Person:

Scott, Kirstin

An epidemic of Ebola virus disease (EVD) beginning in 2013 has claimed an estimated 11 310 lives in West Africa. As the EVD epidemic subsides, it is important for all who participated in the emergency Ebola response to reflect on strengths and weaknesses of the response. Such reflections should take into account perspectives not usually included in peer-reviewed publications and after-action reports, including those from the public sector, nongovernmental organizations (NGOs), survivors of Ebola, and Ebola-affected households and communities. In this article, we first describe how the international NGO Partners In Health (PIH) partnered with the Government of Sierra Leone and Wellbody Alliance (a local NGO) to respond to the EVD epidemic in 4 of the country's most Ebola-affected districts. We then describe how, in the aftermath of the epidemic, PIH is partnering with the public sector to strengthen the health system and resume delivery of regular health services. PIH's experience in Sierra Leone is one of multiple partnerships with different stakeholders. It is also one of rapid deployment of expatriate clinicians and logistics personnel in health facilities largely deprived of health professionals, medical supplies, and physical infrastructure required to deliver health services effectively and safely. Lessons learned by PIH and its partners in Sierra Leone can contribute to the ongoing discussion within the international community on how to ensure emergency preparedness and build resilient health systems in settings without either.

Background: Early childhood development (ECD) is a critical period that continues to impact human health and productivity throughout the lifetime. Failing to provide policies and programs that support optimal developmental attainment when such services are financially and logistically feasible can result in negative population health, education and economic consequences that might otherwise be avoided. Rwanda, with its commitment to rights-based policy and program planning, serves as a case study for examination of the national, regional, and global human rights legal frameworks that inform ECD service delivery. Discussion In this essay, we summarize key causes and consequences of the loss of early developmental potential and how this relates to the human rights legal framework in Rwanda. We contend that sub-optimal early developmental attainment constitutes a violation of individuals’ rights to health, education, and economic prosperity. These rights are widely recognized in global, regional and national human rights instruments, and are guaranteed by Rwanda’s constitution. Recent policy implementation by several Rwandan ministries has increased access to health and social services that promote achievement of full developmental potential. These ECD-centric activities are characterized by an integrated approach to strengthening the services provided by several public sectors. Combining population level activities with those at the local level, led by local community health workers and women’s councils, can bolster community education and ensure uptake of ECD services. Conclusions: Realization of the human rights to health, education, and economic prosperity requires and benefits from attention to the period of ECD, as early childhood has the potential to be an opportunity for expedient intervention or the first case of human rights neglect in a lifetime of rights violations. Efforts to improve ECD services and outcomes at the population level require multisector collaboration at the highest echelons of government, as well as local education and participation at the community level.

Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs.

Corrado Cancedda and colleagues outline a framework for health professional training initiatives in low-income countries.

Improving the quality of care provided by the U.S. healthcare system is an important societal goal. Policymakers who wish to operationalize this goal must navigate an increasingly polarized health policymaking environment. In this dissertation, I examine three stakeholders who can influence this environment: the public, state governors, and health care providers. In Chapter 1, I explore attitudes of and experiences with health care quality among Democrats and Republicans. Relying on a national survey of 1,508 American adults, I find that regardless of having a recent medical issue, Democrats express greater concerns about national quality of care problems relative to Republicans. At the same time, I find no difference in their personal experiences with quality of care received while hospitalized or with healthcare providers. In Chapter 2, I examine how gubernatorial candidates treat health policy in the 2012 and 2014 elections given the states’ increasing role in ACA implementation, which can collectively impact the quality of care provided nationally. After generating a novel database of all gubernatorial candidates’ campaign websites, I summarize the presence of healthcare content, framing of health system problems, and issue engagement with the ACA and its key coverage provisions in these two elections. I find the majority of gubernatorial candidates discuss health policy but are selective in their focus. Republicans, who are more likely than Democrats to express their views specifically regarding the ACA (which they nearly all refer to as “Obamacare”), won the majority of these 47 gubernatorial seats. Winning candidates from both parties discussed the Medicaid expansion decision of their state, with some expressing intentions to reverse course relative to their current expansion status. In Chapter 3, I examine a trend expected to grow under the ACA: hospital-physician integration. Using national hospital and Medicare data from 2003-2012, I document the rise of hospital employment of physicians and examine whether or not this yields improvements in mortality, readmission rates, length of stay or patient satisfaction. Though I find that a plurality of hospitals now enter into employment relationships with physicians, this study provides no evidence that these changes are associated with improvements in quality of care.

The November 2014 midterm election was the first election since key coverage provisions of the Affordable Care Act (ACA) were implemented, including the Medicaid expansion and creation of the health insurance exchanges. The pre-election variability in the states’ implementation of these provisions coupled with the large number of states selecting their next governor made the election important at the state level. To better understand the role of health care in the recent gubernatorial elections, we analyzed health policy content presented by 71 candidates for governor on their campaign Web sites. Nearly 80% of all candidates discussed health policy on their Web site, including the subset of the 36 winning governors. The predominant focus of health policy content was on the ACA as a whole or its provisions. Medicaid was discussed more often by candidates in non-expansion states than those from expansion states. Based on the statements of winning governors, we expect serious consideration of the Medicaid expansion to occur in at least 4 states, whereas 2 states may make efforts to reverse course. Relatively few winning governors (33%) mentioned the exchanges. Only 1 expressed interest in switching from the federal exchange to a state exchange, which has particular relevance given the Supreme Court’s pending decision on King v. Burwell that could invalidate tax credits on the federal exchange. The prominence of health care in the gubernatorial campaigns strengthens the likelihood that governors will play an influential role in the health system’s future, especially as the ACA undergoes further federal debate.