Cinism, differentiated federal autonomy and sustainability of health services.

BackgroundHumanitarian health assistance programmes have expanded from temporary approaches addressing short-term needs to providing long-term interventions in emergency settings. Measuring sustainability of humanitarian health services is important towards improving the quality of health services in refugee settings.ObjectiveTo explore the sustainability of health services following the repatriation of refugees from the west Nile districts of Arua, Adjumani and Moyo.MethodsThis was a qualitative comparative case study conducted in three west Nile refugee-hosting districts of Arua, Adjumani, and Moyo. In-depth interviews were conducted with 28 purposefully selected respondents in each of the three districts. Respondents included health workers and managers, district civic leaders, planners, chief administrative officers, district health officers, project staff of aid agencies, refugee health focal persons and community development officers.ResultsThe study shows that in terms of organization capacity, the District Health Teams provided health services to both refugee and host communities with minimal support from aid agencies. Health services were available in most former refugee hosting areas in Adjumani, Arua and Moyo districts. However, there were several disruptions notably reduction and inadequate services due to shortage of drugs and essential supplies, lack of health workers, and closure or relocation of health facilities in around former settlements. To minimize disruptions the district health office reorganized health services. In restructuring health services, the district local governments closed or upgraded health facilities to address reduced capacity and catchment population. Health workers employed by aid agencies were recruited into government services while others who were deemed excess or unqualified were laid off. Equipment and machinery including machines and vehicles were transferred to the district health office in specific health facilities. Funding for health services was mainly provided by the Government of Uganda through the Primary Health Care Grant. Aid agencies, however, continued to provide minimal support health services for refugees who remained in Adjumani district.ConclusionOur study showed that while humanitarian health services are not designed for sustainability, several interventions continued at the end of the refugee emergency in the three districts. The embeddedness of the refugee health services in the district health systems ensured health services continued through public service delivery structures. It is important to strengthen the capacity of the local service delivery structures and ensure health assistance programmes are integrated into local health systems to promote sustainability.

One of the most important elements of health services management is to ensure the sustainability of services. In this context, the economic sustainability of health services and the development of policies for the financing of health services come to the fore. The aim of this research is to identify current research topics in economics and financing policies in health management. Within the scope of the research, open access international articles published in the last five years were searched by searching the keywords "health management" or "healthcare management" or "health care management" or "health administration" or "health care administration" or "healtcare administration" AND "economy" or "economics" or "finance" or "financing" AND "policy" or "politics" in the subject title on the Web Of Science database, and 58 articles that were found to be about economic and financing policies in the field of health management were subjected to content analysis. As a result of the research, it was determined that researches were conducted on "Policy development in health" (16) and "Financing in health" (14) and on the themes of "Economic effectiveness in health services" (11) and "Ensuring Financial Sustainability of Health Services" (8). In the analysed articles, while most of the evaluations are made on the basis of documents, studies on bureaucrats and health administrators come to the forefront in general. Health financing performance is important in terms of providing sustainable resources for health services. The prominence of financing studies for health services as a result of this research supports this situation. Likewise, emphasising the necessity of developing health policies to ensure inclusive service provision in health and to prevent inequality in health reveals the importance of this research.

