BMC Health Services Research

Introduction. Practice coaching is increasingly used to strengthen quality improvement (QI) capacity in primary healthcare (PHC) systems in low and middle income countries (LMICs), yet the causal pathways through which it shifts provider behaviour, and the systemic conditions that enable or constrain those pathways, remain under theorised. Using a theory based qualitative evaluation, we examined how and why a practice coaching intervention influenced QI in cervical cancer screening (CCS) and antenatal care (ANC) within Honduras decentralised PHC system during the third phase of the Salud Mesoamerica Initiative (SMI). Methods. We conducted a within case explanatory case study. A programme theory was reconstructed before data collection and iteratively refined against evidence. Data comprised semi structured interviews with 11 midlevel managers, 6 PHC team medical leads, and 2 regional managers, complemented by direct observation and document review. We applied combined deductive and inductive coding, thematic analysis, and pattern matching, and reporting per COREQ. Results. We identified four causal patterns that refined the initial programme theory. Three were activated pathways: (1) novel professional identity among participating managers; (2) collective efficacy and data driven learning, sustained through verifiable progress on observable indicators, strong for CCS but null for ANC, where outcomes were less attributable to teams actions; and (3) relational coordination, psychological safety, and trust, which provided the interpersonal basis for the first two. A fourth, unanticipated pattern showed structural misalignment between coaching enabling, learning based logic and the directive, punitive logic of Honduras performance based contracting environment, confining gains to localised enabling bubbles. Conclusion. Coaching can activate meaningful QI pathways in LMIC primary care, but sustained, equitable impact requires deliberate alignment between coaching learning oriented principles and the institutional performance management architecture, and matching of coaching investment to clinical processes with observable, attributable outcomes.

Background: Health-related social needs (HRSNs), particularly housing instability, are significant drivers of poor health outcomes among Medicaid populations. New York State's Social Care Networks (SCNs) aim to systematically connect members to housing services through coordinated referral systems. However, limited systematic analysis of referral patterns hinders quality improvement efforts. We analyzed housing referral outcomes and workflows to identify barriers to successful service connections. Methods: We conducted a mixed-methods quality improvement study at Public Health Solutions' WholeYouNYC SCN Coordination Center. Quantitative analysis examined 4,258 housing referrals submitted between June 2025 and January 2026, extracted from the Unite Us platform via Power BI dashboard. We calculated acceptance rates, analyzed time metrics, and examined outcomes by receiving organization. Qualitative data were collected through structured consultations with 7 staff members (5 navigators, 2 supervisors) and review of internal workflow documentation. Process mapping identified workflow bottlenecks. Results: Of 4,258 housing referrals, only 45% (n=1,936) were accepted by receiving organizations, while 19% (n=815) were rejected and 32% (n=1,382) remained awaiting response with no recorded action. Average time to acceptance was 8 days for accepted referrals. Acceptance rates were consistent across top receiving organizations (44-46%), suggesting systemic rather than partner-specific barriers. Analysis of unresolved referrals revealed prolonged cases, with the longest pending 271 days. Three critical workflow bottlenecks were identified: CBO response delays, missing housing documentation, and challenges with client engagement. Conclusions: Low housing connection rates (45%) and prolonged unresolved referrals (up to 271 days) indicate systemic barriers requiring interventions at multiple levels. Recommendations include establishing CBO response time benchmarks, implementing automated follow-up protocols, standardizing documentation requirements, and enhancing real-time data monitoring. These findings provide an evidence-based framework for quality improvement in social care coordination programs.

Background: The rising prices of cancer medicines have intensified concerns about treatment access and health system sustainability particularly in low- and middle-income settings. Systematic facility level evidence on what medicines is actually available, at what prices, and at what cost to patients remains scarce, constraining evidence-based policy reform. Methods: Using adapted WHO/Health action international methodology, we conducted a cross-sectional survey of 52 cancer medicines across five therapeutic classes at five health facilities in Kisumu County, Kenya. Availability was measured as the proportion of facilities stocking each medicine. Affordability was assessed using days' wages required for the lowest-paid government worker to purchase standard treatment regimens, calculated per one chemotherapy cycle and maximum possible cycles. Results: Overall medicine availability was 48.1%, with marked inter-facility variation. Affordability analysis revealed severe financial barriers. The breast cancer AC regimen required 19.6-47.4 days' wages per full course; cervical cancer cisplatin, 19.8-49.2 days' wages; colorectal FOLFOX, 80.0-303.6 days' wages; and prostate docetaxel reached 437 days' wages at the highest-cost facility. The Social Health Authority's (SHA) KES 550,000 annual ceiling adequately covered cytotoxic regimens for common cancers at competitive prices but was exceeded by 24-116% for HER2-positive breast cancer requiring trastuzumab, with further strain for recurrent cervical and metastatic prostate cancers. Conclusions: Cancer medicines in Kisumu County are inconsistently available and highly variable in price resulting in inequitable access. We call for urgent retail price markup regulation, expanded pooled procurement through KEMSA, inclusion of priority targeted therapies on the Kenya Essential Medicines List, and SHA benefit packages redesigned around full-course regimen costs.

