Teach-back: A systematic review of implementation and impacts

Patients often have difficulty comprehending or recalling information given to them by their healthcare providers. Use of 'teach-back' has been shown to improve patients' knowledge and self-care abilities, however there is little guidance for healthcare services seeking to embed teach-back in their setting. This review aims to synthesize evidence about the translation of teach-back into practice including mode of delivery, use of implementation strategies and effectiveness. We searched Ovid Medline, CINAHL, Embase and The Cochrane Central Register of Controlled Trials for studies reporting the use of teach-back as an educational intervention, published up to July 2019. Two reviewers independently extracted study data and assessed methodologic quality. Implementation strategies were extracted into distinct categories established in the Implementation Expert Recommendations for Implementing Change (ERIC) project. Overall, 20 studies of moderate quality were included in this review (four rated high, nine rated moderate, seven rated weak). Studies were heterogeneous in terms of setting, population and outcomes. In most studies (n = 15), teach-back was delivered as part of a simple and structured educational approach. Implementation strategies were infrequently reported (n = 10 studies). The most used implementation strategies were training and education of stakeholders (n = 8), support for clinicians (n = 6) and use of audits and provider feedback (n = 4). Use of teach-back proved effective in 19 of the 20 studies, ranging from learning-related outcomes (e.g. knowledge recall and retention) to objective health-related outcomes (e.g. hospital re-admissions, quality of life). Teach-back was found to be effective across a wide range of settings, populations and outcome measures. While its mode of delivery is well-defined, strategies to support its translation into practice are not often described. Use of implementation strategies such as training and education of stakeholders and supporting clinicians during implementation may improve the uptake and sustainability of teach-back and achieve positive outcomes.

Development and pilot of a multicriteria decision analysis (MCDA) tool for health services administrators

INTRODUCTION

Health administration is complex and serves many masters. Value, quality, infrastructure and reimbursement are just a sample of the competing interests influencing executive decision-making. This creates a need for decision processes that are rational and holistic.

METHODS

We created a multicriteria decision analysis tool to evaluate six fields of healthcare provision: return on investment, capacity, outcomes, safety, training and risk. The tool was designed for prospective use, at the beginning of each funding round for competing projects. Administrators were asked to rank their criteria in order of preference. Each field was assigned a representative weight determined from the rankings. Project data were then entered into the tool for each of the six fields. The score for each field was scaled as a proportion of the highest scoring project, then weighted by preference. We then plotted findings on a cost-effectiveness plane. The project was piloted and developed over successive uses by the hospital's executive board.

RESULTS

Twelve projects competing for funding at the Royal Brisbane and Women's Hospital were scored by the tool. It created a priority ranking for each initiative based on the weights assigned to each field by the executive board. Projects were plotted on a cost-effectiveness plane with score as the x-axis and cost of implementation as the y-axis. Projects to the bottom right were considered dominant over projects above and to the left, indicating that they provided greater benefit at a lower cost. Projects below the x-axis were cost-saving and recommended provided they did not harm patients. All remaining projects above the x-axis were then recommended in order of lowest to highest cost-per-point scored.

CONCLUSION

This tool provides a transparent, objective method of decision analysis using accessible software. It would serve health services delivery organisations that seek to achieve value in healthcare.

"Everything Possible Is Being Done": Labour, Mobility, and the Organization of Health Services in Mid-20th Century Newfoundland

This article is the Presidential Address to the 2018 meeting of the Canadian Society for the History of Medicine at the University of Regina. It examines the organization of the nursing service in Newfoundland during the 1950s and 1960s, as well as the recruitment and retention of nurses in cottage hospitals and nursing stations in outport communities. A number of interconnected strategies were used by the Newfoundland government to staff the nursing service, including recruiting internationally educated nurses, adjusting expectations with respect to registration standards, and using both trained and untrained workers to support nurses' labour. Although this article is intended more as a reconnaissance suggesting the possibilities of such research, it does analyze the interconnected issues of geography, funding and pay, the nursing shortage, and the renegotiation of nursing labour that characterized this period. Furthermore, although this is a case study of Newfoundland and Labrador, it is worth considering how, or whether, the linked strategies used in the province were transferable to other communities across rural, remote, or northern Canada.

[SWOT-ANALYSIS OF PROFESSIONAL-PERSONAL COMPETENCE OF ECONOMISTS IN MEDICAL ORGANIZATIONS]

In modern conditions, there is a tendency to replace the qualification approach of assessing economists in medical organizations - competence. The purpose of the study was to identify the professional and personal abilities of economists in medical organizations to actively participate in the management decisions of the medical organization in the transition from public administration to the right of economic management. The study was carried out in 3 stages. At the first stage, the degree of influence of the experience of the economist, the frequency of training and its burden on the profitability of the medical organization was analyzed. At the second stage - the personal evaluation of the respondents by psychodiagnostic methods (memory, attention, the level of the person's orientation, self-esteem, the level of personal claims). At the third stage, the data of professional behavior and personal evaluation were summarized in the table of SWOT-analysis factors, for determining the personnel strategy of development of economists in medical organizations. The sample size was 43 respondents, which amounted to 10.3% of the participation of medical organizations. The results of the SWOT analysis of the personal and professional qualities of medical economists in medical organizations showed the predominance of weaknesses in corporate competencies among medical economists over strong ones, while personal opportunities prevail over risks. In general, the professional-personal SWOT analysis showed the prevalence of the possibilities of medical economists (Ps=5,3) over threats (Ps = 4,9), strong (Ps = 4,4) and weak sides (Ps = 3,8). At the same time, the force of influence does not suffice: the length of work for profitability (r = -0.3, p <0.05), and the ratio of one economist to employees on the growth of the specific weight of paid services (r = 0.001, p <0.05). The revealed relationships confirm: a direct strong dependence of the training frequency of economists on the profitability of the medical organization (r = 0.7, p<0.05), i.e. The higher the frequency of training economists, the higher the profitability, showed our results in the studied medical organizations. The results of the study made it possible to identify the behavioral professional and personal capabilities of medical economists in market conditions.

