فهرست مطالب

Health Policy and Management - Volume:7 Issue:12, 2018
  • Volume:7 Issue:12, 2018
  • تاریخ انتشار: 1397/08/27
  • تعداد عناوین: 15
  • Zakaria Belrhiti *, Ariadna Nebot Geralt, Bruno Marchal Pages 1073-1084
    Nowadays, health systems are generally acknowledged to be complex social systems. Consequently, scholars, academics, practitioners, and policy-makers are exploring how to adopt a complexity perspective in health policy and system research. While leadership and complexity has been studied extensively outside health, the implications of complexity theories for the study of leadership in healthcare have received limited attention. We carried out a scoping review of complex leadership (CL) in healthcare to investigate how CL in healthcare has been defined, theorised and conceptualised and to explore how ‘CL’ has been applied in healthcare settings.
    We followed the methodological steps proposed by (Arksey and O’Malley, 2005): (1) specifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating and summarizing the findings, and (6) reporting the results. We searched using Medline, Psychinfo, Wiley online library, and Google Scholar. Our inclusion criteria were: publication type (peer reviewed articles, theses, and book chapters); phenomenon of interest: complex leadership; context: healthcare and period of publication: between 2000 and 2016.
    Our search and selection resulted in 37 papers (16 conceptual papers, 14 empirical studies and 7 advocacy papers). We note that empirical studies on CL are few and almost all research reported by these papers was carried out in the North (mainly in USA and UK). We found that there is some variation in definitions of CL. Furthermore, the research papers adopt mostly an explorative or explanatory approach and do not focus on assessing effectiveness of CL approaches. Finally, we found that the majority of researchers seem to adhere to the mathematical complexity perspective.
    Complexity concepts derived from natural sciences may not automatically fit management of health services. Further research into how social complexity theories may offer researchers useful grounds to empirically test CL theories in health settings is warranted. Specific attention should be paid to the multi-layered nature of leadership.
    Keywords: Complex Leadership, Complexity, Leadership, Healthcare, Scoping Review
  • Graeme Kohler, Timothy Holland, Ashley Sharpe, Mandi Irwin, Tara Sampalli *, Kolten MacDonell, Natalie Kidd, Lynn Edwards, Rick Gibson, Amy Legate, Ruth Ampi Kanakam Pages 1085-1089
    Refugees tend to have greater vulnerability compared to the general population reporting greater need for physical, emotional, or dental problems compared to the general population. Despite the importance of creating strong primary care supports for these patients, it has been demonstrated that there is a significant gap in accessing primary care providers who are willing to accept the refugee population. These have resulted in bottlenecks in the transition or bridge clinics and have left patients orphaned without a primary care provider. This in turn results in higher use of emergency service and other unnecessary costs to the healthcare system. Currently there are few studies that have explored these challenges from primary care provider perspectives and very few to none from patient perspectives. A novel collaborative implementation initiative in primary healthcare (PHC) is seeking to improve primary medical care for the refugee population by creating a globally recommended transition or beacon clinic to support care needs of new arrivals and transitions to primary care providers. We discuss the innovative elements of the clinic model in this paper.
    Keywords: Refugees, Primary Healthcare, Beacon Clinic, Care Transitions, Nova Scotia
  • Zahra Karimian, Mehrnaz Kheirandish *, Naghmeh Javidnikou, Gholamreza Asghari, Fariba Ahmadizar, Rassoul Dinarvand Pages 1090-1096
    Medication errors are the second most common cause of adverse patient safety incidents and the single most common preventable cause of adverse events in medical practice. Given the high human fatalities and financial burden of medication errors for healthcare systems worldwide, reducing their occurrence is a global priority. Therefore, appropriate policies to reduce medication errors, using national data and valid statistics are required. The primary objective of this study was to provide a national ‘characteristic profile’ of medication error-associated adverse drug reactions (ADRs), which are also known as preventable ADRs (pADRs). A retrospective study of pADR reports submitted to the national pharmacovigilance center (PCV) within Iran’s Food and Drug Administration was conducted over a 2-year period (2015-2017). Preventability Method (P-Method), which is a standardized tool developed and recommended by the World Health Organization (WHO), was used for preventability assessment. The results of the analyses revealed that while the number of pADRs increased from year one to two (601 to 630), their proportion out of all ADRs per year decreased (7.32% to 6.44%). The percentage of pADRs was higher in females (61.01%) and adults (83.27%), and the highest number of reports were received by nurses (71.57%). Having ‘a documented hypersensitivity to an administered drug or drug class’ was the most common preventable factor in both years (61.23% and 54.29% respectively), and ‘anti-infectives used systemically’ were the medication class which primarily contributed to both serious (53.29%) and non-serious pADRs (39.19%). The specific characteristics of medication errors associated with ADRs from this study, especially the preventable criteria which led to their occurrence, can help devise more specific preventative policies.