ObjectiveTo quantify waiting time in days for scheduled outpatient specialist consultations and to compare waiting time between standardized and non-standardized access pathways in Ecuadorian public hospitals. MethodsWe analyzed hospital-based survey data from Ecuadorian public hospitals, restricted to adults attending a scheduled outpatient specialist consultation (n = 4,436). Emergency care, unscheduled urgent visits, procedures, and follow-up visits were excluded by design. Access pathway was classified from participants self-report as standardized (institutional or system-based) or non-standardized (informal or non-system-based). Waiting time, defined as the number of days between obtaining the appointment and attending the consultation, was compared using the Mann-Whitney U test. Sociodemographic correlates of non-standardized access were examined using adjusted logistic regression, and adjusted median differences were estimated using quantile regression ({tau} = 0.50). Analyses were stratified into direct-access specialties and referral-required specialties. ResultsNon-standardized access was associated with shorter waiting times than standardized access. In adjusted median regression, non-standardized access was associated with a 3.2-day shorter median waiting time (95% CI -4.6 to -1.8). The difference was larger in direct-access specialties (-15.0 days, 95% CI -15.0 to -6.0) than in referral-required specialties (-5.0 days, 95% CI -5.0 to 0.0). ConclusionAmong patients who attended a scheduled outpatient specialist consultation in Ecuadorian public hospitals, non-standardized access was associated with shorter waiting times, particularly in direct-access specialties. These findings suggest that, within routine outpatient care, parallel access pathways may shape timeliness and warrant greater transparency in appointment allocation and referral coordination.

BackgroundAlthough virtual consultations are increasingly used in healthcare, mode affects attendance patterns remains limited, particularly across demographic groups. Within NHS secondary care, telephone consultations have been the most widely adopted form of telephone care; however, few studies have examined non-attendance (commonly termed Did Not Attend [DNA]) patterns specifically for telephone consultations and fewer still have explored how patient characteristics influence attendance differently across consultation modes. Understanding these patterns is essential for equitable service planning. ObjectiveTo compare non-attendance rates between telephone and in-person secondary care consultations among adults with type 2 diabetes (T2D), and to identify patient characteristics associated with non-attendance under each mode. MethodsData from 853,693 secondary care consultations (January 2020-August 2024) for 45,618 patients with T2D in Northwest London were analysed. Telephone consultations in this dataset consisted exclusively of telephone consultations; we therefore refer to them as telephone consultations throughout. Patient-level consultations were aggregated into patient-mode strata for regression modelling. Zero-inflated Negative Binomial regression assessed factors associated with missed consultation rates by mode (in-person or telephone). Propensity-score balance diagnostics (inverse probability of treatment weighting) were conducted to assess measured confounding by mode assignment. Specialty-stratified non-attendance rates were examined across 34 major specialties. ResultsIn-person consultations had higher unadjusted non-attendance rates than telephone consultations (9.1% vs 7.2%, p<0.001). This pattern was consistent for both first consultations (9.3% vs 6.2%, p<0.001) and follow-up consultations (9.0% vs 7.50%, p<0.001). For in-person consultations, higher non-attendance was associated with younger age (18-39: 12.2%, 40-59: 11.1% vs 60-79: 9.9%, p<0.001), Black or Black British ethnicity (18.9% vs White: 7.6%, p<0.001), and greater deprivation (most deprived IMD1: 10.3% vs least deprived IMD5: 7.0%, p<0.001). For telephone consultations, higher non-attendance was associated with male gender (7.3% vs female: 7.0%, p<0.01), younger age (18-39: 11.3%, 40-59: 9.5% vs 60-79: 6.1%, 80+: 5.6%, p<0.001), and greater socioeconomic deprivation (most deprived: 8.3% vs least deprived: 4.7%, p<0.001). Interaction analyses revealed that demographic disparities were amplified for telephone relative to in-person consultations. Specialty-stratified analysis showed that in-person non-attendance exceeded telephone non-attendance in the majority of high-volume specialties. ConclusionsIn-person consultations had higher non-attendance rates than telephone consultations. Various demographic factors influenced non-attendance rates, with younger age and greater socioeconomic deprivation consistently associated with non-attendance for both in-person and telephone consultations. These findings suggest that a personalised, equity-informed approach to consultation mode selection is needed. Findings apply to telephone consultations and may not generalise to video-based modalities.