Value of Investment as a Key Driver for Prioritization and Implementation of Healthcare Software

Health systems across the nation are recovering from massive financial and resource investments in electronic health record applications. In the midst of these recovery efforts, implementations of new care models, including accountable care organizations and population health initiatives, are underway. The shift from fee-for-service to fee-for-outcomes and fee-for-value payment models calls for care providers to work in new ways. It also changes how physicians are compensated and reimbursed. These changes necessitate that healthcare systems further invest in information technology solutions. Selecting which information technology (IT) projects are of most value is vital, especially in light of recent expenditures. Return-on-investment analysis is a powerful tool used in various industries to select the most appropriate IT investments. It has proven vital in selecting, justifying, and implementing software projects. Other financial metrics, such as net present value, economic value added, and total economic impact, also quantify the success of expenditures on information systems. This paper extends the concept of quantifying project value to include clinical outcomes and nonfinancial value as investment returns, applying a systematic approach to healthcare software projects. We term this inclusive approach Value of Investment. It offers a necessary extension for application in clinical settings where a strictly financial view may fall short in providing a complete picture of important benefits. This paper outlines the Value of Investment process and its attributes, and uses illustrative examples to explore the efficacy of this methodology within a midsized health system.

The Future of European Health Policies

The role of the European Union in health policies is changing. The European social model is under threat due to shifts in E.U. policies on liberalization of service provision, limited public budgets, a focus on the health sector as a productive sector in the context of broader European policies and the Lisbon strategy, and changes in the context of the new Constitutional Treaty. These changes are evident in a new reflection paper on European health strategy and its focus. E.U. health policies are at a critical juncture. The danger is that the current processes will lead European health policies and the health systems of member states more in the direction of U.S. health policies and the commercialization of health systems than toward improvement of the current situation.

Ethical priority setting for universal health coverage: challenges in deciding upon fair distribution of health services

Priority setting is inevitable on the path towards universal health coverage. All countries experience a gap between their population's health needs and what is economically feasible for governments to provide. Can priority setting ever be fair and ethically acceptable? Fairness requires that unmet health needs be addressed, but in a fair order. Three criteria for priority setting are widely accepted among ethicists: cost-effectiveness, priority to the worse-off, and financial risk protection. Thus, a fair health system will expand coverage for cost-effective services and give extra priority to those benefiting the worse-off, whilst at the same time providing high financial risk protection. It is considered unacceptable to treat people differently according to their gender, race, ethnicity, religion, sexual orientation, social status, or place of residence. Inequalities in health outcomes associated with such personal characteristics are therefore unfair and should be minimized. This commentary also discusses a third group of contested criteria, including rare diseases, small health benefits, age, and personal responsibility for health, subsequently rejecting them. In conclusion, countries need to agree on criteria and establish transparent and fair priority setting processes.

Determinants of routine immunization costing in Benin and Ghana in 2011

BACKGROUND

Existing tools to evaluate costs do not always capture the heterogeneity of costs at the facility level. This study seeks to address this issue through an analysis of determinants of health facility immunization costs.

METHODS

A statistical analysis on facility routine delivery and vaccine costs was conducted using ordinary least squares regression. Explanatory variables included the number of doses administered; proportion of time spent by facility staff on immunization; average staff wage; whether the health facility had enough staff; presence of cold chain equipment; distance to a vaccine collection point; and, facility ownership. Data were drawn from representative samples of primary care facilities in Benin and Ghana (46 and 50 facilities, respectively) collected as part of the EPIC studies.

RESULTS

Weighted average RI immunization facility cost was US$ 16,459 in Ghana and US$ 14,994 in Benin. The regression found total doses administered to be positively and significantly associated with facility cost in both countries. A 10% increase in doses resulted in a 4% increase in cost in Ghana, and a 7.5% increase in Benin. In Ghana, the proportion of immunization time, presence of cold chain, and sufficiency of staff were positively and significantly associated with total cost. In Benin, facility cost was negatively and significantly related to distance to the vaccine collection point. In the pooled sample, facilities in capital cities were associated with significantly higher costs.

CONCLUSIONS

This study provides evidence on the importance of the level of scale in determining facility immunization cost, as well as the role of availability of health workers and time they spend on immunization in Ghana and Benin. This type of analysis can provide insights into the costs of scaling up immunization services, and can assist with development of more efficient immunization strategies.