    Keywords: Medication Errors, Preventable Adverse Drug Reactions, P-Method, Preventability, Pharmacovigilance, Patient Safety
  • Colin Baynes *, Dominic Mboya, Samuel Likasi, Doroth Maganga, Senga Pemba, Jitihada Baraka, Kate Ramsey, Helen Semu Pages 1097-1109
    Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community which involves training and supporting CHW to assess, classify and treat sick children at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia and diarrhea could be implemented by CHW in that country.
    This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors.
    In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics.
    CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems.
    Keywords: Child Mortality, Community Case Management, Community Health Workers, Sick Child-Care, Observational Study, Tanzania
  • Karen Van der Veken *, Fahdi Dkhimi, Bruno Marchal, Peter Decat Pages 1110-1119
    A free obstetric care policy (FOCP) has been implemented in Morocco in 2008 in order to further decrease maternal mortality.
    Through in-depth interviews we explored the perceptions of health professionals in public Moroccan hospitals with regard to fee exemption policies. We tried to understand what drives health professionals to ignore, modify or apply a health policy as formulated.
    Respondents express significant influences of such policies on their work environment (higher workload and scarcity of resources) and on the patient/provider relationship, both of which may cause a negative effect on health workers’ motivation. A mix of motivational determinants incites health workers in their turn to influence policy implementation.
    Understanding the motivational determinants of health workers may optimize policy implementation at the point of service delivery.
    Keywords: Health Workers’ Motivation, Morocco, Exemption Mechanisms, Healthcare Reform, Policy Implementation
  • Suzanne Ruwaard *, Rudy C M H Douven Pages 1120-1129
    Transparency in quality of care is an increasingly important issue in healthcare. In many international healthcare systems, transparency in quality is crucial for health insurers when purchasing care on behalf of their consumers, for providers to improve the quality of care (if necessary), and for consumers to choose their provider in case treatment is needed. Conscious consumer choices incentivize healthcare providers to deliver better quality of care. This paper studies the impact of quality on patient volume and hospital choice, and more specifically whether high quality providers are able to attract more patients.
    The dataset covers the period 2006-2011 and includes all patients who underwent a cataract treatment in the Netherlands. We first estimate the impact of quality on volume using a simple ordinary least squares (OLS), second we use a mixed logit to determine how patients make trade-offs between quality, distance and waiting time in provider choice.
    At the aggregate-level we find that, a one-point quality increase, on a scale of one to a hundred, raises patient volume for the average hospital by 2-4 percent. This effect is mainly driven by the hospital with the highest quality score: the effect halves after excluding this hospital from the dataset. Also at the individual-level, all else being equal, patients have a stronger preference for the hospital with the highest quality score, and appear indifferent between the remaining hospitals.
    Our results suggest that the top performing hospital is able to attract significantly more patients than the remaining hospitals. We find some evidence that a small share of consumers may respond to quality differences, thereby contributing to incentives for providers to invest in quality and for insurers to take quality into account in the purchasing strategy.
    Keywords: Hospital Demand, Patient Choice, Quality Indicators, Quality Competition
  • Rose N. Chesoli, Roseanne C. Schuster, Stephen Okelo, Moshood O. Omotayo * Pages 1130-1137
    Primary healthcare facility managers (PHFMs) occupy a unique position in the primary healthcare system, as the only cadre combining frontline clinical activities with managerial responsibilities. Often serving as ‘street-level bureaucrats,’ their perspectives can provide contextually relevant information about interventions for strengthening primary healthcare delivery, yet such perspectives are under-represented in the literature on primary healthcare strengthening. Our objective in this study was to explore perspectives of PHFMs in western Kenya regarding how to leverage human resource factors to improve immunization programs, in order to draw lessons for strengthening of primary healthcare delivery.
    We employed a sequential mixed methods approach. We conducted in-depth interviews with key informants in Kakamega County. Emergent themes guided questionnaire development for a cross-sectional survey. We randomly selected 94 facility managers for the survey which included questions about workload, effects of workload on immunization program, and appropriate measures to address workload effects. Participants provided self-assessment of their general motivation at work, their specific motivation to ensure that all children in their catchment areas were fully immunized, and recommendations to improve motivation. Participants were asked about frequency of supervisory visits, supervisor activities during those visits, and how to improve supervision.
    The most frequently reported consequences of high workload were reduced accuracy of vaccination records (47%) and poor client counseling (47%). Hiring more clinical staff was identified as an effective remedy to high workload (69%). Few respondents (20%) felt highly motivated to ensure full immunization coverage and only 13% reported being very motivated to execute their role as a health worker generally. Increasing frequency of supervisory visits and acting on the feedback received during those visits were mostly perceived as important measures to improve program effectiveness.
