Collective sensemaking for action: researchers and decision makers working collaboratively to strengthen health systems

Lucy Gilson and colleagues draw on experiences from Kenya and South Africa to consider the practice, benefits, and challenges of research co-production for strengthening health systems

Vaccination strategies for measles control and elimination: time to strengthen local initiatives

BACKGROUND

Through a combination of strong routine immunization (RI), strategic supplemental immunization activities (SIA) and robust surveillance, numerous countries have been able to approach or achieve measles elimination. The fragility of these achievements has been shown, however, by the resurgence of measles since 2016. We describe trends in routine measles vaccine coverage at national and district level, SIA performance and demographic changes in the three regions with the highest measles burden.

FINDINGS

WHO-UNICEF estimates of immunization coverage show that global coverage of the first dose of measles vaccine has stabilized at 85% from 2015 to 19. In 2000, 17 countries in the WHO African and Eastern Mediterranean regions had measles vaccine coverage below 50%, and although all increased coverage by 2019, at a median of 60%, it remained far below levels needed for elimination. Geospatial estimates show many low coverage districts across Africa and much of the Eastern Mediterranean and southeast Asian regions. A large proportion of children unvaccinated for MCV live in conflict-affected areas with remote rural areas and some urban areas also at risk. Countries with low RI coverage use SIAs frequently, yet the ideal timing and target age range for SIAs vary within countries, and the impact of SIAs has often been mitigated by delays or disruptions. SIAs have not been sufficient to achieve or sustain measles elimination in the countries with weakest routine systems. Demographic changes also affect measles transmission, and their variation between and within countries should be incorporated into strategic planning.

CONCLUSIONS

Rebuilding services after the COVID-19 pandemic provides a need and an opportunity to increase community engagement in planning and monitoring services. A broader suite of interventions is needed beyond SIAs. Improved methods for tracking coverage at the individual and community level are needed together with enhanced surveillance. Decision-making needs to be decentralized to develop locally-driven, sustainable strategies for measles control and elimination.

Représentations des acteurs de la mise en œuvre du projet régional de santé dans deux régions

BACKGROUND

The Regional Health Project (RHP) is an important lever to build a health producing system. The RHP serves as the reference for health policies in the French regions. It is developed in three main stages, preparation, diagnosis and priorities. Different institutional actors are involved: managers, administrators, leaders for democracy and medico-social services as well as primary care professionals. How have all of these actors been involved in the three main stages of preparation of the RHP?

AIM

The aim of this article is to analyze the implementation of the RHP in two French regions and how the actors in those regions perceived that implementation.

METHOD

The analysis of the implementation of the RHP focused on the definition of the implementation process, the diagnosis and the identification of the problems. This later one included the development of the priorities and the objectives while taking into account the resources and the evaluation. This analysis was conducted in two medium-sized regions in France between 2011 and 2015.

RESULTS

The formulation of the problems in the RHP is rather general. Priorities and objectives are poorly justified. Resources and evaluation are not taken into account. We attribute these weaknesses to the difficulty of crossing the administrative, managerial and democratic representations with care practices in the regions.

CONCLUSIONS

A method and process that integrates the two public policy representations should be specified in a detailed document established prior to formally engaging the planning process. Therefore, the harmonization of methodology and terms is first needed as well as the development of training and research.

Patient Input in Regional Healthcare Planning-A Meaningful Contribution

Background: There are well-known methodological and analytical challenges in planning regional healthcare services (HCS). Increasingly, the need for data-derived planning, including user-perspectives, is discussed. This study aims to better understand the possible contribution of citizen experience in the assessment of regional HCS needs in two regions of Germany. Methods: We conducted a written survey in two regions of differing size-a community (3653 inhabitants) and a county (165,211 inhabitants). Multinomial logistic regression was used to assess the impact of sociodemographic and regional factors on the assessment of HCS provided by general practitioners (GPs) and specialists. Results: Except for age and financial resources available for one's own health, populations did not differ significantly between the regions. However, citizens' perception of HCS (measured by satisfaction with 1 = very good to 5 = very poor) differed clearly between different services (e.g., specialists: 3.8-4.3 and pharmacies: 1.7-2.5) as well as between regions (GPs: 1.7-3.1; therapists: 2.9-4). In the multivariate model, region (next to income and age) was a consistent predictor of the perception of GP- and specialist-provided care. Discussion: Citizens' perceptions of HCS correspond to regional provider density (the greater the density, the better the perception) and add insights into citizens' needs. Therefore, they can provide valuable information on regional HCS strengths and weaknesses and are a valid resource to support decision makers in shaping regional care structures.

Developing a regional cancer service; lessons from the Waitemata Cancer Patient Experience Survey

AIM

As part of a project developing cancer service capability, the National Health Service (NHS) Cancer patient experience survey was used to assess the currently available services at Waitemata District Health Board (WDHB).

METHODS

Patients presenting with cancer to WDHB in the previous 12 months were mailed a copy of the survey, to the initial cohort in 2013 and to the second in 2015. Results were compared between survey periods and with the 2015 NHS Cancer Patient Experience Survey.

RESULTS

In 2013, 329 patients completed the survey while 319 responded in 2015. Over 90% of patients classed their experience as good or excellent in both survey periods and comparison showed significant overall improvement (p=0.001) in patient experience between 2013 and 2015. Overall, WDHB benchmarked with the NHS experience but the NHS performed better than WDHB in cancer nurse specialist contact for ongoing support and information related to eligibility for financial assistance.

CONCLUSION

The results of these confirm that the NHS Cancer Patient Experience Survey provides meaningful data within New Zealand and that WDHB cancer patient experience has improved over the survey period. This data has assisted WDHB in prioritising patient information resources and treatment planning in developing services.