Abstract Objective To Estimate cost of integrating HBV, HCV, and HIV screening at Antenatal using Time-Driven Activity Based Costing (TDACB) Approach; A providers perspective comparing Intervention and standard of care at lower health facilities in West Nile sub region, Uganda Methods Design The Time Driven Activity-Based Costing (TDABC) approach was used to capture resource use and costs associated with delivering integrated HBV, HCV, and HIV screening among pregnant women. This study compared screening uptake among study participants in the intervention, and control group respectively. Five lower health facilities in Koboko and Maracha districts respectively in West Nile region of Uganda. A total of 1,338 study participants wo were pregnant mothers in first ANC, first trimester at the selected 10 facilities were enrolled in this study. Data were abstracted, and also collected on; Personnel/staff time; facility space utilisation; and Medical and non-medical equipment. Total cost per patient visit=Staff time costs+Space cost Equipment cost. Outcome Measure was the estimated provider-perspective costs of delivering integrated screening for HBV, HCV and HIV, using Integrated Care Model by comparing intervention and control groups. Results Staff CCRs demonstrated considerable variability across cadres and facilities, with an overall mean of USD 0.492 per minute (Range: USD 0.167 - 1.318). Laboratory technicians exhibited the highest mean CCR at USD 0.767 per minute for personnel CCRs per patient visit. the mean lowest CPP visit was noted for HBV in the intervention arm (USD 11.43) while HIV test was the lowest in the control arm (USD 0.43). HCV test had the highest cost in the control arm (USD 0.52). The CPP visit for positive clients were generally higher than those that were negative. Equipment CCRs were minimal and highly consistent across facilities, with a mean of USD 0.00069 per minute ({+/-}0.0002). HIV/Syphilis combo was the costliest test kits at USD 3.14 per test kit followed by viral hepatitis C test kit and Hep B at USD 2.47 and USD 0.28 respectively. Facility space CCRs exhibited moderate variation across facilities, ranging from USD 0.01593 to USD 0.03474 per minute. Overall mean CCR for the space for delivering HBV, HCV or HIV testing was USD 0.0256 (0.0066). Conclusion; Overall, the integration of screening resulted in: Cost efficiencies where the same staff and space were used for multiple simultaneous tests, reduced marginal costs for HIV tests due to larger procurement volumes, and higher marginal cost additions for HBV and HCV due to pricier reagents.

IntroductionAccess to specialist care in the Netherlands requires a general practitioner (GP) referral, yet referrals to secondary care keep rising. Triage has been proposed to manage this demand and may be relevant for internal medicine, which addresses diverse and increasingly complex conditions. This study aimed to identify the internal medicine healthcare needs which were redirected to the GP after triage and to explore the factors driving GP referral behaviour. MethodsThis multi-method study combined quantitative referral data with qualitative insights from GP focus groups. Data were extracted from a hospital in an urban region, including adults with non-acute complaints referred for outpatient consultation to internal medicine between August 2019 and July 2021. Referrals were triaged for appropriateness and redirected where possible. Focus groups explored GPs perspectives on referral practices. ResultsOf 5,826 referrals triaged, 998 (17%) were redirected to the GP with advice and guidance. Endocrinology accounted for 35% of redirected cases, followed by nephrology (8.6%). Focus groups revealed underlying drivers of referral behaviour, identifying four themes: medical factors; GP-related factors, including professional uncertainty and autonomy; patient-related factors; and external factors, such as contextual and regulatory influences. ConclusionThis study demonstrates that triage is a feasible strategy for managing referral volumes, particularly within domains such as endocrinology where many medical problems can be managed in primary care. However, referrals are shaped by more than clinical need, reflecting uncertainty, emotional considerations, patient expectations and systemic factors. Strengthened collaboration between primary and secondary care, alongside pre-referral consultation strategies, is essential to ensure appropriate, high-quality patient care.