Mapping financial flows for immunisation in Uganda 2009/10 and 2010/11: New insights for methodologies and policy

BACKGROUND

The Global Vaccine Action Plan highlights the need for immunisation programmes to have sustainable access to predictable funding. A good understanding of current and future funding needs, commitments, and gaps is required to enhance planning, improve resource allocation and mobilisation, and to avoid funding bottlenecks, as well as to ensure that co-funding arrangements are appropriate. This study aimed to map the resource envelope and flows for immunisation in Uganda in 2009/10 and 2010/11.

METHODS

To assess costs and financing of immunisation, the study applied a common methodology as part of the multi-country Expanded Program on Immunisation Costing (EPIC) study (Brenzel et al., 2015). The financial mapping developed a customised extension of the System of Health Accounts (SHA) codes to explore immunisation financing in detail. Data were collected from government and external sources. The mapping was able to assess financing more comprehensively than many studies, and the simultaneous costing of routine immunisation collected detailed data about human resources costs.

RESULTS

The Ugandan government contributed 56% and 42% of routine immunisation funds in 2009/10 and 2010/11, respectively, higher than previously estimated, and managed up to 90% of funds. Direct delivery of services used 93% of the immunisation financial resources in 2010/11, while the above service delivery costs were small (7%). Vaccines and supplies (41%) and salaries (38%) absorbed most funding. There were differences in the key cost categories between actual resource flows and the estimates from the comprehensive multi-year plan (cMYP).

CONCLUSIONS

Results highlight that governments and partners need to improve systems to routinely track immunisation financing flows for enhanced accountability, performance, and sustainability. The modified SHA coding allowed financing to be mapped to specific immunisation activities, and could be used for standardised, resource tracking compatible with National Health Accounts (NHA). Recommendations are made for refining routine resource mapping approaches.

Costs and cost-effectiveness of community health workers: evidence from a literature review

OBJECTIVE

This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems.

METHODS

From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings.

RESULTS

Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria.

CONCLUSION

Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.

[The role of supply-side characteristics of services in AIDS mortality in Mexico]

OBJECTIVE

To document the association between supply-side determinants and AIDS mortality in Mexico between 2008 and 2013.

MATERIALS AND METHODS

We analyzed the SALVAR database (system for antiretroviral management, logistics and surveillance) as well as data collected through a nationally representative survey in health facilities. We used multivariate logit regression models to estimate the association between supply-side characteristics, namely management, training and experience of health care providers, and AIDS mortality, distinguishing early and non-early mortality and controlling for clinical indicators of the patients.

RESULTS

Clinic status of the patients (initial CD4 and viral load) explain 44.4% of the variability of early mortality across clinics and 13.8% of the variability in non-early mortality. Supply-side characteristics increase explanatory power of the models by 16% in the case of early mortality, and 96% in the case of non-early mortality.

CONCLUSIONS

Aspects of management and implementation of services contribute significantly to explain AIDS mortality in Mexico. Improving these aspects of the national program, can similarly improve its results.

Overview of cervical cancer screening practices in the extended Middle East and North Africa countries

National Organized Cervical Cancer Screening (NOCCS) programs are lacking in most of the "Extended Middle East and North Africa" (EMENA) countries. Consequently, most cervical cancers are diagnosed late and are associated with high mortality. In fact, in most of these countries, national mortality data are unknown due to the absence of population-based mortality registries. Most countries of the EMENA practice more or less limited opportunistic, cytology-based, screening tests, which often lack quality assurance and follow-up care. A few countries, within the initiation of a National Cancer Control Plan, have just started to implement organized screening programs using, for cervical cancer detection, visual inspection with acetic acid (Morocco) or cytology (Turkey). Moreover, most countries of the EMENA lack national guideline, as well as resources for the management of abnormal cytologic screening (or any other screening test). The main obstacle for the implementation of NOCCS is a lack of political understanding to support such public health programs and provide the necessary resources. Other obstacles that hinder the participation of women in cervical screening include a lack of knowledge of the disease, socio-religious and cultural barriers, and geographic and economic difficulties in accessing medical services. These countries are already convinced that prevention of cervical cancers in women who have cervical intraepithelial neoplasia is possible through various screening and treatment algorithms, but most countries still need to invest in well organized programs that can reduce cervical cancer incidence and mortality in women. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Extended Middle East and North Africa Region" Vaccine Volume 31, Supplement 6, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

Health care cost containment in Denmark and Norway: a question of relative professional status?

The demand for publicly subsidized health care services is insatiable, but the costs can be contained in different ways: formal rules can limit access to and the number of subsidized services, demand and supply can be regulated through the price mechanism, the relevant profession can contain the costs through state-sanctioned self-regulation, and other professions can contain the costs (e.g. through referrals). The use of these cost containment measures varies between countries, depending on demand and supply factors, but the relative professional status of the health professions may help explain why different countries use cost containment measures differently for different services. This article compares cost containment measures in Denmark and Norway because these countries vary with regard to the professional status of the medical profession relative to other health care providers, while other relevant variables are approximately similar. The investigation is based on formal agreements and rules, historical documents, existing analyses and an analysis of 360 newspaper articles. It shows that high relative professional status seems to help professions to avoid user fees, steer clear of regulation from other professions and regulate the services produced by others. This implies that relative professional status should be taken into consideration in analyses of health care cost containment.