Establishment of trauma treatment teams within a regional severe trauma treatment system in China: study protocol for a national cluster-randomised trial

INTRODUCTION

The implementation of first aid processes for patients with trauma in China faces significant challenges. These challenges include long response times of prehospital first aid services, lack of information exchange between prehospital first aid services and in-hospital emergency services, lack of a professional rescue team in the majority of hospitals, and lack of standardised training for prehospital and in-hospital emergency personnel. The purpose of the trial is to guide the establishment of an urban trauma treatment system in China, highlight the construction of a trauma treatment system tailored to the Chinese context and improve levels of medical treatment by selecting approximately 100 counties across China as pilots to establish a regional trauma treatment system.

METHODS AND ANALYSIS

A cluster-randomised controlled trial will be performed in 98 county-level research institutes. Included research institutes will be randomised into an experimental group and a control group. Patients in both experimental and control groups will receive basic treatments. A trauma treatment team will be established in the experimental group. The primary outcome measure is in-hospital mortality rate of patients. The secondary outcome measures include mortality rate of patients within 30 days after trauma attack and within 30 days after discharge, the time between arrival in the institution and receiving consultation, and the time from admission to the start of surgery. The effects of establishment of trauma treatment teams on the treatment of severe trauma will be evaluated in all counties.

ETHICS AND DISSEMINATION

The procedures have been approved by The Medical Ethics Committee of Peking University People's Hospital (No.2017PHB098-01) and conform to the Declaration of Helsinki. Data will be collected and analysed in accordance with participant privacy laws and regulations. Results will be disseminated through policy briefs, workshops, peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

NCT03363880; Pre-results.

Development of a hexagonal, mesh-based distribution method for community health centres

Community health centres (CHCs) are the health gatekeepers of the local population. Location and numbers of the CHCs affect fairness and effectiveness with regard to access to primary health care. In the past, the distribution of the CHCs was solely empiric-based. The goal of this study was to devise a method for CHC distribution based on the principle of improving equity as well as ensuring efficiency. We tested the effectiveness and operability of the method through a process of revision and simulation using Guangdong Province, China as sample district. A methodology based on literature review and expert consultation was repeatedly applied until an ideal result had been reached. A hexagonal, mesh-based method was developed and used to find a solution where the CHCs could be distributed where their location would be the most needed and total number suitable. Testing the effectiveness of the proposed plan, we found the proportion of area covered to be 52.8% and the proportion of the population covered 80.7%, which is 15.4% and 14.7%, respectively, better than before. It was concluded that the hexagonal mesh-based, distribution method can effectively define the location as well as the number or required CHCs, not only improving the accessibility for residents to primary health care services but also maximizing cost-effectiveness. Management of the city by grid is a new idea in urban management, which improves rationality of planning and also may be applied for many different purposes in addition to CHC localization.

Equity and efficiency of medical service systems at the provincial level of China's mainland: a comparative study from 2009 to 2014

BACKGROUND

The astonishing economic achievements of China in the past few decades have remarkably increased not only the quantity and quality of medical services but also the inequalities in health resources allocation across regions and inefficiency of the medical service delivery.

METHODS

A descriptive analysis was used to compare the inequities in inputs and outputs of the provincial medical service systems, a non-radial super-efficiency data envelopment analysis model was then used to estimate the efficiency, and a regression analysis of the panel data was used to explore the determinants.

RESULTS

The inputs and outputs of most provincial medical service systems increased gradually from 2009 to 2014. Overall, the eastern region allocated more human and capital resources than the other two regions, and produced more than 50% of the total outpatient and emergency room visits, whereas the western region produced more inpatient services (about 30% of the total volume of inpatient services) according to the distribution of the population. The average efficiency scores of the provincial medical systems in China's mainland were 0.895, 0.927, 0.929, 0.963, 0.977 and 0.968 from 2009 to 2014, with a slight average improvement of 1.60%. The efficiency score of each provincial medical service system varied greatly from one another: Tibet (1.475 ± 0.057) performed extremely well, whereas several others including Heilongjiang (0.579 ± 0.001) performed poorly. Furthermore, the proportion of high-class medical facilities was negatively associated with efficiency, whereas the proportion of the vulnerable population, the per capita Gross Domestic Product, the proportion of the illiterate population and the improvement of primary health care had positive effects on efficiency.

CONCLUSION

Inequity in health resources allocation and service provision existed across the regions, but not all the gaps have begun to narrow since 2009. The difference of efficiency was great among provincial medical service systems but minor across regions, and the score changed very little over time. More importantly, the central region held the lowest average efficiency score in the past 6 years, while the western region held the largest average efficiency score at the first 5 years, which should receive enough attention of the government and decision-makers. In practice, efficiency was related to many complicated factors, indicating that the improvement of efficiency is a complex and iterative process that requires the strong cooperation of many sectors.

Planning of effective evaluation of the activities of hospital district at the example of poltava region

OBJECTIVE

Introduction: Increasing of the availability and quality of health care in rural areas is one of the priority directions of public health and regional development policy. The need for reforming of the network of secondary health care facilities is due to the fact, that they are unable to meet the needs of the population in this specialized type of medical care in the conditions of the existing structure and funding system. The aim: to analyze the existing legislation regulating the establishment and operation of hospital districts; to determine the methodology for monitoring and evaluating of the activity of the hospital district on the example of the Poltava region.

PATIENTS AND METHODS

Materials and methods: In this work a set of methods is used: system approach, bibliosemantic, legal, logical modeling.

RESULTS

Review: A managerial tool capable of tracking the process and demonstrating the impact of projects, programs and development policies is monitoring and evaluation. The basis of evaluation is the creation of different indicators and indexes. The system of these indicators provides an opportunity to assess the social, medical, economic and environmental aspects of development of hospital district. The monitoring and evaluation program should include monitoring of implementation (contributions and activities) and monitoring of the results of work of the hospital districts (short-term and long-term).