    Besides increasing the number of staff providing clinical care, PHFMs endorsed introducing some financial incentives contingent on specified targets and making supervisory visits meaningful with action on feedback as strategies to increase program effectiveness in primary healthcare facilities in Kenya. Targeting health worker motivation and promoting supportive supervision may reduce missed opportunities and poor client counseling in primary healthcare facilities in Kenya.
    Keywords: Kenya, Immunization, Primary Healthcare, Child Health, Health Systems
  • Ajit Sood, Vandana Midha, Shivalingappa S. Halli, Vikram Narang *, Ramit Mahajan, Varun Mehta, Kirandeep Kaur, Vijay Surlikar, Subodh Kanchi, Dharmatma Singh Pages 1138-1144
    Financial constraints, social taboos and beliefs in alternative medicine are common reasons for delaying or not considering treatment for hepatitis C in India. The present study was planned to analyze the impact of non-banking interest free loan facility in patients affected with hepatitis C virus (HCV) in North India.
    This one year observational, retrospective study was conducted in Department of Gastroenterology (January 2012-December 2013), Dayanand Medical College and Hospital Ludhiana, to evaluate the impact of program titled “Sambhav” (which provided non-banking financial assistance and counselor services) on treatment initiation and therapeutic compliance in HCV patients. Data of fully evaluated patients with chronic hepatitis, and/or cirrhosis due to HCV infection who were treated with Peginterferon alfa and ribavirin (RBV) combination during this duration (2012-2013) was collected from patient medical records and analyzed. In the year 2012, eligible patients who were offered antiviral treatment paid for treatment themselves, while in 2013, ‘Sambhav’ program was launched and this provided interest free financing by non-banking financial company (NBFC) for the treatment of HCV in addition to free counselor services for disease management. The treatment initiation and compliance rates were compared between the patients (n = 585) enrolled in 2013 who were offered ‘Sambhav’ assistance and those enrolled in 2012 (n = 628) when ‘Sambhav’ was not available.
    Introduction of Sambhav program improved the rates of treatment initiation (59% in 2013 vs. 51% in 2012, P = .004). Of the 585 eligible patients offered ‘Sambhav’ assistance in 2013, 233 patients (39.8%) applied but 106/233 (45.4%) received assistance. Antiviral therapy was started in 93/106 (87.7%) of these patients, while only 52 (42.5%) of 127 patients whose applications were rejected underwent treatment. Compliance to antiviral therapy also improved with the introduction of ‘Sambhav’ program (87.7% vs. 74.1%, P = .001).
    ‘Sambhav’ program had significant impact on the initiation of antiviral therapy by overcoming the financial hurdles. The free counselor services helped to mitigate social taboos and imparted adequate awareness about the disease to the patients. Initiatives like ‘Sambhav’ can be utilized for improving healthcare services in developing countries, especially for chronic diseases.
    Keywords: Sambhav Program, Hepatitis C, Pegylated Interferon Gamma, Treatment Access, India
  • Understanding Contextual Factors in Cost, Quality and Priority Setting Decisions in Health; Comment on / “Contextual Factors Influencing Cost and Quality Decisions in Health and Care: A Structured Evidence Review and Narrative Synthesis”
    Stuart Peacock *, Colene Bentley Pages 1145-1147
    There is growing recognition in the academic literature that critical decisions concerning resource allocation and resource management in health and care are influenced by a range of contextual factors. In their paper in this journal, Williams et al define these ‘decisions of value’ as being characterized by a significant and demonstrable impact on quality and resources in health and care. ‘Decisions of value’ are key functions of health and care organizations, yet relatively little is known about how contextual factors (such as different sources and types of evidence used, organizational context and decision-making structures, and the wider interests of patients, the public and politicians) influence those decisions. In this commentary we offer some reflections on our international experiences in capacity building, developing and implementing priority setting and resource allocation (PSRA) mechanisms in the health and care sectors in a range of low-, middle-, and high-income countries. We focus on the role of organizational culture, the relationship to government including political and regulatory environments, and the potential for patient and public engagement in PSRA mechanisms.
    Keywords: Healthcare Decision-Making, Cost, Quality, Health Management, Priority Setting
  • Ann Mongoven * Pages 1148-1150
    Swiss-CHAT’s playful approach to public rationing can be considered in terms of deliberative process design as well as in terms of health policy. The process’ forced negotiation of trade-offs exposed unexamined driving questions, and challenged prevalent presumptions about health care demand and about conditions of public reasoning that enable transparent rationing. While the experiment provided grounds for optimism that public deliberation can contribute to the design of fair insurance service-packages, it also left unanswered questions. What are the ethical and policy implications of non-consensuses? What is the presumed relationship between process and justice of outcome?
