How to Achieve Meaningful Change.

Health Human Resources are the backbone of the health care efforts face an increase in the number and proportion of productive age population and the elderly in the future mendatang.Terutama in the face of the Asean Economic Community. Health Human Resources, aims to produce human resources that develop and update health science and technology in the field of health promotion. HRH able to identify and formulate solutions development and management of health human resources through research, develop / improve the performance of professional indicated by the sharpness of the analysis of health problems, formulate and advocate for programs and health policies for the development and management of health human resources.

IntroductionOne of the principal goals of any health care system is to improve health through the provision of clinical and public health services. Decentralization as a reform measure aims to improve inputs, management processes and health outcomes, and has political, administrative and financial connotations. It is argued that the robustness of a health system in achieving desirable outcomes is contingent upon the width and depth of ‘decision space’ at the local level. Studies have used different approaches to examine one or more facets of decentralization and its effect on health system functioning; however, lack of consensus on an acceptable framework is a critical gap in determining its quantum and quality. Theorists have resorted to concepts of ‘trust’, ‘convenience’ and ‘mutual benefits’ to explain, define and measure components of governance in health. In the emerging ‘continuum of health services’ model, the challenge lies in identifying variables of performance (fiscal allocation, autonomy at local level, perception of key stakeholders, service delivery outputs, etc.) through the prism of decentralization in the first place, and in establishing directed relationships among them.MethodsThis focused review paper conducted extensive web-based literature search, using PubMed and Google Scholar search engines. After screening of key words and study objectives, we retrieved 180 articles for next round of screening. One hundred and four full articles (three working papers and 101 published papers) were reviewed in totality. We attempted to summarize existing literature on decentralization and health systems performance, explain key concepts and essential variables, and develop a framework for further scientific scrutiny. Themes are presented in three separate segments of dimensions, difficulties and derivatives.ResultsEvaluation of local decision making and its effect on health system performance has been studied in a compartmentalized manner. There is sparse evidence about innovations attributable to decentralization. We observed that in India, there is very scant evaluative study on the subject. We didn’t come across a single study examining the perception and experiences of local decision makers about the opportunities and challenges they faced. The existing body of evidences may be inadequate to feed into sound policy making. The principles of management hinge on measurement of inputs, processes and outputs. In the conceptual framework we propose three levels of functions (health systems functions, management functions and measurement functions) being intricately related to inputs, processes and outputs. Each level of function encompasses essential elements derived from the synthesis of information gathered through literature review and non-participant observation. We observed that it is difficult to quantify characteristics of governance at institutional, system and individual levels except through proxy means.ConclusionThere is an urgent need to sensitize governments and academia about how best more objective evaluation of ‘shared governance’ can be undertaken to benefit policy making. The future direction of enquiry should focus on context-specific evidence of its effect on the entire spectrum of health system, with special emphasis on efficiency, community participation, human resource management and quality of services.