CONCLUSION

Conclusions: Hospital districts are created with the aim of optimizing of the organization and functioning of the network of health facilities. The Management Board's decision should be based on valid, reliable information on the development of the hospital district. Compliance with the monitoring and evaluation methodology makes it possible to provide the health care system with qualitative and timely data at all stages of its reformation.

[Gerontological problems and prospects of regional management. Strategy and structure of interdepartmental gerontological assistance in the Kabardino-Balkarian Republic.]

The article presents the structure of interdepartmental gerontological care in the Kabardino-Balkarian Republic. The basic principles, directions and prospects of work are stated. The main principles, directions and prospects of work.

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.

[Social inequalities in health, missions of a regional healthcare agency]

The presence of social inequalities in health requires a multi-faceted intervention, focusing on the social determinants as well as the provision of care and prevention strategies. Regional health agencies have important levers at their disposal, as illustrated by the example of the Île-de-France region.

Changing lives-it starts with a plan

Sam Foster, Chief Nurse at Heart of England NHS Foundation Trust, discusses how nurse leaders can influence the Sustainability and Transformation Plan for the benefit of their local area population.

Future needs for nursing talent in Scandinavian countries: a systematic review protocol

The aim of this review is to systematically identify, appraise and synthesize available text and opinion papers from policy-makers and trade unions in Scandinavian countries (Denmark, Sweden and Norway) containing information about nursing talent needed in healthcare systems for the future. The overall objective is to identify and synthesize the opinions of various stakeholders of what they believe is required in terms of nursing talent in Scandinavia.In this review, "nursing talent" refers to certain skills or competencies that are essential within nursing to meet the challenges and demands of future health care. The purpose of this review is to provide knowledge about the opinions of two key stakeholders (policy-makers and trade unions) on nursing talent needed in future Scandinavian healthcare systems.

Quality of medical care during and shortly after acute care restructuring in Newfoundland and Labrador

Objectives

To critically evaluate the quality of hospital medical care at the beginning, during and shortly after regionalization of health boards in Newfoundland and Labrador, and aggregation of hospitals in the StJohn's region.

Methods

Retrospective chart audits for the years 1995/96, 1998/99 and 2000/01 (at the beginning, during and after restructuring) focused on outcomes in cardiology, respiratory medicine, neurology, nephrology, psychiatry, surgery andwomen's health programmes. Where possible, quality of care was judged on measurable outcomes in relation to published statements of likely optimal care. Comparisons were made over time within the StJohn's region, and separately for hospitals in the rest of the province.

Results

There was improvement in the use of thrombolytics and secondary measures post-myocardial infarction in both regions. Mortality and appropriateness of initial antibiotic choice for community-acquired pneumonia remained stable in both regions, with an improvement in admission appropriateness based on the severity in St John's. Aspects of stroke management (referral and time to see allied health professionals, imaging and discharge home) improved in both regions, while mortality remained stable. There was improvement in fistula rate, quality of dialysis and anaemia management in haemodialysis patients, and improvement in the peritoneal dialysis patient peritonitis rate. Readmission rate for schizophrenia remained unchanged. Stable mortality rates were observed for frequently performed surgical procedures. The post-coronaryartery by pass grafting (CABG) morbid event rate improved, although access to CABG was not optimal.

Conclusions

Aggregation of acute care hospitals was feasible without attendant deterioration in patient care, and in some areas care improved. However, access to services continued to be a major problem in all regions.

Regionalization of health services in Newfoundland and Labrador: perceptions of the planning, implementation and consequences of regional governance

Objectives

To describe the context and key drivers for regionalization of one provincial health care system in Canada; to document the original expectations of regionalization on governance and the extent to which these expectations were met; to identify the perceived successes and weaknesses of the process; and to examine the key issues and concerns that warrant further consideration and action in the future.

Methods

Forty-five CEO/senior administrator or senior health department officials in the period 1993-2001 were invited to participate, of whom 35 were interviewed (67% of senior health officials and 85% of CEOs/ senior administrators).

Results

For the most part, key informants felt that expectations of reform with respect to reduction in the number of boards and integration of services under each board's mandate did occur. However, ongoing financial restraint, failure to include the full range of health services under the regional board mandate (including physician and pharmaceutical services), uncertainty regarding the level of authority the regional boards had for decision-making, and unclear accountability mechanisms between the regional boards and the provincial Ministry of Health limited the extent to which broader expectations related to development of a population health focus, and improved continuity of care for individuals and families was achieved.

Conclusions

Implications for policy-makers were identified in four main areas: alignment between health policy goals and the governance structure; clarification of authority and accountability relationships; clarification of roles and responsibilities among all key actors; and strengthening of mechanisms that support accountability.

Health care quality from the perspective of health care providers and patients during and shortly after acute care restructuring in Newfoundland and Labrador

Objectives

To monitor changes in providers' perceptions of health care quality and the importance of health reform, and in patients' satisfaction with services during and two years after restructuring, comparing the region of the province that was restructured (StJohn's) with those regions in which hospitals were not aggregated.

Methods

The Employee Attitude Survey questionnaire was sent to acute care providers (n=5353) to assess personal characteristics and perceptions of the impact of reform on workplace conditions, work-related attitudes and turnover intentions. The response rate for 2000 and 2002 was 42% (n=1222 and1034, respectively). Only respondents in both surveys (n=589) were used in the analysis because study results were the same for both the repeat sample and total samples. A Patient Satisfaction Survey questionnaire was administered to patients discharged from acute care facilities in 2000 (n=1741) and 2002 (n=704). Response rates were 82.5% and 90.2%, respectively.