The Bangladesh paradox: exceptional health achievement despite economic poverty

Bangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the country's success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Government and non-governmental organisations have pioneered many innovations that have been scaled up nationally. However, these remarkable achievements in equity and coverage are counterbalanced by the persistence of child and maternal malnutrition and the low use of maternity-related services. The Bangladesh paradox shows the net outcome of successful direct health action in both positive and negative social determinants of health--ie, positives such as women's empowerment, widespread education, and mitigation of the effect of natural disasters; and negatives such as low gross domestic product, pervasive poverty, and the persistence of income inequality. Bangladesh offers lessons such as how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints.

Bargaining and the provision of health services

We model and compare the bargaining process between a purchaser of health services, such as a health authority, and a provider (the hospital) in three plausible scenarios: (a) activity bargaining: the purchaser sets the price and activity (number of patients treated) is bargained between the purchaser and the provider; (b) price bargaining: the price is bargained between the purchaser and the provider, but activity is chosen unilaterally by the provider; (c) efficient bargaining: price and activity are simultaneously bargained between the purchaser and the provider. We show that: (1) if the bargaining power of the purchaser is high (low), efficient bargaining leads to higher (lower) activity and purchaser's utility, and lower (higher) prices and provider's utility compared to price bargaining. (2) In activity bargaining, prices are lowest, the purchaser's utility is highest and the provider's utility is lowest; activity is generally lowest, but higher than in price bargaining for high bargaining power of the purchaser. (3) If the purchaser has higher bargaining power, this reduces prices and activity in price bargaining, it reduces prices but increases activity in activity bargaining, and it reduces prices but has no effect on activity in efficient bargaining.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Territory of Guam: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the US Territory of Guam and describes the burdens due to NCD, with an emphasis on diabetes; and assesses the system of service capacity and current activities for service delivery, data collection, and reporting as well as identifying the issues that need to be addressed. There has been an increase of 2.6% in the total population between 2000 and 2010. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors are associated with overweight and obesity. The leading causes of death include heart disease, cancer, and cerebrovascular accidents. Population surveys show that 9.1% of the adult population in 2009 reported being diagnosed with diabetes. Other data reports show that of the adults, 35.4% were overweight and 25.9% were obese; and among youth, 30% were overweight or obese. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address NCDs and diabetes. There is no Territory-wide health plan to address the prevention and control of NCDs including diabetes. There are no common standards of care or policy and procedures that are used by all the various medical and health care providers. Based on these findings, priority issues and needs were identified for the administrative and clinical systems.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Republic of Palau: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Republic of Palau and describes the burden due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection, and reporting as well as identifying the issues that need to be addressed. There has been a 7.1% increase in the population between 2000 and 2010. Significant shifts in the age groups show declines among children and young adults under 34 years of age and increases among adult residents over 45 years of age. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors are associated with overweight and obesity and subsequent NCD that play a significant role in the morbidity and mortality of the population. The leading causes of death include heart disease and cancer. A 2003 community household survey was conducted and 22.4% of them reported a history of diabetes in the household. A survey among Ministry of Health employees showed that 44% of the men and 47% of the women were overweight and 46% of the men and 42% of the women were obese. Other findings show significant gaps in the system of administrative, clinical, and support services to address these NCD. Priority issues and needs for the administrative and clinical systems were identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Republic of the Marshall Islands, Kwajelein Atoll, Ebeye Island: a systems perspective

Non-communicable diseases (NCD) have been declared a health emergency in the US-affiliated Pacific Islands (USAPI). This assessment, funded by the National Institutes of Health, was conducted on Ebeye Island of Kwajelein Atoll, Republic of the Marshall Islands (RMI) to describe the burdens due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); assess the system of service capacity and activities for service delivery, data collection, and reporting; and identify the key issues that need to be addressed. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that impact the morbidity and mortality of the population. Population survey of the RMI show that 62.5% of the total population is overweight or obese with a dramatic increase from the 15-24 year old (10.6%) and the 25-64 year old (41.9%) age groups. The leading causes of death were septicemia, renal failure, pneumonia, cancer, and myocardial infarction. Other findings show gaps in the system of administrative, clinical, and support services to address these NCD. All health care in Ebeye is provided in one setting and there is collaboration, coordination, and communication among medical and health care providers. The Book of Protocols for the Kwajalein Atoll Health Care Bureau provides the guidelines, standards, and policy and procedures for the screening, diagnosis, and management of diabetes and other NCDs. Based on these findings, priority issues and problems to be addressed for the administrative, clinical, and data systems were identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Republic of the Marshall Islands, Majuro Atoll: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-associated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Republic of the Marshall Islands, Majuro Atoll and describes the burdens due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. Findings reveal that the risk factors of poor diet, lack of physical activity, and risky lifestyle behaviors are associated with overweight and obesity and subsequent NCD that are significant factors in the morbidity and mortality of the population. The leading causes of death include sepsis, cancer, diabetes-related deaths, pneumonia, and hypertension. Population-based survey for the RMI show that 62.5% of the adults are overweight or obese and the prevalence of diabetes stands at 19.6%. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is no policy and procedure manual for the hospital or public health diabetes clinics and there is little communication, coordination, or collaboration between the medical and public health staff. There is no functional data system that allows for the identification, registry, or tracking of patients with diabetes or other NCDs. Based on these findings, priority issues and problems to be addressed for the administrative, clinical, and data systems were identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Pohnpei: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Pohnpei and describes the burden due to selected NCD (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifies the issues that need to be addressed. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that are significant factors in the morbidity and mortality of the population. Leading causes of death were due to heart disease, diabetes, cancer, and hypertension. Population survey data show that 32.1% of the adult population had diabetes with a higher rate among women (37.1%) when compared to men (26.4%). The data also showed that 73.1% of the adult population was overweight or obese. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is no overall planning document for the prevention and control of NCDs or diabetes. There is evidence of little communication among the medical and health care providers which leads to fragmentation of care and loss of continuity of care. Based on some of the findings, priority issues and problems that need to be addressed for the administrative and clinical systems are identified.