Despite advances in medical research, the burden of disease in most countries remains high. Further, health inequalities continue to grow and emerging infectious diseases are still wreaking havoc across countries. To respond to contemporary public health challenges, a new systems thinking paradigm has emerged that highlighted a holistic approach towards health systems, resulting to an emerging field - health policy and systems research (HPSR). HPSR seeks to understand and enhance how societies organise themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes. However, research gaps remain particularly in applying this paradigm to strengthen health systems performance across countries. This thesis contributes to HPSR by: a. examining the underlying concepts of health systems strengthening; b. determining how health systems contribute to better health outcomes, particularly on reducing infant mortality rates and improving life expectancies at birth, and c. understanding mechanisms to use findings from health systems strengthening assessments to inform global and national-level health policymaking processes. In 2015, 40% of the Global Fund investments go toward health systems strengthening (HSS). The global health threats posed by recent viral epidemics such as Ebola and Zika even further increased calls to invest in and develop better health systems. These health systems investments were also in most cases subjected to performance-based funding, but contrary to other monitoring and evaluation methods used for other health programs, health systems monitoring and evaluation demand a new analytical frame due to its complexity, along with the very different country capacities, uneven data sources and data availability and quality, including the varied contexts that drive priority areas for health systems. As such, monitoring these initiatives remain to be highly contentious despite its importance to inform health resource allocation. In particular, studies often highlighted different conceptual and methodological challenges associated with health systems assessments worldwide. To address these issues, I first introduced a new HSS framework based on existing monitoring and evaluation frameworks collected from my field experience, systematic reviews, and thematic analyses of existing HSS documents and database. Based on the developed HSS framework, existing HSS indicators were also examined to guide further analysis. Further, I quantitatively assessed health systems performance using a new composite indicator based on previous efforts for a global health systems performance index. To do this index, I used data collected from the Demographic Health Surveys, the World Bank Indicators, and the World Health Organisation (WHO) Global Health Surveys. In particular, I used fixed-effects and random-effects regression analyses to determine how each health system characteristic affects health outcomes, particularly infant mortality rates and life expectancies. Specifically, I examined how global core health indicators can be used to assess each health systems building block (governance, financing, service delivery, health workforce, medical products and technologies, and health information systems. From global health systems assessments, I then examined the use of health systems monitoring and evaluation to assess one of the building blocks – governance – in Cambodia and the Philippines. In this thesis, I found about 3000 health systems indicators that countries can choose from to guide their current or future health systems performance assessments, while tailoring them into their specific country needs and contexts. In addition, I found a significant gap in country capacities to be able to monitor health systems performance, implying the need for better surveillance and reporting systems particularly in low- and middle-income countries. Further, I also quantified the contributions of each of the health systems building blocks to overall infant mortality rates and life expectancies and found that health systems can only effectively improve health outcomes if all of the building blocks are well-functioning. Using these information, I created an index for health systems performance assessments that can be used for global monitoring and evaluation. Using this index, I found that many countries in Africa and Southeast Asia remain to have the least performing health systems, as well as health outcomes. The index was able to account for the different health systems building blocks, while controlling for socioeconomic factors and other health determinants. When applied in assessing health governance in Cambodia and the Philippines, I found that decentralization significantly contributed to improve Cambodia’s infant mortality rates, while finding a lesser effect for the Philippines. Given these findings, I concluded that health systems performance can be quantitatively assessed with these assessments providing comprehensive yet easily understandable overview of health systems performance in both national and global levels; hence, facilitating use in health systems decision-making processes.

<h3>Background</h3> Application of best practices of on line interactive learning in Health Human Resource Management course: A UPOU Experience was explored in this study. <h3>Objectives</h3> This qualitative study used best practices of on line interactive learning criteria to analyze the learnings of the students enrolled in Health Human Resource Management course. <h3>Methods</h3> The students narrate their experiences in terms of behavior criterion, student-faculty interactions, use of technology and their learning environment. The respondents, age, gender, civil status, educational attainment, location and occupation were profiled. <h3>Result</h3> Majority of them are male, married, belong to 35–45 years old, 5 of the 6 respondents were medical doctors, majority of them are in local setting. Analysis of the experiences revealed that students were challenged in answering health human resource cases given to them by the faculty-in-charge and that they are even more challenged in finishing the 180 contact hours of practicum in their preferred agency. Time was a factor since most of them were working full time. All students narrated that they have applied what they learned in their work. <h3>Conclusion</h3> The experiences shared by the students enrolled in health human resource management will continuously evolved as the course is re-tooled and re-developed in the future. Key The experiences shared by the students enrolled in health human resource management will continuously evolved as the course is re-tooled and re-developed in the future.

The expanding health needs and expectations of a growing and changing population in Turkey are placing new pressures on a health system that is increasingly financially constrained. These pressures are bringing into sharp focus the need to take radical approaches to the organization, planning and management of the health sector; and, in particular, in the planning and management of health human resources. Issues of effectiveness, efficiency and value for money are increasingly becoming the central issues for the 1990s and beyond. The article examines the development of the Turkish health system. Within a framework of health care reform proposals emerging from a major development project in the Ministry of Health itself, the text explores current initiatives and future needs in developing human resource planning if the health care reforms are to be successful in meeting the health needs of the population.