Results

Most providers felt, at both time periods, that restructuring of the health care system was a positive step, but felt that health care quality was low. In the StJohn's region, perceptions of quality and standards of care improved over time. Patients were extremely satisfied with the admission process and hospital stay at both time periods in StJohn's. However, satisfaction declined in 2002 in regions outside StJohn's.

Conclusions

Aggregation of acute care hospitals is possible without adverse effects on providers' perceptions of health care quality or on patient satisfaction.

Attitudes and perceptions of registered nurses during and shortly after acute care restructuring in Newfoundland and Labrador

Objectives

To monitor changes in registered nurses' perceptions of the impact of seven years of health care restructuring in Newfoundland and Labrador (NL) and to measure the attitudinal and behavioural reactions over four years comparing the St John's region, where hospital aggregation occurred, to other regions of the province.

Methods

Data were collected on acute care nurses' personal characteristics and perceptions of the importance of reform and its impact on workplace conditions and health care quality in 1995, 1999, 2000 and 2002. Nurses' attitudes and intentions were monitored across three time periods (i.e.1999, 2000 and 2002).

Results

Perceived workplace conditions and health care quality, as well as attitudes and behaviours were generally negative. However, there was some improvement over time. The temporal sequence of scores suggests that restructuring had an adverse impact on nurses' attitudes. Few significant regional differences were observed.

Conclusions

Although health services restructuring had an adverse impact on nurses'attitudes, aggregation of hospitals in St John's region was achieved without further deterioration. Provincial wide initiatives are needed to promote more positive work environments and increase the organizational effectiveness.

Realistic Expectations: Investing in Organizational Capacity Building for Chronic Disease Prevention

Purpose.

This article presents findings that explore investment in organizational capacity building for chronic disease prevention. Specifically, this analysis examines variation in investment inputs, intervention outputs, and capacity changes to inform expectations of health-promotion capacity-building investment.

Design/Setting.

This multiple case study involving both qualitative and quantitative data is based on seven provincial dissemination projects involved in the Canadian Heart Health Initiative.

Methods.

Data on investment, number, and type of capacity-building activities and capacity changes come from a questionnaire, key informant interviews, and project report analysis. Quantitative data were analyzed descriptively and for trends, while qualitative data were analyzed thematically.

Results.

Per capita investments in capacity building ranged from a low of $0.21 in Ontario to $167.41 in Prince Edward Island. Multiple, tailored capacity-building interventions were used in each project. Mostly positive but modest changes were observed in at least five dimensions of capacity in all but one project.

Conclusion.

These findings reveal that capacity building for chronic disease prevention requires a long-term investment and is context specific. Even limited investment can produce interventions that appear to positively influence capacity for chronic disease prevention. The findings also suggest an urgent need to expand surveillance to include indicators of capacity-building investments and interventions to allow policy makers to make more informed decisions about investments in public health.

Evidence-based priority-setting: what do the decision-makers think?

Objectives: Resource scarcity dictates the need for health organisations to set priorities. Although such activity should be based, at least in part, on evidence, there are limited examples in the literature of decision-makers reflecting on their use of evidence in priority-setting.

Methods: A participatory action-research project was conducted in a single health authority in Alberta. It included in-depth interviews and focus groups with senior decision-makers both before and after development and implementation of a macro-level priority-setting framework (programme budgeting and marginal analysis, PBMA). Data were thematically coded and information on the use of evidence in priority-setting is reported.

Results: Barriers to the use of evidence in priority-setting identified by decision-makers included crisis-orientated management, time constraints and a lack of skills. Decision-makers suggested using a mix of 'soft' and 'hard' forms of evidence in priority-setting. Following PBMA implementation, decision-makers wanted better information on capacity to benefit, but preferred to do this pragmatically from multiple sources of information rather than using a single metric.

Conclusion: In examining the perspectives of decision-makers in using evidence to support priority-setting, valuable information was derived which should provide insight for such processes in other jurisdictions. The main finding of a desire for pragmatic assessment of benefit is informative for those involved in both decision-making and research.

Support for the clinician in providing a regional telehealth service

However attractive the idea of telehealth may appear to them, clinicians in regional hospitals will be preoccupied with clinical matters and are unlikely to have either the time or the expertise necessary to address the infrastructure and organizational aspects of establishing a telehealth service. Our experience of telepaediatrics in Queensland has shown that the support of the central service and coordinator has been essential in overcoming initial difficulties and has freed us as clinicians to concentrate on appropriate clinical referrals and consultation via telehealth. The central service is also able to assist in data collection, and in the analysis and interpretation of telehealth activity, for example in measuring cost-effectiveness. We have found that consolidating most consultations into planned clinics creates efficiency. The central coordinator can teach and support those new to telehealth in the regional and primary care setting, thus relieving the local clinician of this responsibility. As telehealth services expand in a regional centre, having a dedicated local telehealth coordinator may become appropriate. A central telehealth support service, which is clinically focused and responsive to clinicians' needs, is an essential foundation for successful telehealth.

Two at the top: relations between Chairs and Chief Executives in the NHS

The relationship between the Chair and Chief Executives of Health Authorities (and Boards) and NHS Trusts denote the managerial and political character of the NHS, creating an organizational apex with 'two at the top'. This article considers the nature of relationships between Chairs and Chief Executives in a variety of different NHS organizations according to two theoretical perspectives: role theory and negotiated order. Empirical evidence addresses the views of the roles of Chairs and Chief Executives, the content of their roles and the local and national factors which influence them (including critical incidents). Conclusions are drawn about the conceptualization of this crucial relationship in the NHS and also on the association between the Chair - Chief Executive relationship and organizational effectiveness.