ObjectivesMost countries in Latin America have committed to adopting HEARTS, PAHOs recommended approach for managing hypertension and diabetes in national primary care health systems. This study aimed to understand and refine a HEARTS pilot for scale-up in Guatemala. MethodsTeam members conducted semi-structured interviews with 30 patients and health workers participating in a HEARTS pilot across 10 primary care facilities in Guatemalas Ministry of Health system. Researchers analyzed interviews using a combined inductive-deductive approach alongside the Tailored Implementation in Chronic Diseases framework and used convergent mixed methods to generate meta-inferences. ResultsDespite high feasibility and acceptability scores, health workers described tensions between HEARTS and competing responsibilities. Patients described rational navigation of an unreliable system, a more fitting explanation for low retention than noncompliance. Both patients and health workers understood HEARTS as another externally funded project with uncertain sustainability. Medication availability improved during the pilot, but district and facility-level incentive structures perpetuated supply unreliability. Greater absolute treatment gains for hypertension than for diabetes likely reflected health worker comfort and preexisting access to blood pressure monitoring supplies. Both patients and health workers identified education gaps. Integration of qualitative and quantitative findings suggested concrete scale-up refinements, including simplifying treatment protocols, strengthening diabetes components, focusing training on nurses, reforming central-level pharmaceutical supply policies, and securing high-level Ministry of Health commitments. ConclusionsA HEARTS pilot trial in Guatemala met pre-specified quantitative outcomes, but qualitative and mixed-methods approaches revealed key barriers. These findings will assist in refining HEARTS in Guatemala for planned national scale-up. Trial registrationClinicalTrials.gov (NCT06080451)

BackgroundUnderstanding of context-specific retention strategies for doctors will guide targeted interventions and policy framework for strengthening the district health system in South Africa. Several strategies have been examined, some more impactful than others, with resilience playing a role in retention of staff, but data is lacking in the Eastern Cape Province, South Africa. AimTo assess factors influencing the retention and resilience of doctors at district hospitals in the Eastern Cape. SettingDistrict hospitals in Amathole and Buffalo City health district municipalities in the Eastern Cape. MethodsIn this cross-sectional survey, participants rated retention strategies as well as a validated resilience scale (the CD-RISC 25). ResultsA total of 74 doctors were surveyed; mostly [&le;]34 years (66%), Black Africans (69%), and [&le;]5 years of professional experience (59%). The majority had worked in their current facilities for [&le;]5 years (76%). Significant proportion of young (78%), single (59%), and Grade 1 medical officers (86%) intend to leave their current facilities. Improving hospital accommodation was significantly associated with the intention to stay longer at the rural district hospitals. While not statistically significant, factors affecting professional development and growth scored higher while those related to financial remuneration scored lowest. There were no associations between resilience and intention to stay. ConclusionEarly career doctors prioritise career growth and development, while more experienced doctors rated improved living condition as the main determinants of retention in the rural health facilities. Future studies should recruit representative sample of doctors from the various municipalities and across provinces in the country. ContributionImproving hospital accommodation and enhancing career growth and development may increase retention of doctors in the rural district hospitals.

Background In the Democratic Republic of the Congo (DRC), health care financing relies heavily on out-of-pocket payments, limiting access to essential services. In a context of declining external funding and ongoing efforts toward Universal Health Coverage (UHC), understanding households willingness to pay (WTP) for health care is critical for designing sustainable financing strategies. This study aimed to assess WTP for primary health care services and identify its associated factors in Eastern Kasai Province. Methods A cross-sectional study based on the contingent valuation method was conducted from 10 to 30 July 2025 among 633 randomly selected households using a multistage probabilistic sampling approach. Data were collected through semi-structured interviews using KoboToolBox. WTP was assessed using a stated preference approach. Logistic regression analyses using R 4.5.0 were performed to identify factors associated with WTP at a significance level of p < 0.05. Adjusted odds ratios (aORs) with 95% confidence intervals (95% CI) were reported. Results Overall, 70% of household heads reported willingness to pay for their own health care, and 73% for other household members. WTP decreased significantly as the cost of services increased, dropping from 95.5% for free care to 6.3% at the highest cost levels (above CDF 230,000). Poor perceived quality of care was a consistent reason for refusal, alongside financial constraints such as low income and indebtedness. Multivariable analysis showed that having a professional activity (OR = 1.9; 95% CI: 1.2-3.0; p = 0.006), residence in rural areas (OR = 2.1; 95% CI: 1.3-3.7; p = 0.008), and higher household income (OR = 2.2; 95% CI: 1.2-4.0; p = 0.011) were significantly associated with WTP. Despite relatively low absolute health care costs, the majority of households perceived them as high. Conclusion Willingness to pay for health care services in Eastern Kasai is moderate but highly sensitive to cost and strongly influenced by socioeconomic conditions and perceived quality of care. These findings underscore the need to strengthen financial protection mechanisms, particularly prepayment and risk-pooling systems, while improving service quality to enhance health care utilization and progress toward UHC in the DRC.

