that financing strategies that ensure low-income and medically and financially at-risk individuals can access health services without the threat of financial catastrophe. Contributory financing schemes and social health insurance (SHI) schemes, in particular, predominate in low- and middle-income countries (LMICs), despite evidence that suggests the most vulnerable remain excluded from such schemes. In this commentary, we discuss the need to re-envision schemes to prioritize equity, offering 3 concrete recommendations: adopt participatory designs for the co-design of schemes with beneficiaries, establish linkages between contributory financial protection schemes with economic empowerment initiatives, and prioritize the needs and preferences of beneficiaries over political expediency. Co-design alone does not necessarily translate into more equitable schemes, underscoring the need for greater monitoring and evaluation of these schemes that consider differential impacts across contexts and subgroups. In doing so, SHI schemes can be both attractive and accessible to populations that have long been excluded from financial protections in LMICs, acting as 1 channel in a broader financing strategy to achieve universal health coverage.

Process evaluation of a complex, multilevel, multicomponent scheme for the prevention and control of non-communicable diseases in Tamil Nadu, India: A mixed-methods protocol.

Background: Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality in India, necessitating development of multilevel and multicomponent interventions. Makkalai Thedi Maruthuvam (MTM) is a complex multilevel, multicomponent intervention developed and implemented by the south Indian State of Tamil Nadu. The scheme aims to deliver services for preventing and controlling diabetes, and hypertension at doorstep. This paper describes the protocol for planning and conducting the process evaluation of the MTM scheme. Methods and analysis: The process evaluation uses mixed methods (secondary data analysis, key informant interviews, in-depth interviews, conceptual content analysis of documents, facility-based survey and non-participant observation) to evaluate the implementation of the MTM scheme. The broad evaluation questions addressed the fidelity, contexts, mechanisms of impact and challenges encountered by the scheme using the Consolidated Framework for Implementation Research (CFIR) framework. The specific evaluation questions addressed selected inputs and processes identified as critical to implementation by the stakeholders. The CFIR framework will guide the thematic analysis of the qualitative interviews to explore the adaptations and deviations introduced during implementation in various contexts. The quantitative data on the indicators developed for the specific evaluation questions will be cleaned and descriptively analysed.