From the trenches: views from decision-makers on health services priority setting

Due to resource scarcity, health organizations worldwide must decide what services to fund and, conversely, what services not to fund. One approach to priority setting, which has been widely used in Britain, Australia, New Zealand and Canada, is programme budgeting and marginal analysis (PBMA). To date, such activity has primarily been based at a micro level, within programmes of care. In order to institute and refine the PBMA framework at a macro level across major service areas within a single health authority, researchers and decision-makers in Alberta embarked on a participatory action research project together.

This paper identifies key issues of importance to decision-makers in a real-world priority-setting context. Themes discussed include making comparisons across disparate patient groups, dealing with political factors, using relevant forms of evidence, recognizing innovations and involving the public. The in-depth insight gained through this qualitative analysis will enable future refinement of PBMA at a macro level in the health authority under study, and should also serve to inform priority-setting activity in regionalized contexts elsewhere. In identifying aspects of priority setting that are important to decision-makers, researchers can also be better informed with respect to realworld processes.

Lost in Maps: Regionalization and Indigenous Health Services

The settlement of the land now known as Canada meant the erasure - sometimes from ignorance, often purposeful - of Indigenous place-names, and understandings of territory and associated obligations. The Canadian map with its three territories and ten provinces, electoral boundaries and districts, reflects boundaries that continue to fragment Indigenous nations and traditional lands. Each fragment adds institutional requirements and organizational complexities that Indigenous nations must engage with when attempting to realize the benefits taken for granted under the Canadian social contract.

[Cytogenetic status of the residents of the Gydansky Peninsula (Gydan)]

The relevance of the study on the Gydansky Peninsula lies in poor knowledge and inaccessibility of the territory, planned intensive industrial development of the Gydansky Peninsula, in 2011 there were received licenses for the exploration of license areas at the peninsula up to 2031. Industrial development will inevitably lead to certain environmental shifts, emission of the harmful substances into biosphere, the accumulation of anthropogenic pollutants in soil and water sources. The proposed development of the territory of the Peninsula Gydan sets the task of assessment of the impact of gas and oil production in conditions of the far North on health, as well indigenous persons as employees recruited to this of the region. One of the informative approaches to the assessment of population health is the assessment of the cytogenetic status with the use of noninvasive analysis of buccal epithelium. The aim of the study is to determine the cytogenetic status of the inhabitants of the village of Antipayuta of the Yamal-Nenets Autonomous Okrug for the assessment of the impact of environmental factors on the health of the population at the present stage of the industrial development of the territory. Samples of buccal epithelium of 81 alien and indigenous people of the Yamal-Nenets Autonomous district were the object of the investigation. There was performed the analysis of indices of cells of buccal epithelium of the residents living in the village in comparison with the control group. The analysis of samples was performed on a Nikon Eclipse E100 microscope. For the assessment of the cytogenetic status of the individual there was used the proposed by Sycheva L. P. (2012-Index of accumulation of cytogenetic damages (Iac). It is shown that the frequency of occurrence of micronucleus and nuclear protrusions does not exceed the performance of the control group. The index of accumulation of cytogenetic damage for the population of the village is 0.78±0.07% and corresponds to a low level. The analysis of indices of buccal epithelial cells of residents living in rural areas was performed in the comparison with the control group The prevalence rate of cells with micronuclei and protrusions were shown to account of 14.6% andfail to exceed indices in the control group. Accumulation index of cytogenetic damages for the village population is 0.78 ± 0.07 % and corresponds to the low level. The amount of cells with micronuclei and protrusions in the current study is by 14.6% lower than the average of the control group. The intensity of proliferative processes and apoptosis in the comparison groups occurs evenly.

Hub and spoke model: making rural healthcare in India affordable, available and accessible

CONTEXT

Quality health care should be within everyone's reach, especially in a developing country. While India has the largest private health sector in the world, only one-fifth of healthcare expenditure is publically financed; it is mostly an out-of-pocket expense. About 70% of Indians live in rural areas making about $3 per day, and a major portion of that goes towards food and shelter and, thus, not towards health care. Transportation facilities in rural India are poor, making access to medical facilities difficult, and infrastructure facilities are minimal, making the available medical care insufficient. The challenge presented to India was to provide health care that was accessible, available and affordable to people in rural areas and the low-income bracket.

ISSUES

The intent of this article is to determine whether the hub and spoke model (HSM), when implemented in the healthcare industry, can expand the market reach and increase profits while reducing costs of operations for organizations and, thereby, cost to customers. This article also discusses the importance of information and communications technologies (ICT) in the HSM approach, which the handful of published articles in this topic have failed to discuss. This article opts for an exploratory study, including review of published literature, web articles, viewpoints of industry experts, published journals, and in-depth interviews. This article will discuss how and why the HSM works in India's healthcare industry while isolating its strengths and weaknesses, and analyzing the impact of India's success. India's HSM implementation has become a paramount example of an acceptable model that, while exceeding the needs and expectations of its patients, is cost-effective and has obtained operational and health-driven results. Despite being an emerging nation, India takes the top spot in terms of affordability of ICT as well as for having the highest number of computer-literate graduates and healthcare workers in the world. These factors further aid the implementation of HSM in India, thereby proving the model as a stable operational environment that is saving costs in a financially challenged nation.

LESSONS LEARNED

HSM has an innovative architecture that emphasizes optimal utilization of scarce healthcare resources in rural areas. HSM demonstrates that medical care can be provided to even the most rural areas while still utilizing modern procedures and equipment at a much more nominal cost to the end user. It also eliminates the need for unnecessary travel, and keeps costs low to medical facilities and patients alike. The model has the potential to create and sustain thousands of local jobs, both direct and indirect. The hope is that the review of the impact of the HSM in Indian health care will result in inquiries of a similar nature in the future.