Since the publication of the World Health Report 2000, which aimed at assessing health systems performance globally, a number of health systems performance assessment (HSPA) frameworks and tools, designed for various purposes, have emerged. In 2017, the joint Universal Health Coverage 2030 Technical Working Group on Health Systems Assessment (TWG), consisting of health policy makers and global actors, such as the WHO, World Bank, USAID, Unicef, European Commission, OECD, etc., was formed with the aim to align the existing tools and develop a common approach to understanding and measuring health systems performance globally. As part of this work, the European Observatory on Health Systems and Policies (OBS) has developed a Health Systems Performance Assessment framework for Universal Health Coverage (HSPA Framework for UHC), that allows to evaluate health system performance, largely by drawing on the information available in the existing tools or through global data collection initiatives. Suggested approach is based on the detailed assessment of the four health system functions (governance, financing, resource generation and service delivery) and their sub-functions, the interaction of which jointly leads to the successes and failures in the achievement of health system goals. We propose distinct assessment areas for specific functions and sub-functions as a way to identify potential strengths and weaknesses, which can then be related to actions or responsibilities of specific actors within a health system, or linkages to other sectors. The objective of the workshop is to introduce the background, rationale, methods and process of developing of the HSPA framework for UHC; present a systematic approach to assessing various functions of health system and their interactions; relate the assessment areas of specific functions and sub-functions to the final health system goals; and, finally, to test the use of the framework in practice. The workshop is structured as follows: the workshop will start from the four 10-minute presentations (outlined below), followed by an interactive session with the audience to discuss the content of the framework and elaborate on its potential use for HSPA and applications globally. Key messages The HSPA framework for UHC is an approach that allows to bring together existing HSPA efforts and moves towards a more systematic and universally applicable health system performance assessment. The approach assesses performance through attribution of various health system outcomes to specific functions and sub-functions, allowing to identify strengths and weaknesses that affect performance.

Despite the widespread adoption of decentralization reforms as a means to improve public service delivery in developing countries since the 1980s, empirical evidence of the role of decentralization on health system improvement is still limited and inconclusive. This study reviewed studies published from 2000 to 2016 with adequate research designs to identify evidence on whether and how decentralization processes have impacted health systems. We conducted a systematic review of peer-reviewed journal articles from the public health and social science literature. We searched for articles within 9 databases using predefined search terms reflecting decentralization and health system constructs. Inclusion criteria were original research articles, low- and middle-income country settings, quantifiable outcome measures, and study designs that use comparisons or statistical adjustments. We excluded studies in high-income country settings and/or published in a non-English language. Sixteen studies met our prespecified inclusion and exclusion criteria and were grouped based on outcomes measured: health system inputs (n = 3), performance (n = 7), and health outcomes (n = 7). Numerous studies addressing conceptual issues related to decentralization but without any attempt at empirical estimation were excluded. Overall, we found mixed results regarding the effects of decentralization on health system indicators with seemingly beneficial effects on health system performance and health outcomes. Only 10 studies were considered to have relatively low risks of bias. This study reveals the limited empirical knowledge of the impact of decentralization on health system performance. Mixed empirical findings on the role of decentralization on health system performance and outcomes highlight the complexity of decentralization processes and their systemwide effects. Thus, we propose a renewed research agenda that focuses on discrete definitions of decentralization and how institutional factors and mechanisms affect health system performance and outcomes within the general context of decentralized governance structures.

BackgroundAssessing the performance of health systems through quantitative and qualitative methods is recognized as an effective approach to strengthening national health systems. However, while many high-income countries have institutionalized health system performance assessment (HSPA) as an integral component of their respective health systems, few studies on HSPA have been documented in low- and middle-income countries, including Ghana. This study aims at providing a comprehensive framework for periodic assessment of the performance of the entire health system in Ghana.MethodsThe study will have four work packages. First, a structured review will be conducted to identify both international and national HSPA frameworks that could be applied to the Ghanaian context. Second, based on the structured review, an assessment framework tailored to the Ghanaian health system context will be developed. Third, the draft framework will be presented and discussed with experts and stakeholders for its appropriateness, feasibility and acceptability. Finally, the framework will be piloted to assess its effectiveness and suitability for full-scale implementation.DiscussionCurrently, Ghana does not have a full-fledged HSPA tool that provides a holistic health sector-wide approach to assessing health system performance. Thus, developing this HSPA framework for the country will provide a tool for periodic and comprehensive assessment of the performance of the health system, which can be compared with that of other countries. Such a comparison will offer the opportunity for mutual learning and for exploring new options for formulating more effective national health policies. As this is expected to be the first attempt to develop a comprehensive HSPA framework in Ghana, this study will provide a basis for future discussions on how to further develop and implement HSPA programmes in the country.