Objective: To identify facility-level characteristics - including care level, ownership type, and funding model - associated with poor HIV treatment outcomes, and quantify their independent contributions after adjustment for patient-level clinical factors. Design: Retrospective cross-sectional analysis using multivariable logistic regression with HC3 cluster-robust standard errors to account for facility-level clustering. Setting: HIV care facilities in the Nigerian national HIV programme, spanning primary health centres, secondary health facilities, and tertiary hospitals. Participants: 27,288 HIV-positive patients enrolled on ART, from a publicly available de-identified Quality of Care dataset. Main outcome measures: Composite poor outcome (poor ART adherence, treatment interruption, or mortality); individual outcomes including poor adherence rate, mortality, ART interruption, and diagnosis-to-ART delay exceeding 90 days. Results: Primary health centres had 15.4% composite poor outcome versus 10.2% at tertiary hospitals. After adjustment for patient age, sex, WHO stage, and CD4 count, primary health centre patients had 95% higher odds of poor outcome (OR=1.95; 95%CI 1.45-2.61; p<0.001). NGO-funded facilities had 24% higher odds (OR=1.24; 95%CI 1.10-1.39; p<0.001) and federally funded facilities 25% higher odds (OR=1.25; 95%CI 1.06-1.48; p=0.008). Female sex was independently protective (OR=0.87; 95%CI 0.79-0.96; p=0.003). Diagnosis-to-ART delays exceeded 90 days in 47.3% of patients, with significant variation by facility level (chi-squared=49.4, p<0.001). Conclusions: Facility level and funding model independently predict HIV treatment outcomes after patient-level adjustment. Primary health centres and NGO/federally funded facilities may require targeted quality improvement support. These findings have direct implications for PEPFAR, the Global Fund, and national HIV programme managers.

Adolescent girls and young women (AGYW) in Ethiopia face persistent barriers to accessing quality sexual and reproductive health (SRH) services, including limited information, stigma, and lack of youth-responsive care. This study aimed to compare the efficacy of digitized versus paper-based counselling tools within an intervention designed to address behavioral and structural barriers contributing to low contraceptive use among AGYW, by reframing contraception as a tool to achieve their life goals. The study employed a cross-sectional mixed-methods design, including client exit interviews with 302 AGYW, key informant interviews with 18 Health Extension Workers (HEWs), secondary analysis of service delivery data from DHIS2, and costing data from program records. Quantitative data were analyzed using descriptive statistics and chi-square tests. Qualitative data were thematically analyzed. Digital counselling was significantly associated with higher MII Plus scores (93% vs. 73.8%, p=0.001), client knowledge of side effects, and confidence in discussing and managing contraception. Clients rated paper-based tools as easier to understand, but digital tools enhanced comprehension, goal-setting, and integration of financial planning and reproductive health concepts. HEWs reported improved consistency in counselling, better referrals, and operational efficiencies with digital tools. Challenges included device glitches, limited connectivity, and variable digital literacy, often requiring concurrent use of paper and digital tools. This study shows that transitioning from paper-based to digital counselling tools improved service quality, client engagement, and informed contraceptive decision-making. Higher MII Plus scores and positive client experiences indicate more standardized, participatory, and respectful counselling. Providers reported operational benefits, including easier counselling and improved data management, though productivity gains were limited. Implementation challenges highlight the need for context-sensitive strategies, ongoing training, and supportive supervision during digital integration. Importantly, the findings suggest that digital tools can improve how services are delivered (quality and consistency), even when service volume remains stable.

BackgroundSubcutaneous oncology monoclonal antibodies (SCOmAbs) offer significant benefits compared to intravenous formulations, including reduced administration time and potential for self-administration. However, little has been published on real-world preparation and administration practices with these novel formulations. MethodsThis was a qualitative, exploratory study of 30 participants (10 patients receiving SCOmAbs, 10 nurses, and 10 pharmacists/pharmacy technicians) across various U.S. healthcare facilities. One-on-one, in-depth interviews examined current practices, pain points, device integration potential, projected impact of increased SCOmAb adoption, and perspectives on home administration. ResultsFindings revealed considerable variability in SCOmAb preparation and administration practices. While preparation methods generally aligned with typical parenteral workflows, notable deviations included bedside preparation by nurses (7/30), use of syringe pump modules (3/19), and one case of patient self-administration at home. Most participants utilized closed-system transfer devices (12/22) despite inconsistent hazardous drug treatment between facilities. Administration challenges included ergonomic difficulties for nurses during manual push (5/9 reporting physical discomfort) and variable injection techniques to accommodate patient comfort. Nurses reported significant workflow impact from being "tethered" to patients during administration, which could require staffing adjustments as SCOmAb frequency increases. Most patients (6/9) expressed interest in home administration for potential time savings and flexibility, though concerns about training, support, and safety were common. ConclusionsAs SCOmAb utilization expands, facilities may face barriers associated with increased demand that could necessitate innovative solutions. To leverage the full potential of SCOmAb products, developers should consider how next generation product presentations might minimize identified pain points, streamline administration, and facilitate safe transition to home self-administration. Delivery device integration, whether through prefilled syringes, portable infusion pumps, or other delivery systems, may address current challenges but requires careful consideration of facility infrastructure, product complexity and usability, workflow impact, and patient training requirements.