[Monitoring of public health in the Kashagan oil and gas field]

According to explored hydrocarbon reserves the Republic of Kazakhstan (RK) is among ten top countries rich in oil deposits. In connection with the intensive development of oil and gas industry environmental protection and public health issues became subject of a great interest from both scientists ’ and health practitioners ’ side. Results of the study included in this article are devoted to the study of health of the population, living near the “Bolashak” installation of complex preparation of oil and gas. There is a preliminary oil refining process coming from the Kashagan field and its further export. Analysis proved air pollution to be the one of the major risk factors for the health of the residing people. In the area there are problems of fresh water supply and frequent accidents at sewage plants. Landfills for municipal solid waste does not meet sanitary standards. The health care system of Makat district is characterized by uncompleted personnel and lack of beds. Indices of the mortality rate over the study period declined by 28.8%. As a result, population growth over the study the period was characterized by a tendency to increase. In 2013 population sought medical advice due to respiratory diseases, injuries and poisoning, diseases of blood and hemopoietic organs, diseases of the skin and subcutaneous tissue and nervous system.

[Trends of change in demographic indices of population in the area of oil and gas deposits of the republic of Kazakhstan]

According to assured resources of hydrocarbons the Republic of Kazakhstan (RK) is among ten largest oil countries in the world, trailing only some states of the Middle East, Latin America, as well Russia and the USA. Public health state is the one of most important indices of social development, the manifestation of the economic and sanitaryhygienic welfare, as well as national defense capability and cultural potential of the state. In relation with the intensive development of oil and gas fields the problems of environmental protection and healthcare of the population in these regions occur critically. Therefore, it causes keen interest both from the side of researches and practical health care workers. Rapid development of the oil and gas industry leads to changes in a medical and demographic situation of given regions that is related both with the natural migration of the population and other migratory processes. According to data of the Ministry of Energetics and natural resources of RK, the Karachaganak oil-gas condensate deposit is considered to be the one of the largest in the world. For the next 40 years, the field is becoming the stable financial donor of the country. Currently Karachaganak field is considered to be the one of the largest investment projects in Kazakhstan. The studied oil and gas condensate field is located in the Burlin district of West Kazakhstan region, which is 140 km far from the city of Uralsk and 160 km far from the city of Orenburg. The field was discovered in 1984.

[Development of a consented set of criteria to evaluate post-rehabilitation support services]

OBJECTIVE

Existing rehabilitation aftercare offers in Germany are heterogeneous, and there is a lack of transparency in terms of indications and methods as well as of (nationwide) availability and financial coverage. Also, there is no systematic and transparent synopsis. To close this gap a systematic review was conducted and a web-based database created for post-rehabilitation support. To allow a consistent assessment of the included aftercare offers, a quality profile of universally valid criteria was developed. This paper aims to outline the scientific approach.

METHODOLOGY

The procedure adapts the RAND/UCLA method, with the participation of the advisory board of the ReNa project. Preparations for the set included systematic searches in order to find possible criteria to assess the quality of aftercare offers. These criteria first were collected without any pre-selection involved. Every item of the adjusted collection was evaluated by every single member of the advisory board considering the topics "relevance", "feasibility" and "suitability for public coverage". Interpersonal analysis was conducted by relating the median and classification into consensus and dissent. All items that were considered to be "relevant" and "feasible" in the three stages of consensus building and deemed "suitable for public coverage" were transferred into the final set of criteria (ReNa set).

RESULTS

A total of 82 publications were selected out of the 656 findings taken into account, which delivered 3,603 criteria of possible initial relevance. After a further removal of 2,598 redundant criteria, the panel needed to assess a set of 1,005 items. Finally we performed a quality assessment of aftercare offers using a set of 35 descriptive criteria merged into 8 conceptual clusters.

CONCLUSION

The consented ReNa set of 35 items delivers a first generally valid tool to describe quality of structures, standards and processes of aftercare offers. So finally, the project developed into a complete collection of profiles characterizing each post-rehabilitation support service included in the database.

Service planning implications of estimating Primary Health Organisation enrolment rate based on a Health Service Utilisation population rather than a Census-derived population

AIM

Estimating Primary Health Organisation (PHO) enrolment rates with a census-derived estimated resident population denominator may provide misleading results because of numerator and denominator mismatch. This study uses the Health Service Utilisation (HSU) population denominator as an alternative.

METHOD

A HSU population was generated by record linkage of routinely collected datasets from the Ministry of Health via encrypted National Health Index (NHI). We compare PHO enrolment rates by age and ethnicity in Counties Manukau District Health Board (CMDHB) in 2013.

RESULTS

In CMDHB, 98% of people who had utilised publicly-funded health services in 2013 were enrolled in a PHO in 2013. Using the HSU population as a denominator, PHO enrolment rates for Maaori, Pacific, Asian, New Zealand European/Other population groups were 98.3%, 97.7%, 97.6%, and 98.3% respectively. Just under 4% of people discharged from CMDHB inpatient facilities were not enrolled in a PHO within a month from the day of discharge in 2013.

CONCLUSION

Using the HSU population as a proxy of health services need, PHO enrolment rates were similar across ethnicities in the CMDHB population. Support to improve PHO enrolment coverage would be more efficient if the HSU population were used to target people who are not yet enrolled in a PHO.

How Can Health System Efficiency Be Improved in Canada?

Improving value for money in the health system is an often-stated policy goal. This study is the first to systematically measure the efficiency of health regions in Canada in producing health gains with their available resources, and to identify the factors that are associated with increased efficiency. Based on the objective elicited from decision-makers that the health system should ensure access to care for Canadians when they need it, we measured the efficiency with which regions reduce causes of death that are amenable to healthcare interventions using a linear programming approach (data envelopment analysis). Variations in efficiency were explained in part by public health factors, such as the prevalence of obesity and smoking in the population; in part by characteristics of the population, such as their average income; and in part by managerial factors, such as hospital readmissions.