Urban adolescents with intellectual disability and challenging behaviour: costs and characteristics during transition to adult services

Young persons with intellectual disabilities and challenging behaviour in transition usually have complex needs, which may not be served well within existing resources. In this article, we present a survey of all the young people, between 16 and 18 years of age with intellectual disabilities and challenging behaviour identified in one inner London borough. They were in transition to adult services at the time of the study (between 2006 and 2008). The objective was to examine their socio-demographic and clinical characteristics, pattern of service use and associated costs of care. An assessment toolkit was devised to measure the mental and physical health, challenging behaviour and service use of the sample. Instruments within the toolkit included the Strengths and Difficulties Questionnaire, challenging behaviour scale, Client Service Receipt Inventory (CSRI) and socio-demographic data form. Twenty-seven individuals in transition to adult services had challenging behaviour, 23 of whom had mental health diagnoses and 18 of whom had physical diagnoses. Severity of challenging behaviour did not correlate with cost of care. Informal care accounted for the highest proportion of the total cost of care (66%) with education being the second largest contributor at 22%. Evidence on transition outcomes for young people with complex needs and intellectual disabilities and associated costs is lacking. This article illustrates some of the relevant issues in this area. Further research is required to investigate these aspects and guide commissioning of appropriate services.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Kosrae: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI). This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Kosrae and describes the burdens due to NCDs, including diabetes, and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. There has been a 13.9% decline in the population between 2000 and 2010. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that are a significant factor in the morbidity and mortality of the population. Leading causes of death were due to nutrition and metabolic diseases followed by diseases of the circulatory system. Data from selected community programs show that the prevalence of overweight and obese participants ranged between 82% and 95% and the rate of reported diabetes ranged from 13% to 14%. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is no functional data system that is able to identify, register, or track patients with diabetes. Priority administrative and clinical issues were identified that need to be addressed to begin to mitigate the burdens of NCDs among the residents of Kosrae State.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Chuuk: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Chuuk and describes the burdens due to selected NCDs (diabetes, heart disease, hypertension, stroke, chronic kidney disease); and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. There has been a 9.2% decline in the total population between 2000 and 2010. Findings of medical and health data reveal that diabetes, myocardial infarction, and septicemia are the leading causes of death and lower limb surgical procedures and amputations was a major problem that was addressed with a foot care education program to prevent amputations. No data were available on the prevalence of diabetes among the population of Chuuk. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCDs. There is a lack of policy and procedure manuals, coordination among providers, and common standards of care. There is no functional data system to identify and track patients with diabetes and other chronic diseases. Priority issues and problems were identified for the clinical, administrative, and data systems.

An assessment of non-communicable diseases, diabetes, and related risk factors in the Federated States of Micronesia, State of Yap: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Federated States of Micronesia, State of Yap, and describes the burdens due to diabetes and other NCDs (heart disease, hypertension, stroke, chronic renal disease), and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifying the issues that need to be addressed. There has been a 1.2% increase in the population between 2000 and 2010; however, there was a significant increase in the 45-64 year old age group. Findings reveal that the risk factors of poor diet, lack of physical activity, and lifestyle behaviors lead to overweight and obesity and subsequent NCD that are a significant factor in the morbidity and mortality of the population. The leading causes of death include cancer, heart disease, and diabetes. Local household surveys show that 63% to 80% of the adults and 20.5% to 33.8% of the children were overweight or obese. The surveys also showed that 23% of the adult population had diabetes and 35% were hypertensive. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCD. There is a policy and procedure manual that guides the NCD staff. There is no functional data system that is able to identify, register, or track patients with diabetes and other NCDs. Priority administrative and clinical issues were identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the commonwealth of the Northern Mariana Islands: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in the Commonwealth of the Northern Mariana Islands (CNMI) and describes the burdens due to NCDs, with an emphasis on diabetes, and assesses the system of service capacity and current activities for service delivery, data collection and reporting as well as identifies the issues that need to be addressed. There has been a 22.7% decline in the population between 2000 and 2010. Findings of medical and health data reveal that the risk factors of lifestyle behaviors lead to overweight and obesity and subsequent NCD. The leading causes of death are heart disease, stroke and cancer. The 2009 BRFSS survey reveals that the prevalence rate for diabetes was 9.8%. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCDs. There is no overall health plan to address NCDs or diabetes, there is little coordination between the medical care and public health staff, and there is no functional data system to identify, register, and track patients with diabetes. Based on the findings, priority issues and problems to be addressed for the administrative system and clinical system are identified.