Background Tanzanias Direct Health Facility Financing (DHFF) reform was introduced to strengthen primary health care through decentralized financing, autonomy, and accountability, but persistent weaknesses in monitoring and evaluation (M&E) data management and use continue to constrain implementation effectiveness, particularly in rural settings. Methods A convergent mixed-methods design was used to examine how M&E data management and use influence DHFF implementation effectiveness in an urban council (Kinondoni Municipal Council, KMC) and a rural council (Morogoro District Council, MDC), while also assessing the role of stakeholder perceptions of the DHFF M&E framework and contextual variation. Quantitative data were analyzed using descriptive statistics, relative importance indices, regression and ANOVA, while qualitative data from key informant interviews and focus group discussions were thematically analyzed and triangulated with quantitative results. Results Of 233 respondents analysed, 51.1% were from Morogoro District Council, 48.9% from Kinondoni Municipal Council, 51.2% worked in rural settings, 42.9% were from health centres, and 38.2% from dispensaries, providing an analytically useful spread across managerial and frontline contexts relevant to DHFF implementation. Descriptive statistics showed generally favourable perceptions across the five major constructs, with mean scores ranging from 3.09 for M&E capacity to 3.73 for urban-rural M&E practice context, while DHFF implementation effectiveness scored 3.71 overall. Data quality checks showed acceptable factor loadings above 0.4, reliability coefficients above 0.7, bivariate correlations of 0.34-0.76, and VIF values of 1.31-2.95, indicating that the dataset was screened, cleaned and analytically fit for regression and ANOVA modelling. In the aggregated model, the explanatory variables jointly accounted for about 52% of the variation in DHFF implementation effectiveness, with M&E data management and use, stakeholder perceptions of the DHFF M&E framework, and urban-rural context emerging as the most influential predictors. Qualitative testimonies clarified these patterns: one council respondent explained, "We have DHIS2... GoTHOMIS... FFARS... also PlanRep," while another facility respondent observed, "We only add up numbers for the monthly report--we dont really analyze what they mean," illustrating the contrast between data availability and meaningful local use. Conclusions DHFF implementation effectiveness in Tanzania depends substantially on robust M&E data management and use, supportive stakeholder perceptions of the M&E framework, and context-sensitive strategies that address persistent urban-rural inequities. Strengthening technical capacity, digital infrastructure, participatory governance and feedback systems is essential for sustaining DHFF gains and improving equitable service delivery.

ObjectiveTo characterize the magnitude and geographic distribution of commercially negotiated hospital facility rates for fourteen common interventional radiology (IR) procedures using publicly posted Hospital Price Transparency Machine-Readable Files (MRFs), and to describe the relationships between state-level commercial pricing, population rurality, and within-system rate uniformity. MethodsIn this cross-sectional observational analysis, we examined hospital-weighted commercial rate observations from U.S. hospital MRFs for fourteen IR procedures spanning image-guided drainage, embolization, peripheral vascular intervention, dialysis access maintenance, and percutaneous spine. The unit of analysis was one observation per distinct negotiated rate per state-CPT cell, deduplicating multi-facility same-system reporting in which two or more hospitals posted identical rate, range, and payer-count tuples. Outliers were excluded using transparent absolute and CMS-relative bounds. State-level statistics were computed where [&ge;]5 distinct hospital-system observations were reported. Commercial rates were compared to CY 2026 CMS Outpatient Prospective Payment System (OPPS) facility payments. Relationships between state-level commercial rate and 2020 U.S. Census percent-rural population were assessed by Spearman rank correlation. ResultsAcross 14 procedures, state-level commercial median rates varied 3.7-to 8.3-fold between the highest- and lowest-priced states. The largest spreads were observed for fem-pop angioplasty (CPT 37224, 8.3-fold), fem-pop atherectomy (37225, 8.1-fold), and iliac stenting (37221, 7.1-fold). National median commercial rates ranged from 1.34x (PAE/GAE) to 3.60x (paracentesis) the corresponding CMS OPPS facility payment. Across all 14 procedures, the relationship between state percent-rural and median commercial rate was negative (mean Spearman {rho} = -0.46, range -0.33 to -0.80; 14 of 14 codes negative), with the most-rural quartile of states showing a median commercial rate 42% below the most-urban quartile. Deduplication identified 660 multi-facility groups in which a single negotiated rate was applied across two or more affiliated hospitals within a state. DiscussionSubstantial state-level variation in commercially negotiated facility rates exists for common IR procedures, with consistently lower rates in more rural states. Within-system rate uniformity is a frequent feature: many regional health systems post identical commercial rates across multiple owned facilities. The findings are consistent with prior literature linking commercial pricing to market structure and support continued investment in price transparency as a precondition for informed decision-making.