Family motivation card: An innovative tool for increasing case detection in a resource poor setting

INTRODUCTION

Leprosy is a chronic infectious disease, causing various physical disabilities and deformities. Even today, stigma leads to late detection of new cases. Household contacts are considered a primary focus for the spread of infection.

AIM AND OBJECTIVE

To find new cases among household contacts of leprosy patients by providing a family motivation card (FMC) to each leprosy patient, thereby enabling early diagnosis and treatment leading to a decrease in disease and disability burden in the community.

MATERIALS AND METHODS

100 patients diagnosed with leprosy (both new and old cases) were enrolled in the study. All patients were provided with a family motivation card. The purpose of giving the card was discussed in detail with each patient. New family contacts brought by old patients were examined thoroughly for the presence of leprosy. Digital color photographs were taken of all family contacts. Data analysis was done.

RESULTS

23 new cases of leprosy (15 (65%) MB and eight (35%) PB cases) were detected among family members of primary cases. Most cases belonged to the under 15 years (43.47%) and over 60 years (34.78%) age groups.

CONCLUSION

Adoption of a simple, cheap yet effective strategy such as the FMC could act as a bridge between intensive case-finding approaches, such as the Modified Leprosy Elimination Campaign (MLEC) and voluntary reporting.

Lifestyle modifications supported by regional health nurses lowered insulin resistance, oxidative stress and central blood pressure in subjects with metabolic syndrome

BACKGROUND

This study was attempted to investigate whether lifestyle modifications supported by regional health nurses should improve cardio-metabolic factors--including adipocytokines, oxidative stress, and arterial stiffness--in subjects with metabolic syndrome.

METHODS

Thirty-six subjects with metabolic syndrome were enrolled, 28 of whom completed the 6-month lifestyle modifications (male:female=19:9). Blood and urine test results were examined in relation to metabolic factors before and after 6-month nutritional and physical activity modifications. In addition, oral glucose tolerance tests were performed and arterial stiffness was measured by brachial-ankle pulse wave velocity and radial augmentation index before and after them.

RESULTS

Six-month lifestyle modifications significantly reduced body weight, homeostasis model assessment index, and low-density lipoprotein cholesterol (LDL-C). They significantly attenuated oxidative stress measured by the urinary 8-hydroxy-2-deoxyguanosine/creatinine ratio. They also lowered brachial and central systolic blood pressure. They tended to decrease waist circumferences and the levels of C-reactive protein. However they did not significantly change the levels of adipocytokines, including tumour necrosis factor, soluble tumour necrosis factor receptors, and interleukin 6, or arterial stiffness measured by brachial-ankle pulse wave velocity and radial augmentation index.

CONCLUSIONS

Six-month lifestyle modifications supported by regional health nurses lowered body weight, insulin resistance, LDL-C, oxidative stress, and peripheral and central blood pressure in subjects with metabolic syndrome.

[Analysis of Efficiency of the Standard of Sanatorium Care of Patients With Arterial Hypertension]

Analysis of efficiency of the standard of sanatorium care of patients with arterial hypertension is presented. Rates of arbitrary use of methods of care and their use in accordance with requirements of the standard were compared in patients with diferent results of treatment. It was found that existing standard was insufficiently adequate for application in the work of attending physician. Observance of requirements of the standard was associated with 93 ± 0.8% achievement of positive results. Rates of use of methods of care in groups of patients with positive and negative result of sanatorium stay were significantly different.

From gap analysis to solution and action: the RNAS⁺ model

The overall aim of the Regional Network for Asian Schistosomiasis and other Helminth Zoonoses (RNAS(+)) is to strengthen collaboration between control authorities in the regional, endemic countries. The network has provided critical research input during its 12 years of existence developing gradually from a small forum for information exchange. RNAS(+) now provides advice on regional strategies regularly and contributes to the mobilization of resources with respect to multi-country projects on several parasitic diseases in Southeast Asia, primarily schistosomiasis but also other helminth infections including polyparasitism. To make progress towards these goals, RNAS(+) has focused on platform design and technical standardization aiming at fostering research capacity and the development of networking capacities with easy access to information databases. This administrative body is largely virtual connecting RNAS(+) members via the Internet, providing database and administrative back-up. This strategy, aiming at boosting research on the target diseases, strongly emphasizes ways and means to alleviate the spectre of disease and poverty from the endemic areas.

How to organize for a large-scale openEHR-based Electronic Patient Record

This paper reports from a large-scale openEHR-based EPR project 2012-2016 in the North Norway Regional Health Authority. To be able to support patient pathways across the health region's trusts, there is a need for standardized routines and practices. Therefore, the North Norway Regional Health Authority has since 2011 had an increased regional focus to prepare for this new system. This includes a) centralizing its IT portfolio to one location, b) creating regional work standards for using the EPR system, and c) establishing a Regional Department for functional ICT. There are several challenges connected to changing the focus from working as individual health trusts to work as one region. There are issues of power balance and local influence that will need a careful consideration to ensure a successful outcome.

Introduction of an Advance Care Planning Clinic in a Regional Care Coordination Service

Advance Care Planning is an increasingly important consideration in health care service provision. Barriers to Advance Care Planning including lower prioritization than clinical care, and the complex logistics of completing the documentation have been identified in the literature and clinical practice. The Chronic Care Program within Canberra Hospital and Health Services introduced mobile and outpatient Advance Care Planning Clinics for care coordinated patients with chronic diseases, to address some of these barriers and facilitate end-of-life care discussion amongst this patient group. The implementation of the clinics was evaluated, looking at the practicality of running these clinics within existing resources and patient acceptability. The number of Statement of Choices completed was used as a marker of whether the clinics led to an increase in Advance Care Planning amongst this patient group. The introduction of the clinics received positive feedback from patients and was able to beimplemented without requiring additional external resources. Following introduction of the Advance Care Planning clinics, an increase in the proportion of patients with a completed a Statement of Choices was seen.