BackgroundThe shortage of primary medical staff is an important issue in the management of health human resources, and it is also a problem that all countries in the world need to face together. Since 2009, China has implemented a new series of medical system reforms and the shortage and loss of primary medical staff have been alleviated accordingly. However, China has a large population and it is difficult to distribute health human resources evenly across regions. This study aimed to explore the current status of turnover intention and its relationship with psychological capital, social support, and job burnout, as well as how these factors influence turnover intention of primary medical staff in Anhui province, China.MethodsUsing structured questionnaires to collect data, including demographic characteristics, turnover intention, psychological capital, social support, and Chinese Maslach Burnout Inventory scale. A total of 1152 primary medical workers of Anhui were investigated. Data were analyzed by t-test, analysis of variance (ANOVA), Pearson correlation analysis, and multiple linear regression model.ResultsTotal scores of turnover intention, psychological capital, social support, and job burnout of subjects were 14.15 ± 4.35, 100.09 ± 15.98, 64.93 ± 13.23 and 41.07 ± 9.437, respectively. Multiple linear regression showed the related factors of turnover intention were age, job position, work unit, and scores of job burnout. Pearson correlation showed psychological capital and social support were negatively correlated with turnover intention, while the score of job burnout was positively correlated with turnover intention.ConclusionThe improvement of psychological capital and social support and the reduction of job burnout may play an important role in reducing turnover intention of primary medical staff. Primary medical managers should strengthen the humanistic care for primary medical staff, optimize the incentive mechanism, and improve internal management of medical institutions for stability.

Governance is increasingly recognized as an important factor in health system performance, yet conceptually and practically it remains poorly understood and subject to often vague and competing notions of both what its role is and how to address its weaknesses. This overview article for the symposium on health governance presents a model of health governance that focuses on the multiplicity of societal actors in health systems, the distribution of roles and responsibilities among them and their ability and willingness to fulfil these roles and responsibilities. This focus highlights the principal-agent linkages among actors and the resulting incentives for good governance and health system performance. The discussion identifies three disconnects that constitute challenges for health system strengthening interventions that target improving governance: (1) the gap between the good governance agenda and existing capacities, (2) the discrepancy between formal and informal governance and (3) the inattention to sociopolitical power dynamics. The article summarizes the three country cases in the symposium and highlights their governance findings: health sector reform in China, financial management of health resources in Brazilian municipalities and budget reform in hospitals in Lesotho. The concluding sections clarify how the three cases apply the model's principal-agent linkages and highlight the importance of filling the gaps remaining between problem diagnosis and the development of practical guidance that supports 'best fit' solutions and accommodates political realities in health systems strengthening.

Introduction Comparing health systems allows policymakers to benchmark against other countries, and improve processes and performance. A template to guide authors on how to present systems' features and performance in a meaningful manner is the basis for understanding and assessing a country's health system. This study presents an overview of approaches for standardized descriptions and analyses of health systems. Methods We conceptualized four criteria to define a “template” for our analysis. It must have (1) a framework, (2) a list of indicators, (3) instructions for authors on how to write an informative document, and (4) should cover health systems design and performance. Based on these criteria we searched the academic and grey literature, and the web for templates. Results We found 29 tools that can be used as templates to describe and assess health systems. While ten tools are comprehensive, 19 tools focus on specific topics such as primary care, universal coverage, and quality of care. Another 21 tools focused on health system performance assessment but cannot serve as templates, as we define it. Most tools were developed by big organizations such as WHO, OECD and USAID. Discussion New models of governance and accountability are leading to increased interest in health system performance. A good template is key to write documents with an organized, coherent and meaningful description and assessment of a health system while allowing for cross-country comparison. We found ten tools that may serve as models of comprehensive templates, while most tools focus on specific topics or on performance assessment only. Conclusions This study provides a first-ever overview of templates that analyze health systems features and performance. Future studies could explore successful examples to consolidate a template that may potentially improve analysis and comparison of health systems in order to support policymaking. Key messages We found ten comprehensive tools for describing and assessing health systems. Our overview may help to improve existing templates by learning from experiences of different organizations.