An assessment of non-communicable diseases, diabetes, and related risk factors in the territory of American Samoa: a systems perspective

Non-communicable diseases (NCD) have been identified as a health emergency in the US-affiliated Pacific Islands (USAPI).1 This assessment, funded by the National Institutes of Health, was conducted in American Samoa and describes the burden of selected NCDs (ie, diabetes, heart disease, hypertension, stroke, and chronic kidney disease); and assesses the system of service capacity and activities regarding service delivery, data collection and reporting as well as identifies the issues needing to be addressed. Findings reveal that nutrient-poor diet, lack of physical activity, and other lifestyle behaviors are associated with overweight and obesity and subsequent NCDs that impact the morbidity and mortality of the population. The leading causes of death include heart disease, diabetes, cancer and stroke. Population surveys show that 93% of the adults are overweight or obese and 47% have diabetes. Among public school children, 44.6% are overweight or obese. Other data show that between 2006 and 2010, there was a 33% increase in the number of patients receiving hemodialysis. Other findings show significant gaps in the system of administrative, clinical, data, and support services to address these NCDs. There is a paucity of health plans, policy and procedure manuals, coordination among providers, and lack of common standards of care. The combined administrative and clinical system of service needs were identified and prioritized. They include the need for a Territory-wide health strategy and plan, need for standards of care, and a need for collaborative team approach for the treatment and management of patients with diabetes and other chronic diseases.

Interview: Dr Giovanni Putoto, Head of Planning, Doctors with Africa CUAMM. Interview by Christo Hall

Dr Giovanni Putoto is interviewed by Christo Hall, Editorial Assistant, Pathogens & Global Health, Imperial College, London, UK.

Kazakhkstan health system review

Since becoming independent, Kazakhstan has undertaken major efforts in reforming its post-Soviet health system. Two comprehensive reform programmes were developed in the 2000s: the National Programme for Health Care Reform and Development 2005-2010 and the State Health Care Development Programme for 2011-2015 Salamatty Kazakhstan. Changes in health service provision included a reduction of the hospital sector and an increased emphasis on primary health care. However, inpatient facilities continue to consume the bulk of health financing. Partly resulting from changing perspectives on decentralization, levels of pooling kept changing. After a spell of devolving health financing to the rayon level in 2000-2003, beginning in 2004 a new health financing system was set up that included pooling of funds at the oblast level, establishing the oblast health department as the single-payer of health services. Since 2010, resources for hospital services under the State Guaranteed Benefits Package have been pooled at the national level within the framework of implementing the Concept on the Unified National Health Care System. Kazakhstan has also embarked on promoting evidence-based medicine and developing and introducing new clinical practice guidelines, as well as facility-level quality improvements. However, key aspects of health system performance are still in dire need of improvement. One of the key challenges is regional inequities in health financing, health care utilization and health outcomes, although some improvements have been achieved in recent years. Despite recent investments and reforms, however, population health has not yet improved substantially.

Bulgaria health system review

In the last 20 years, demographic development in Bulgaria has been characterized by population decline, a low crude birth rate, a low fertility rate, a high mortality rate and an ageing population. A stabilizing political situation since the early 2000s and an economic upsurge since the mid-2000s were important factors in the slight increase of the birth and fertility rates and the slight decrease in standardized death rates. In general, Bulgaria lags behind European Union (EU) averages in most mortality and morbidity indicators. Life expectancy at birth reached 73.3 years in 2008 with the main three causes of death being diseases of the circulatory system, malignant neoplasms and diseases of the respiratory system. One of the most important risk factors overall is smoking, and the average standardized death rate for smoking-related causes in 2008 was twice as high as the EU15 average. The Bulgarian health system is characterized by limited statism. The Ministry of Health is responsible for national health policy and the overall organization and functioning of the health system and coordinates with all ministries with relevance to public health. The key players in the insurance system are the insured individuals, the health care providers and the third party payers, comprising the National Health Insurance Fund, the single payer in the social health insurance (SHI) system, and voluntary health insurance companies (VHICs). Health financing consists of a publicprivate mix. Health care is financed from compulsory health insurance contributions, taxes, outofpocket (OOP) payments, voluntary health insurance (VHI) premiums, corporate payments, donations, and external funding. Total health expenditure (THE) as a share of gross domestic product (GDP) increased from 5.3% in 1995 to 7.3% in 2008. At the latter date it consisted of 36.5% OOP payments, 34.8% SHI, 13.6% Ministry of Health expenditure, 9.4% municipality expenditure and 0.3% VHI. Informal payments in the health sector represent a substantial part of total OOP payments (47.1% in 2006). The health system is economically unstable and health care establishments, most notably hospitals, are suffering from underfunding. Planning of outpatient health care is based on a territorial principle. Investment for state and municipal health establishments is financed from the state or municipal share in the establishments capital. In the first quarter of 2009, health workers accounted for 4.9% of the total workforce. Compared to other countries, the relative number of physicians and dentists is particularly high but the relative number of nurses remains well below the EU15, EU12 and EU27 averages. Bulgaria is faced with increased professional mobility, which is becoming particularly challenging. There is an oversupply of acute care beds and an undersupply of longterm care and rehabilitation services. Health care reforms after 1989 focused predominantly on ambulatory care and the restructuring of the hospital sector is still pending on the government agenda. Citizens as well as medical professionals are dissatisfied with the health care system and equity is a challenge not only because of differences in health needs, but also because of socioeconomic disparities and territorial imbalances. The need for further reform is pronounced, particularly in view of the low health status of the population. Structural reforms and increased competitiveness in the system as well as an overall support of reform concepts and measures are prerequisites for successful progress.