Background High Intensity Use of urgent medical services by patients is widely recognised in urgent and emergency care. Studies of high intensity use of the emergency department have consistently shown features of complex systems behaviour in addition to highly heterogeneous individual patient characteristics. There have been no comparable studies of prehospital care use. Methods We examined the use of prehospital urgent and emergency services (NHS 111 and ambulance dispatch) using routinely collected data from regional service in the UK (population 5 million). We used a complex systems perspective, to examine (1) distribution of contacts per individual; (2) the temporal stability of service use by individuals and at the whole-system level (3) the distribution of bursts of contacts. Results We analysed data from 847555 individuals who contacted NHS111 and 389550 who contacted the ambulance dispatch service. 35120 (4.2%) individuals who contacted NHS111 had 5 or more contacts with the service over the two-year period and accounted for 290625 (20.1%) of contacts. 16755 (4.3%) individuals had 5 or more ambulance dispatch contact days and accounted for 169085 (25.8%) of contacts. The distribution of contacts per individual showed a monotonic distribution between 5 and over 100 contacts that was heavy tailed and compatible with a power law distribution. At any level of use, patients with one or more mental health related contacts had a greater likelihood of further contact than those without. Conclusion Prehospital emergency service use shows multiple statistical features typical of a complex system. Interventions to manage demand need to consider both individual high intensity users (particularly in relation to their mental health) and the behaviour of the whole system.

Rational use of medicines (RUM) is a global health priority, yet significant challenges persist in low- and middle-income countries (LMICs), particularly around medicine access, affordability, and quality. While RUM studies often focus on prescribing practices, systemic barriers such as supply chain inefficiencies and pricing receive less attention. This study assessed three key health system components of RUM (availability, affordability, and quality of essential medicines) at two public primary health facilities in Ghana and examined patient care practices against WHO RUM standards. A quantitative, cross-sectional study was conducted at Kekele Polyclinic and Rawlings Circle Polyclinic in Accra. Retrospective data were extracted from prescription sheets, medicine tally cards, and ledgers to evaluate WHO Level II core drug use indicators. Fifteen essential medicines were selected based on the Ghana Essential Medicines List, Standard Treatment Guidelines, and municipal disease burden data. Exit interviews with 107 patients assessed dispensing and counselling practices, and structured observation covered storage conditions and pharmaceutical handling. Availability of key medicines fell significantly short of WHO targets, with Rawlings Circle meeting only 40% and Kekele 73.3% of the 100% benchmark. Treatment of malaria and pneumonia cost patients up to three times the national daily minimum wage, indicating poor affordability. The average number of medicines prescribed per encounter (3.2) exceeded the WHO recommended standard ([&le;]2). Storage and handling infrastructure was inadequate, with both facilities falling short of recommended conservation standards. Gaps in medicine availability, affordability, and infrastructure undermine rational medicine use in primary healthcare. Strengthening procurement systems, enforcing storage protocols, and implementing financial protection mechanisms are essential for equitable and safe medicine use within Ghanas health system.