Background Health workforce governance is increasingly recognized as a burning policy issue and focused on workforce shortages. Yet the most pressing problem is to solve maldistributions through governance and integration. Poor management of health human resources is relevant on all levels and areas of governance. Including, for instance, regional and international imbalances in the health workforce reinforced by austerity agendas, inefficient distribution of skills and tasks within and between professions, and lack of integration of women doctors in leadership positions and some specialties. …

Employment is a social determinant of health whose ambivalence is a well-established fact. Unemployment is therefore detrimental not only to the health of the unemployed but also to that of their families. Research even suggests that they (the unemployed and their family members) would be more likely to die prematurely than others. On the other hand, a safe job is conducive to the good health of the workers, to their well-being and it brings them satisfaction on the professional level. Nevertheless, the ambivalent nature of work means that it can also determine poor health for workers insofar as “the social organization of work, the mode of management and social relations in the workplace have an impact on the health.” This article aims to identify the organizational and social factors that have a negative impact on the health of health workers and in the light of social determinants and hospital magnetism, to propose a nonexhaustive list of recommendations for redesigned health human resource (HHR) management.

Accountability is crucial for improved functionality of health systems and can be ensured through community participation in health governance. To engage the community in the governance of the local health system, health facility governing committees (HFGCs) have been implemented in several low-income and middle-income countries including Tanzania. However, the effect of HFGCs on health system performance is not well studied. The aim of this study was to investigate the relationship between the functionality of the HFGCs and health system performance in 180 districts of mainland Tanzania, and to assess whether this relationship varies between dispensaries, health centres and hospitals. We conducted an ecological study in which the studied outcome was health system performance. The main independent variable was functionality of HFGCs, that is, to what extent these committees reflect the concerns of and connect back to the community. Other explanatory variables included staff availability, location of the facility, gender of the manager of the facility and ownership of the facility. Data on all of the variables were retrieved from the Star Rating Assessment of 2017/2018, measured as mean proportions of all facilities in the districts. The analyses included linear regression for all facility levels combined, as well as for the levels of facility separated (dispensaries, health centres and hospitals). We found a positive relationship between the functionality of the HFGCs and health system performance (β=0.53; 95% CI=0.47 to 0.60). The relationship was stronger for dispensaries (β=0.56; 95% CI=0.50 to 0.63) compared to health centres (β=0.39; 95% CI=0.33 to 0.44) and hospitals (β=0.23; 95% CI=0.15 to 0.31). Districts that have functional HFGCs tend to have better health system performance than others. This relationship is stronger in dispensaries compared to health centres and hospitals. Therefore, we believe the district authorities should allocate resources to strengthen the HFGCs.

BackgroundGlobally, good health system performance has resulted from continuous reform, including adaptation of Decentralisation by Devolution policies, for example, the Direct Health Facility Financing (DHFF). Generally, the role of decentralisation in the health sector is to improve efficiency, to foster innovations and to improve quality, patient experience and accountability. However, such improvements have not been well realised in most low- and middle-income countries, with the main reason cited being the poor mechanism for disbursement of funds, which remain largely centralised. The introduction of the DHFF programme in Tanzania is expected to help improve the quality of health service delivery and increase service utilisation resulting in improved health system performance. This paper describes the protocol, which aims to evaluate the effects of DHFF on health system performance in Tanzania.MethodsAn evaluation of the effect of the DHFF programme will be carried out as part of a nationwide programme rollout. A before and after non-controlled concurrent mixed methods design study will be employed to examine the effect of the DHFF programme implementation on the structural quality of maternal health, health facility governing committee governance and accountability, and health system responsiveness as perceived by the patients’ experiences. Data will be collected from a nationally representative sample involving 42 health facilities, 422 patient consultations, 54 health workers, and 42 health facility governing committees in seven regions from the seven zones of the Tanzanian mainland. The study is grounded in a conceptual framework centered on the Theory of Change and the Implementation Fidelity Framework. The study will utilise a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews and documentary review). The study will collect information related to knowledge, acceptability and practice of the programme, fidelity of implementation, structural qualities of maternal and child health services, accountability, governance, and patient perception of health system responsiveness.DiscussionThis evaluation study will generate evidence on both the process and impact of the DHFF programme implementation, and help to inform policy improvement. The study is expected to inform policy on the implementation of DHFF within decentralised health system government machinery, with particular regard to health system strengthening through quality healthcare delivery. Health system responsiveness assessment, accountability and governance of Health Facility Government Committee should bring autonomy to lower levels and improve patient experiences. A major strength of the proposed study is the use of a mixed methods approach to obtain a more in-depth understanding of factors that may influence the implementation of the DHFF programme. This evaluation has the potential to generate robust data for evidence-based policy decisions in a low-income setting.