Sweden health system review

Life expectancy in Sweden is high and the country performs well in comparisons related to disease-oriented indicators of health service outcomes and quality of care. The Swedish health system is committed to ensuring the health of all citizens and abides by the principles of human dignity, need and solidarity, and cost-effectiveness. The state is responsible for overall health policy, while the funding and provision of services lies largely with the county councils and regions. The municipalities are responsible for the care of older and disabled people. The majority of primary care centres and almost all hospitals are owned by the county councils. Health care expenditure is mainly tax funded (80%) and is equivalent to 9.9% of gross domestic product (GDP) (2009). Only about 4% of the population has voluntary health insurance (VHI). User charges fund about 17% of health expenditure and are levied on visits to professionals, hospitalization and medicines. The number of acute care hospital beds is below the European Union (EU) average and Sweden allocates more human resources to the health sector than most OECD countries. In the past, the Achilles heel of Swedish health care included long waiting times for diagnosis and treatment and, more recently, divergence in quality of care between regions and socioeconomic groups. Addressing long waiting times remains a key policy objective along with improving access to providers. Recent principal health reforms over the past decade relate to: concentrating hospital services; regionalizing health care services, including mergers; improving coordinated care; increasing choice, competition and privatization in primary care; privatization and competition in the pharmacy sector; changing co-payments; and increasing attention to public comparison of quality and efficiency indicators, the value of investments in health care and responsiveness to patients needs. Reforms are often introduced on the local level, thus the pattern of reform varies across local government, although mimicking behaviour usually occurs.

Does HIV services decentralization protect against the risk of catastrophic health expenditures?: some lessons from Cameroon

OBJECTIVE

Scaling up antiretroviral treatment (ART) through decentralization of HIV care is increasingly recommended as a strategy toward ensuring equitable access to treatment. However, there have been hitherto few attempts to empirically examine the performance of this policy, and particularly its role in protecting against the risk of catastrophic health expenditures (CHE). This article therefore seeks to assess whether HIV care decentralization has a protective effect against the risk of CHE associated with HIV infection. DATA SOURCE AND STUDY DESIGN: We use primary data from the cross-sectional EVAL-ANRS 12-116 survey, conducted in 2006-2007 among a random sample of 3,151 HIV-infected outpatients followed up in 27 hospitals in Cameroon. DATA COLLECTION AND METHODS: Data collected contain sociodemographic, economic, and clinical information on patients as well as health care supply-related characteristics. We assess the determinants of CHE among the ART-treated patients using a hierarchical logistic model (n = 2,412), designed to adequately investigate the separate effects of patients and supply-related characteristics.

PRINCIPAL FINDINGS

Expenditures for HIV care exceed 17 percent of household income for 50 percent of the study population. After adjusting for individual characteristics and technological level, decentralization of HIV services emerges as the main health system factor explaining interclass variance, with a protective effect on the risk of CHE.

CONCLUSION

The findings suggest that HIV care decentralization is likely to enhance equity in access to ART. Decentralization appears, however, to be a necessary but insufficient condition to fully remove the risk of CHE, unless other innovative reforms in health financing are introduced.

Examining quality and efficiency of the U.S. healthcare system

PURPOSE

The fundamental concern of this research study is to learn the quality and efficiency of U.S. healthcare services. It seeks to examine the impact of quality and efficiency on various stakeholders to achieve the best value for each dollar spent for healthcare. The study aims to offer insights on quality reformation efforts, contemporary healthcare policy and a forthcoming change shaped by the Federal healthcare fiscal policy and to recommend the improvement objective by comparing the U.S. healthcare system with those of other developed nations.

DESIGN/METHODOLOGY/APPROACH

The US healthcare system is examined utilizing various data on recent trends in: spending, budgetary implications, economic indicators, i.e., GDP, inflation, wage and population growth. Process maps, cause and effect diagrams and descriptive data statistics are utilized to understand the various drivers that influence the rising healthcare cost. A proposed cause and effect diagram is presented to offer potential solutions, for significant improvement in U.S. healthcare.

FINDINGS

At present, the US healthcare system is of vital interest to the nation's economy and government policy (spending). The U.S. healthcare system is characterized as the world's most expensive yet least effective compared with other nations. Growing healthcare costs have made millions of citizens vulnerable. Major drivers of the healthcare costs are institutionalized medical practices and reimbursement policies, technology-induced costs and consumer behavior.