Reflections on the term "sustainability' and its implications for health development are a daily challenge for all who work in the field of international health, be it in research or in direct service provision. An enquiry into concepts and strategies of sustainable health development entails three key issues: sustainability, health and partnership. They are briefly reviewed and possible principles to guide the health development process and assure it for future generations are proposed for discussion. The keyword "sustainability' far too often is a buzzword in all aspects of development co-operation. Any efforts put into development processes not only aim at obtaining results within a short period, but ought to be relevant and beneficial for generations to come. Sustainable development means ". . . to ensure that development meets the needs of the present without compromising the ability of future generations to meet their own needs . . . (Brundtland Commission 1987). This definition still remains to be fully and coherently put into action in the health sector. While a generally agreed definition of sustainability for health development is easily established, an operational definition for a given social, cultural, economic and political setting is far more difficult to formulate. One major problem that prevents effective implementation of sustainability is the lack of a clear understanding among most actors in health development of what needs to be sustained. Is sustainability mainly seen as a social, ecological or economic goal or as a combination of some or all of these dimensions? Neglecting careful discussion on what a comprehensive understanding of sustainability means for a given context inevitably affects sustainable development. Moreover, sustainable development is not a firm state of equilibrium or harmony, but a process of change in which investments, resources and institutional arrangements must match present as well as future needs. This is of particular importance for the health sector, as changes in health development issues and health sector reforms are frequent and substantial: decentralization and health district management, cost-sharing by the population concerned, health insurance schemes, priority-setting based on the assessment of disease burden (World Bank 1993), optimizing the public-private mix in services offered, sectorial funding policies, etc. are key concepts currently being discussed and implemented in the health sectors of many countries. However, so far they have hardly been scrutinised in the light of our definition of sustainability, where provisions for the future and equality are underlying features. Considering this situation, accomplishing sustainability in concrete health development activities implies focusing on the processes of decision-making based on the views and perceptions of all actors and beneficiaries. At the operational level we are therefore less interested in being guided by outcome or social and economic impact indicators such as growth, fertility, morbidity and mortality rates or gross regional or national domestic products. Accepting this view further implies substantial changes in how we approach planning in the health sector. It means a move from the prevailing epidemiological planning concepts towards problem-based, managerial planning (Lorenz et. 1995) Understanding health and well-being is fundamental for any development process that aims at sustainability. We have readily adopted the Alma Ata definition of health as "a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity . . .' (WHO 1978). In reality, however, health still tends to be seen as absence of disease or as an exclusively biomedical concept. If we are truly committed to assisting and ensuring sustainable health development, we need to adopt the comprehensive definition of health and see it as a positive quality that one can put at risk, maintain or enhance. This also prevents "medicalization' of health service provision and promotion and the continued existence of unhelpful categories such as (i) preventive and curative medicine, (ii) traditional and "modern' medicine, or (iii) clinical and social and preventive medicine as antagonistic dichotomies that affect successful sustainable developments. At this stage it should be noted that many bi- and multilateral governmental and nongovernmental agencies have recently revised and readjusted their health development policies and now promote a holistic approach to health. Weaknesses relate to the operationalization of the holistic approach in a given setting and, thus, to the approach used in the planning of health service provision. Health seen as a positive quality means considering measured and perceived risks, understanding the needs and demands of the population concerned as well as an analysis of the health systems in place. This situation calls for a problem-based planning approach (Lorenz et al. 1995) which includes the voices of the communities concerned. Moreover, it shows us that equality, one of the underlying principles of sustainability, means "social equality', i.e. equity, at the operational level. Understanding health and health development in these terms reveals that only an interdisciplinary approach will lead us towards the transdisciplinary solution of securing sustainable health development. Sustainability in health development cannot be discussed without addressing the crucial driving force of the process ? the nature and dynamics of partnership. We have all moved from the concept and strategies of aid towards committed co-operation. This move in conceptual and strategic thinking, also at governmental and international agency level, was based on the significant expertise of nongovernmental organizations, whose experience in participatory priority-setting by involving actors and beneficiaries and by respecting local needs and demands motivated this change. Partnership became the cornerstone of joint responsibility and the driving force for joint action. However, we often forget how much the nature and pattern of partnership needs to be tailored to the changing economic climate and socio-political anatomy of a country or a region. We have to accept and tackle the challenges that partnerships and institutional change face at a time when many new concepts enter the discussion of health reform processes. Unfortunately, not all actors in health development are sensitive to these crucial issues, which may be partly due to their less comprehensive understanding of sustainability and health. A further point related to the latter discussion, is the nature of interactions between providers and users of health services. Traditionally, providers offer a service and users consume the "products' offered. A holistic understanding of health and health services no longer supports this hierarchical scheme but calls for a partnership in which users are also providers and vice versa. Clearly, all partners need to engage in a learning process through which problems and potential solutions are identified and related to concepts and possibilities at national and international level. This may appear visionary or highly unrealistic. However, we already have a wealth of convincing experience from participatory approaches (originally called "recherche-action-formation', RAF) in the field of agriculture, urbanization and health generated by the nongovernment organization ENDA-Graf-Sahel in West Africa over many years (ENDA 1993, 1994). It appears that the actors in health development cannot be satisfied with a partnership once it is created, but that its nature and dynamics may require readjustment or even new paradigms. At least we are challenged to review our partnerships. More concretely, classical formats of co-operation such as "the project' or "the programme' will require critical assessment against the background of the need for growing networks of south-south exchange, mutual assistance and collaboration. The RAF approach offers attractive options and concrete steps towards partnerships for sustainable development at individual and population level, i.e. partnerships of solidarity that combine and respect the principles of equity and caring for future generations. Based on this short review of the three key factors, the following theoretical and practical guiding principles towards sustainable health development are offered for discussion: • Sustainability can be achieved and lived provided we introduce equity and caring for the future in our health service, health promotion and research activities at individual, community and institutional level. • Health and well-being can be assured if we consider health as a positive quality in any socio-cultural and socio-economic setting where we are engaged in health development and research activities. • Firm and committed partnerships are created and maintained provided they incorporate mutual exchange of expertise and experience and joint analysis of problems and potentials for solutions at the individual, community and institutional level.