    Keywords: Deliberation, Healthcare Rationing, Health Policy, Health Insurance, Tradeoff Negotiation
  • Gregory L. Peck *, Joseph S. Hanna Pages 1151-1154
    In 2015, the Lancet Commission on Global Surgery (LCoGS) working groups developed a National Surgical, Obstetric, and Anesthesia Plan (NSOAP) framework to guide national surgical system development globally predicated on six data points (indicators) which can assess surgical systems. Zambia as well as other subSaharan Africa (SSA) countries have forged ahead in designing and implementing interventions based on LCoGS indicators collected to inform NSOAP. Concurrently, the Zambian team and others have recognized the need for rigorous scientific inquiry to assess and iteratively improve upon the NSOAP process and outputs. Based on the Zambian experience, as well as that of ours in Colombia, we have identified “core principles” through convergent works which inform a scientific framework through which NSOAP can be evaluated. We propose that when contextualized, participatory action research (PAR) and dissemination and implementation science are methodologies upon which a robust framework can be developed to achieving objective and iterative NSOAP evaluation, and ultimately universal health coverage as envisioned by the World Health Organization (WHO).
    Keywords: Surgery Systems Science, Participatory Action Research, Dissemination, Implementation Science, Colombia, GSRU
  • Elvira Beracochea* Pages 1155-1157
    This article studies how six key aid effectiveness principles for “Hitting the bull’s eye” can bring about the scale up of maternal and newborn health (MNH) interventions. These key principles are based on accepted international agreements such as the Paris Declaration on Aid Effectiveness. The results indicate that the six principles should be a guide for recipient countries to take ownership of the development process and work with donors to plan effective coordination structures. Countries that take ownership will be able to work with donors and implementers to not only test new interventions that address pressing challenges to deliver quality MNH care but also include the successful knowledge transfer and handover of these interventions, the effective integration of the new intervention as part of the country’s health system and a costed scale-up plan. The article could have been strengthened with clear and actionable recommendations for the three countries to improve their ownership of donor-funded assistance, but it showed that there is need to change how aid is delivered and that embracing and applying these principles will help countries take ownership of MNH programs and lead the dialog and effective scale up with those involved. The authors should be commended on taking the lead in the field of aid effectiveness, and encouraged to conduct quantitative and further qualitative measurements of the application of their findings in the three counties included in the study.
    Keywords: Aid Effectiveness, Sustainability, Universal Coverage, Health Systems
  • Roberto Nu?o, Solin?s * Pages 1158-1160
    Worldwide most health systems are facing a series of common challenges characterized by the increasing burden of chronic diseases and multimorbidity, and the accelerated pace of biomedical and technological innovations, on the other side. There is a growing recognition that many changes are needed at the macro, meso and micro management levels to tackle these challenges. Therefore, knowing if healthcare organizations are ready for change is a key issue, as high organizational readiness for change (ORC) has been positively related with higher organizational effort and staff motivation for overcoming barriers and setbacks in change endeavours. In practice, readiness for change is not commonly measured and there is a need of adequate metrics for it. In this commentary, a new tool for measuring readiness change is reviewed, the OR4KT. It has been developed based on a solid theoretical background and with the involvement of experts and potential users in the design and it has been tested and validated in three languages and in different organizational settings. Although its generalizability needs to be further tested, it seems to be a promising and useful tool to diagnose if organizations are ready to implement evidence-informed changes. A broader recognition of the key role that the science of implementation can play in the success of much needed transformations in healthcare provides a good opportunity for the dissemination of the OR4KT.
    Keywords: Readiness for Change, Measure Development, Implementation, Change Management
  • Ditte Heering Holt* Pages 1161-1164
    This commentary discusses the interesting and surprising findings by Hagen and colleagues, focusing on the role of the public health coordinator as a Health in All Policies (HiAP) tool. The original article finds a negative association between the employment of public health coordinators in Norwegian municipalities and consideration of a fair distribution of social and economic resources between social groups in local policy-making and planning. The commentary contemplates whether this surprising negative association should be interpreted as a failure of implementation, as suggested by the authors, or whether it might be the theory of change that has failed. On this basis, it is suggested that the very notion of HiAP could be flawed by the assumption that health should function as an overarching aim across government sectors. Potentially, the social determinants of health (SDH) might be more efficiently addressed by means of sectoral action by the corresponding sectors, emphasizing equity rather than health.
    Keywords: HiAP, Health Equity, Municipalities, SDH, Theory of Change
  • Emmanouil K. Symvoulakis, Adelais Markaki *, Dimitrios Anyfantakis, George Rachiotis Pages 1165-1166