PRACTICAL IMPLICATIONS

Reviewing many articles, congressional reports, internet websites and related material, a simplified process map of the US healthcare system is presented. The financial process map is also created to further understand the overall process that connects the stakeholders in the healthcare system. Factors impacting healthcare are presented by a cause and effect diagram to further simplify the complexities of healthcare. This tool can also be used as a guide to improve efficiency by removing the "waste" from the system. Trend analyses are presented that display the crucial relationship between economic growth and healthcare spending.

ORIGINALITY/VALUE

There are many articles and reports published on the US healthcare system. However, very few articles have explored, in a comprehensive manner, the links between the economic indicators and measures of the healthcare system and how to reform this system. As a result of the US healthcare system's complex structure, process map and cause-effect diagrams are utilized to simplify, address and understand. This study linked top-level factors, i.e., the societal, government policies, healthcare system comparison, potential reformation solutions and the enormity of the recent trends by presenting serious issues associated with U.S. healthcare.

[The health system of El Salvador]

This paper describes the health conditions in El Salvador and the main característics of the Salvadoran health system, including its structure and coverage, its financial sources, the physical, material and human resources available, the stewardship functions developed by the Ministry of Public Health, and the participation of health care users in the evaluation of the system. It also discusses the most recent policy innovations including the approval of the Law for the Creation of the National Health System, which intends to expand coverage, reduce health inequalities and improve the coordination of public health institutions.

[The health system of Ecuador]

This paper describes the health conditions in Ecuador and, in more detail, the characteristics of the Ecuadorian health system, including its structure and coverage, its financial sources, the physical, material and human resources available, and the stewardship activities developed by the Ministry of Public Health. It also describes the structure and content of its health information system, and the participation of citizens in the operation and evaluation of the health system. The paper ends with a discussion of the most recent policy innovations implemented in the Ecuadorian system, including the incorporation of a chapter on health into the new Constitution which recognizes the protection of health as a human right, and the construction of the Comprehensive Public Health Network.

[The health system of Nicaragua]

This paper describes the health conditions in Nicaragua and discusses the characteristics of its national health system including its structure and coverage, its financial sources its physical, material and human resources the stewardship functions developed by the Ministry of Health the participation of citizens in the operation and evaluation of the system and the level of satisfaction of health care users. It also discusses the most recent policy innovations, including the new General Health Law, the decentralization of the regulation of health facilities and the design and implementation of a new health care model known as Family and Community Health Model.

[The health system of Colombia]

This document briefly describes the health conditions of the Colombian population and, in more detail, the characteristics of the Colombian health system. The description of the system includes its structure and coverage; financing sources; expenditure in health; physical material and human resources available; monitoring and evaluation procedures; and mechanisms through which the population participates in the evaluation of the system. Salient among the most recent innovations implemented in the Colombian health system are the modification of the Compulsory Health Plan and the capitation payment unit, the vertical integration of the health promotion enterprises and the institutions in charge of the provision of services and the mobilization of additional resources to meet the objectives of universal coverage and the homologation of health benefits among health regimes.

[The health system of Chile]

This paper describes the Chilean health system, including its structure, financing, beneficiaries, and its physical, material and human resources. This system has two sectors, public and private. The public sector comprises all the organisms that constitute the National System of Health Services, which covers 70% of the population, including the rural and urban poor, the low middle-class, the retired, and the self-employed professionals and technicians.The private sector covers 17.5% of the population, mostly the upper middle-class and the high-income population. A small proportion of the population uses private health services and pays for them out-of-pocket. Around l0% of the population is covered by other public agencies, basically the Health Services for the Armed Forces. The system was recently reformed with the establishment of a Universal System of Explicit Entitlements, which operates through a Universal Plan of Explicit Entitlements (AUGE), which guarantees timely access to treatment for 56 health problems, including cancer in children, breast cancer, ischaemic heart disease, HIV/AIDS and diabetes.

[The health system of Costa Rica]

This paper describes the Costa Rican health system which provides health, water and sanitation services. The health component of the system includes a public and a private sector. The public sector is dominated by the Caja Costarricense de Seguro Social (CCSS), an autonomous institution in charge of financing, purchasing and delivering most of the personal health services in Costa Rica. CCSS is financed with contributions of the affiliates, employers and the state, and manages three regimes: maternity and illness insurance, disability, old age and death insurance, and a non-contributive regime. CCSS provides services in its own facilities but also contracts with private providers. The private sector includes a broad set of services offering ambulatory and hospital care. These services are financed mostly out-of-pocket, but also with private insurance premiums. The Ministry of Health is the steward of the system, in charge of strategic planning, sanitary regulation, and research and technology development. Among the recent policy innovations we can mention the establishment of the basic teams for comprehensive health care (EBAIS), the de-concentration of hospitals and public clinics, the introduction of management agreements and the creation of the Health Boards.

[The health system of Cuba]

This paper describes the health conditions in Cuba and the general characteristics of the Cuban health system, including its structure and coverage, its financial sources, its health expenditure, its physical, material and human resources, and its stewardship functions. It also discusses the increasing importance of its research institutions and the role played by its users in the operation and evaluation of the system. Salient among the social actors involved in the health sector are the Cuban Women Federation and the Committees for the Defense of the Revolution. The paper concludes with the discussion of the most recent innovations implemented in the Cuban health system, including the cardiology networks, the Miracle Mission (Misión Milagro) and the Battle of Ideas (Batalla de Ideas).