Fragile states and developing countries increasingly contract out health services to non-state providers (NSPs) (such as non-governmental organisations, voluntary sector and private sector). The paper identifies ethical issues when contracts...

Background Social care provision is vital for ensuring the health of ageing and vulnerable populations. The UK relies on informal care for 50% of care provision, meaning that social care policies have significant implications for health services sustainability in this context. We present an agent-based simulation of UK informal care provision, demonstrating how this framework captures troubling trends and inequalities in social care. Methods We constructed an agent-based model in Python that simulates individual human agents in a virtual UK from the year 1860 to 2022. Population dynamics are driven by UK birth rates and mortality rates. Agents can form partnerships, reproduce, migrate domestically for work or other purposes, change jobs, and provide social care. Care decisions are taken based on employment status, salary, age, health status, geographical location, and their relationship to those in need of care. Simulated agents participate in a detailed economy, and are members of different socioeconomic status groups depending on their income. Output files track agents’ socioeconomic status, social mobility, informal care provision, and payment for formal care services. Simulation output includes individual-level agent statistics and population-level analyses of care provision by age, sex, socioeconomic status, and employment status. Simulation results were calibrated against 2011 UK Census data for key population dynamics measures. Results Simulation results in the year 2022 show significant inequalities in social care need and provision by gender and SES group. Agents in the lowest SES quintile (Group I) show a mean unmet care need of 19 hours/week, as compared to 12.5/week in in the highest (Group V). Carers in Group I supply an average 8.6 hours/week of care, compared to 3.6 hours/week in Group V. Thus, agents in Group I not only make a lower wage, they also lose more hours of work to care provision, and need more care themselves. In addition, female agents provide 1.9 times more informal care than males, while receiving lower average wages. Finally, the simulation shows a trend of growth in unmet care need from 1.17 hours per capita in 1976 to 2.38 by 2022. Conclusion This work demonstrates that a well-constructed agent-based simulation can provide a platform for investigating the influence of economic and social factors on social care provision. This framework thus provides a means to develop and test new social care policies which better account for the complexities and challenges facing informal carers across the country, and in turn better protect health services sustainability.

Introduction: The development of telenursing is very rapid in various countries. The practice of telenursing supports nurses in providing care to patients without requiring nurses to meet directly with patients so as to reduce the spread of COVID-19 from nurses to patients, or vice versa. Telenursing is an alternative in providing health and long-distance services during the COVID-19 pandemic era. This literature review aims to determine the benefits of telenursing in health services in the COVID-19 pandemic era.
 Methods: The method used is a literature study analyzed from several journals. related to the topic taken. Journals were searched through ProQuest, EBSCO and google scholar with keywords telenursing, COVID-19 and health services.
 Results: The results of 11 articles show the benefits of telenursing in health services, including preventing the transmission of COVID-19 infection, media and health counseling, analysis costs and sustainable health services.
 Conclusion: Telenursing is one of the answers in overcoming the changes that occur to meet the needs of health access in the community. The application of telenursing during the COVID-19 pandemic provides various benefits for both patients and health workers. Telenursing has positive implications in preventing the transmission of COVID-19, as a medium for counseling and health promotion, minimizing medical costs and as a continuity of care.