Aligning with physicians to regionalize services

When effectively designed and implemented, regionalization allows a health system to coordinate care, eliminate redundancies, reduce costs, optimize resource utilization, and improve outcomes. The preferred model to manage service lines regionally will depend on each facility's capabilities and the willingness of physicians to accept changes in clinical delivery. Health systems can overcome physicians' objections to regionalization by implementing a hospital-physician alignment structure that gives a measure of shared control in the management of the organization.

[MALPROF and the Plan for Prevention]

The Inail data show that in the last years the complaints and acknowledgments of occupational diseases has been increasing, in contrast what happened previously. This growth is the expected and desired emergence of work- related diseases and it's also an alarm bell that the institutions can not ignore. In addition to the data provided by INAIL, the MalProf system gives an important contribution to tlhe understanding of occupational diseases. MalProf is a system for recording and analysis of reported occupational diseases using the source information provided by Service Prevention of ASL. The model used by the Surveillance System MALPROF, by combines the information in a consistent and standardized, assesses the relevance of a causal link between the disease and reports the activity carried out by the worker during his professional history. The two systems (INAIL database and MALPROF), although with some differences have largely confirmed the same data. The past decade has marked the final decline of the working traditional occupational diseases (respiratory toxic substance related diseases and by the accumulation of poisoning, skin, etc....); the hearing loss is still frequent but less important than it was in the past relevance. Tumors and, in particular, musculoskeletal disorders, have been emerging as one of the hidden problems before tumors but, above all, appeared on the scene and the group of musculoskeletal disorders. As indicated by the National Plan for the preventive actions should be directed in several directions: active surveillance, training of the subjects of prevention and other figures, the promotion of the quality of the risk assessment documents.

Do federal and state audits increase compliance with a grant program to improve municipal infrastructure (AUDIT study): study protocol for a randomized controlled trial

BACKGROUND

Poor governance and accountability compromise young democracies' efforts to provide public services critical for human development, including water, sanitation, health, and education. Evidence shows that accountability agencies like superior audit institutions can reduce corruption and waste in federal grant programs financing service infrastructure. However, little is know about their effect on compliance with grant reporting and resource allocation requirements, or about the causal mechanisms. This study protocol for an exploratory randomized controlled trial tests the hypothesis that federal and state audits increase compliance with a federal grant program to improve municipal service infrastructure serving marginalized households.

METHODS/DESIGN

The AUDIT study is a block randomized, controlled, three-arm parallel group exploratory trial. A convenience sample of 5 municipalities in each of 17 states in Mexico (n=85) were block randomized to be audited by federal auditors (n=17), by state auditors (n=17), and a control condition outside the annual program of audits (n=51) in a 1:1:3 ratio. Replicable and verifiable randomization was performed using publicly available lottery numbers. Audited municipalities were included in the national program of audits and received standard audits on their use of federal public service infrastructure grants. Municipalities receiving moderate levels of grant transfers were recruited, as these were outside the auditing sampling frame--and hence audit program--or had negligible probabilities of ever being audited. The primary outcome measures capture compliance with the grant program and markers for the causal mechanisms, including deterrence and information effects. Secondary outcome measure include differences in audit reports across federal and state auditors, and measures like career concerns, political promotions, and political clientelism capturing synergistic effects with municipal accountability systems. The survey firm and research assistants assessing outcomes were blind to treatment status.

DISCUSSION

This study will improve our understanding of local accountability systems for public service delivery in the 17 states under study, and may have downstream policy implications. The study design also demonstrates the use of verifiable and replicable randomization, and of sequentially partitioned hypotheses to reduce the Type I error rate in multiple hypothesis tests.

TRIAL REGISTRATION

Controlled-trials.com Identifier ISRCTN22381841: Date registered 02/11/2012.

Federalism and health policy: the intergovernmental committees in Brazil

OBJECTIVE

To analyze the dynamics of operation of the Bipartite Committees in health care in the Brazilian states.

METHODS

The research included visits to 24 states, direct observation, document analysis, and performance of semi-structured interviews with state and local leaders. The characterization of each committee was performed between 2007 and 2010, and four dimensions were considered: (i) level of institutionality, classified as advanced, intermediate, or incipient; (ii) agenda of intergovernmental negotiations, classified as diversified/restricted, adapted/not adapted to the reality of each state, and shared/unshared between the state and municipalities; (iii) political processes, considering the character and scope of intergovernmental relations; and (iv) capacity of operation, assessed as high, moderate, or low.

RESULTS

Ten committees had advanced level of institutionality. The agenda of the negotiations was diversified in all states, and most of them were adapted to the state reality. However, one-third of the committees showed power inequalities between the government levels. Cooperative and interactive intergovernmental relations predominated in 54.0% of the states. The level of institutionality, scope of negotiations, and political processes influenced Bipartite Committees' ability to formulate policies and coordinate health care at the federal level. Bipartite Committees with a high capacity of operation predominated in the South and Southeast regions, while those with a low capacity of operations predominated in the North and Northeast.

CONCLUSIONS

The regional differences in operation among Bipartite Interagency Committees suggest the influence of historical-structural variables (socioeconomic development, geographic barriers, characteristics of the health care system) in their capacity of intergovernmental health care management. However, structural problems can be overcome in some states through institutional and political changes. The creation of federal investments, varied by regions and states, is critical in overcoming the structural inequalities that affect political institutions. The operation of Bipartite Committees is a step forward; however, strengthening their ability to coordinate health care is crucial in the regional organization of the health care system in the Brazilian states.