IntroductionAdolescents with mental health disorders represent a vulnerable group with complex care needs, yet their and their relatives experiences in acute inpatient mental health services remain poorly understood. While patient-reported experience measures (PREMs) are increasingly recognized as essential for improving healthcare quality, validated instruments for child and adolescent mental health inpatient settings are lacking--particularly from the perspective of relatives, who are often deeply involved in care. ObjectiveThis study aims to develop and psychometrically evaluate the Relatives Experience Questionnaire for Acute Inpatient Child and Adolescent Mental Health Services (REQ-AICAMHS), the first instrument designed to capture relatives experiences in Norwegian acute inpatient mental health units for adolescents. MethodsThe REQ-AICAMHS will be developed using the Norwegian Institute of Public Healths (NIPH) standard methodology, including a literature review, expert consultation, qualitative interviews, and cognitive testing with relatives. Data will be collected digitally from relatives of all adolescents admitted to 17 acute inpatient child and adolescent mental health units across Norway. Descriptive statistics, exploratory factor analysis (EFA), and Item Response Theory (IRT) using the Generalized Partial Credit Model (GPCM) will be applied to assess data quality, factor structure, construct validity, and internal consistency. Open-ended responses will be analysed using both qualitative and machine learning methods to identify key themes and subdomains of experience. ResultsPreliminary results will include descriptive statistics of respondents, item-level analysis (missing data, ceiling effects), factor loadings and reliability coefficients (Cronbachs alpha [&ge;]0.7), inter-item and scale correlations, construct validity testing, and IRT parameters (item discrimination and threshold estimates). Findings will inform the development of a shortened version of the questionnaire for broader implementation in quality improvement initiatives.

Introduction -- Emergency Medical Dispatch Systems (EMDS) can reduce delays in accessing emergency care by providing structured communication, triage, and coordination. However, such systems remain absent or underdeveloped in most low- or middle-income countries (LMICs). This study aimed to establish international consensus on essential EMDS components to inform global guidance. Methods -- We convened a multidisciplinary expert group to draft a preliminary list of essential components for three EMDS levels reflecting resource availability and system maturity. We then conducted a three-round Delphi with international experts to reach consensus on core EMDS components. Components which had [&ge;]75% agreement were included, those with [&ge;]75% disagreement were excluded. Components not achieving consensus by Round 3 were removed. Results were analysed overall and stratified by respondents' country income level. A subsequent online expert meeting resolved inconsistencies and finalised the component list. Results -- The expert group generated 111 components for each of three EMDS levels (Foundational, Emerging, and Established) spanning 11 operational domains. Of the 68 experts invited to the Delphi, 43 participated in Round 1 and 30 in Round 3. Across all Delphi rounds, 289 components reached consensus for inclusion. The consensus resulted in a final list of 227 components (63 Foundational, 84 Emerging, and 80 Established). Consensus agreement clustered around core EMDS domains including communication, structured call-taking and prioritisation, advice-giving, resource dispatch and tracking, and foundational governance and data functions, whereas items showing either non-consensus or consensus disagreement were typically technology-dependent or context-specific. Conclusions -- This international consensus offers guidance for EMDS development across diverse resource settings and provides a scalable roadmap to strengthen emergency care systems.

Background: Many mental health problems originate in childhood, highlighting the need for early preventive approaches. Preventive services to promote children's mental health are offered in the health, education, and social sectors (H-E-S) but are often not used by certain at-risk groups or early enough. To identify children at-risk and provide needs-oriented support, professionals from all sectors must be well trained, collaborate closely to refer to specialized services for specific mental health problems or risk factors, and understand the regional psychosocial support system and its services. A comprehensive approach to preventing mental health problems requires structured planning and a systematic overview of all institutions and services in the region and their collaboration. This study aims to map the preventive mental health and psychosocial support service system and the collaboration between institutions across three sectors (H-E-S) in two exemplary city districts. The study is integrated into a whole-district approach to child mental health promotion that is being implemented in one of the researched city districts, and its results will inform further activities there. Methods: We use a mixed-methods approach, combining qualitative interviews with a quantitative survey to map psychosocial services for children aged 4 to 10 and their families across the H-E-S sectors in two socioeconomically disadvantaged city districts in East and West Germany. All institutions that potentially offer psychosocial services for children and families will be approached to recruit professionals (e.g., schools, practices, counseling centers). To understand the regional psychosocial support system, we will analyze existing services and their characteristics (e.g., target groups, intervention types) descriptively. Social network analysis will be applied to gain an in-depth understanding of collaboration between institutions, to identify potential gaps in services and pathways, and to inform an intervention aimed at improving interinstitutional and intersectoral collaboration. Discussion: To our knowledge, this is the first study to comprehensively analyze regional preventive psychosocial support systems for children and families across sectors at the community level. Previous mappings of psychosocial services have focused on a single sector (e.g., health) or specific diagnoses only. The psychosocial preventive landscape spanning the H-E-S sectors involves complex financing structures and referral logics. Understanding the characteristics of the existing support landscape requires a systematic and comprehensive approach. Our study advances service mapping and operationalization methods in public health research. Additionally, the findings will inform recommendations for improving comprehensive prevention approaches in the selected city districts.