1986–2016: from Ottawa to Vienna

BackgroundIdentifying occupational health hazards among Registered Nurses (RNs) and other health personnel and implementing effective preventive measures are crucial to the long-term sustainability of health services. The objectives of this study were (1) to assess the 12-month prevalence rates of exposure to workplace aggression, including physical violence, threats of violence, sexual harassment, and bullying; (2) to identify whether the perpetrators were colleagues, managers, subordinates, or patients and their relatives; (3) to determine whether previous exposure to these hazards was associated with RNs’ current turnover intention; and (4) to frame workplace aggression from an occupational health and safety perspective.MethodsThe third version of the Copenhagen Psychosocial Questionnaire (COPSOQ III) was used to assess RNs’ exposure to workplace aggression and turnover intention. A national sample of 8,800 RNs in Norway, representative of the entire population of registered nurses in terms of gender and geography, was analysed. Binary and ordinal logistic regression analyses were conducted, and odds for exposure and intention to leave are presented, with and without controls for RNs’ gender, age, and the type of health service they work in.ResultsThe 12-month prevalence rates for exposure were 17.0% for physical violence, 32.5% for threats of violence, 12.6% for sexual harassment, and 10.5% for bullying. In total, 42.6% of the RNs had experienced at least one of these types of exposure during the past 12 months, and exposure to more than one of these hazards was common. Most perpetrators who committed physical acts and sexual harassment were patients, while bullying was usually committed by colleagues. There was a strong statistical association between exposure to all types of workplace aggression and RNs’ intention to leave. The strongest association was for bullying, which greatly increased the odds of looking for work elsewhere.ConclusionsEfforts to prevent exposure to workplace aggression should be emphasised to retain health personnel and to secure the supply of skilled healthcare workers. The results indicate a need for improvements. To ensure the sustainability of health services, labour and health authorities should join forces to develop effective workplace measures to strengthen prevention, mitigation, and preparedness regarding incidents of workplace aggression in health services and the response and recovery regarding incidents that could not be prevented.

IntroductionThe elevated costs with biologic products threaten the sustainability of health services, and, therefore, the access to these medicines in the perspectives of user, health professional, health manager and system. The entry of biosimilar products in the market could be an option to subsidize the search for solutions to those problems.MethodsWe conducted a rapid review using the databases Medline (via PubMed), EMBASE, Cochrane Library and CRD. The eligibility criteria were HTAs, systematic reviews and cross-sectional studies.ResultsLiterature search retrieved 640 registries and, after duplicate removal, screening of titles and abstracts and full text reading, nine cross-sectional studies were selected. From a user's point of view, the following barriers were identified: lack of knowledge about the medicine, distance between the place of living and the health service (especially in the rural area), long waiting periods for service, passivity in regard to treatment. From a health professional's point of view the barriers were: acceptability of the expert in regard to treatment, interchangeability and substitution, the perception of lack of data showing efficacy and safety. Finally, from the payer's (or health manager) point of view, the barriers were: high cost of medicine, problems with reimbursement and bureaucracy. We did not retrieve any barriers from the health system's perspective from the selected studies.ConclusionsThe entry of biosimilar medicines in the market can induce competition and, therefore, reduce prices of biologic treatments. It is necessary to search for potential solutions to the access barriers identified in this rapid review.

Sustainable health service delivery plays a vital role for the development of countries. Sustainability of health services is associated with many factors. One of these factors is energy costs. Hospitals are buildings with high energy consumption. Accordingly, it is important to reduce energy costs in hospitals. For this purpose, it is necessary to determine the factors affecting the costs. In this way, improvements can be made without incurring very high costs. However, there are limited studies on determining the factors affecting energy costs in hospitals. Therefore, the aim of this study is to identify the important factors affecting energy costs in hospitals. In this context, the research question of the study is to determine which strategies will be implemented to reduce energy costs in hospitals. As a result of the literature review, the criteria affecting these costs are determined. The identified criteria are weighted by intuitionistic fuzzy DEMATEL method. The analysis results show that the most appropriate strategy is to reduce energy dependency with renewable energy alternatives (w=0,143). The criterion of reducing energy costs through government incentives also has an important place (w=0,136). The least influential factor is distributing informative documents on energy saving to patients/caregivers (w=0,9). Therefore, to manage energy costs in hospitals, it is appropriate to turn to renewable energy alternatives. Furthermore, government incentives such as tax exemptions are an important strategy. Establishing a good monitoring mechanism by the management would be appropriate to reduce costs.

Attempts to decentralize Health Information Systems (HISs) are ongoing in various developing countries as a part of health sector reforms. Donor communities in particular have often insisted on decentralization of health care systems as a mechanism to encourage quality and sustainability of health services and availability of timely resources at local levels by removing layers of bureaucracy. The decentralization of HISs along with the system of health care delivery is emphasized to support the efficiency and management of health services by incorporating local use of information in decision making and planning. However, these goals of decentralization are not easily achieved because of the complexity of the institutional context in which the decentralization is being carried out. Drawing from institutional theory, we study the process of decentralizing HIS in Tanzania. We identify three key sets of institutional influences on the HIS originating from the political administrative, health management, and health service delivery systems. Through an ongoing empirical analysis, we identify the gaps between the formal rules that govern the reform process and the informal constraints that operate on the ground and “keep the show going.” The existence of these gaps contributes to the ineffective results obtained through the reform process. The need for both vertical and horizontal alignment is emphasized as an approach to addressing these gaps in the future. © 2007 Wiley Periodicals, Inc.

Background: Community empowerment is the process and outcome where community itself is able to identify, prioritize health problems and address them. It has been considered as the key strategy for scalability and sustainability of health services.
 Objectives: To explore the status of community empowerment in health in rural areas in West Bengal, India and the interplay of different stakeholders.
 Methods: A cross-sectional, qualitative study was conducted in 2017 – 2018 among the people residing in rural areas of Birbhum district in West Bengal, India who utilized the public health system (lay informants), formal and informal leaders of the community, community level health workers and peripheral health staff (key informants). Three community blocks, two sub-centers from each block and one village from each sub-center were selected randomly. In-depth interviews were conducted among 36 lay and 36 key informants using Laverack’s nine dimension model of community empowerment. Framework analysis was done to summarize data.
 Results: Participation of people was restricted to awareness and utilization of existing health services. Unmet aspiration for greater participation was noted among a small section of the community. They were mostly fitted to the role of beneficiaries. Functioning of village level organization to promote communitization as envisaged in national health programmes was largely deficient. The community health workers acted as the most peripheral appendages of formal health system rather than the health activists to empower community regarding community’s health.
 Conclusion: Although, every national health programme advocated community empowerment, the current status and the process of empowerment in health is in nascent stage.

The heart of navigation is personalized care” which applies to patients, families, and caregivers. Nurse Navigators focus first & foremost on the clinical aspects of care. Nurse navigator can make a significant contribution to health reform by working towards patient-centred care where in patients receive timely, seamless, culturally appropriate guidance and support for developing health literacy. It has the system knowledge & access, clinical skills and time to understand each person’s needs and to partner with them to develop a plan of care that addresses their health needs and respects & values their time and circumstances. It also contributes to health system improvement by improving access, equity, efficiency, effectiveness and sustainability of health services. These improvements are most notable during transitions from acute to continuing care, where the nurse navigator can also be instrumental in achieving better service integration. The nurse navigator offer a unique service for the provision of quality care.

ObjectiveTo explore how four small towns in rural New South Wales known as the 4Ts are addressing challenges accessing quality care and sustainable health services through a collaborative approach to workforce planning using the collaborative care framework.DesignDescriptive case study approach.SettingThe collaborative care project was developed as a result of ongoing partnerships between 2 rural Local Health Districts, 2 Primary Health Networks and a non‐governmental health workforce organisation. The collaboration works with 5 subregions each comprising 2 or more rural communities. This paper focuses on the 4Ts subregion.ParticipantsStakeholders of the collaborative design including organisations and the community.InterventionA place‐based approach to co‐designing health services with community in one sub‐region of Western New South Wales.Main outcome measuresA synthesis of field observations and experiences of community and jurisdictional partners in implementation of the 4Ts subregional model. Mapping of implementation processes against the collaborative care framework.ResultsThe collaborative care framework is a useful planning and community engagement tool to build health workforce literacy and to impact on system change at the local level. We identify key elements of effectiveness in establishing the 4Ts model, including the need for coordinated health system planning, better integrating existing resources to deliver services, community engagement, building health workforce literacy and town‐based planning.ConclusionThis study adds to the body of knowledge about how to successfully develop a collaborative primary health care workforce model in practice. The findings demonstrate that the implementation of a collaborative primary health care workforce model using the collaborative care framework can improve service access and quality, which in turn might facilitate workforce sustainability.

Big programmes, big errors