Care Service Delivery Models Research Articles

Near vision impairment and effective refractive error coverage for near vision in Andhra Pradesh, India – The Akividu Visual Impairment Study (AVIS)

ABSTRACT Clinical relevance Near Vision Impairment (NVI) is common in developing countries. A substantial proportion of NVI can be addressed by providing spectacles. Innovative eye care programmes are needed to address NVI. Population-based epidemiological studies can provide vital data to plan such eye care service delivery models. Background To report the prevalence of NVI and effective Refractive Error Coverage (eREC) for near vision in West Godavari and Krishna districts in Andhra Pradesh, south India. Methods A population-based cross-sectional study was carried out using a Rapid Assessment of Visual Impairment methodology. Presenting and pinhole distance visual acuity were assessed followed by near vision assessment using a N notation chart at a fixed distance of 40 cm. If the presenting near vision was worse than N8, the best corrected near visual acuity was recorded with age appropriate near vision correction. NVI was defined as presenting near vision worse than N8 among those without distance vision impairment (6/18 or better in the better eye). Effective Refractive Error Coverage for near was calculated as the proportion of individuals with an adequate correction to the total participants, including those with inadequate, adequate, and no correction for near vision. Results Data of 2,228 participants aged ≥40 years were analysed. The mean age of these participants was 54.0 ± 10.4 years; 53.8% were women; 44.5% had no formal education. The prevalence of NVI was 27.1% (95% CI: 25.2–29.0%). NVI significantly associated with 70 and above age group (adjusted OR: 1.97; 95% CI: 1.45-3.70). Participants with formal education had lower odds for NVI (adjusted OR: 0.75; 95 % CI: 0.68-0.83). The eREC for near vision was 48.0%. Conclusion NVI affects over a quarter of people aged ≥40 years in the West Godavari and Krishna districts of Andhra Pradesh. However, eREC is under 50% and there is scope for improving this by establishing eye care services to achieve universal eye health for all.

Cape York Kidney Care: service description and baseline characteristics of a client-centred multidisciplinary specialist kidney health service in remote Australia

BackgroundChronic Kidney disease (CKD) is over-represented amongst First Nation people with more than triple the rate of CKD in those aged 15 years and over. The impact of colonisation, including harmful experiences of health practices and research, has contributed to these health inequities. Cape York Kidney Care (CYKC) has been created as an unique service which provides specialist care that aims to centre the client within a multidisciplinary team that is integrated within the primary care setting of the remote health clinics in six communities in western Cape York, Australia. This research aims to describe the Cape York Kidney Care service delivery model, and baseline service data, including aggregated client health measures.MethodsThe model of care is described in detail. Review of the first 12 months of service provision has been undertaken with client demographic and clinical profile baseline data collected including kidney health measures. Participants are adults (> 18 years if age) with CKD grades 1–5. This data has been de-identified and aggregated.ResultsCYKC reviewed 204 individuals, with 182 not previously been reviewed by specialist kidney health services. Three quarters of clients identified as Aboriginal. The average age was 55 with a high level of comorbidity, with majority having a history of hypertension and Type 2 diabetes (average Hba1c 8.2%). Just under one third had cardiovascular disease. A large proportion of people had either Grade 2 CKD (32%) or Grade 3 CKD (~ 30%), and over half had severely increased albuminuria (A3), with Type 2 diabetes being the predominant presumed cause of CKD. Most clients did not meet evidence-based targets for diabetes, blood pressure or lipids and half were self-reported smokers. The proportion of clients reviewed represents 6.2% of the adult population in the participating First Nation communities.ConclusionThe CYKC model was able to target those clients at high risk of progression and increase the number of people with chronic kidney disease reviewed by specialist kidney services within community. Baseline data demonstrated a high burden of chronic disease that subsequently will increase risk of CKD progression and cardiovascular disease. People were seen to have more severe disease at younger ages, with a substantial number demonstrating risk factors for rapid progression of kidney disease including poorly controlled Type 2 diabetes and severely increased albuminuria. Further evaluation concerning implementation challenges, consumer and community satisfaction, and health outcomes is required.

A Review of Palliative Care Service Delivery Models and Patient Outcomes for Adults with Cancer in Selected East and Southeast Asian Countries

Cancer is one of the key leading causes of deaths worldwide, with a disproportionately high burden in Asia in terms of incidence and mortality. Guidelines and recommendations published by the World Health Organization (WHO) state palliative care as an essential service for patients with cancer and other chronic diseases. Currently, there is extensive evidence regarding different models of palliative care delivery. However, development of palliative care services remains fragmented in Asia, and more research is needed to synthesize available models of care in this region and provide the latest evidence-based information for healthcare providers. This narrative review identified 11 peer-reviewed studies published after 2017 that reported both on models of palliative care service delivery and outcomes for adult patients with cancer in selected East and Southeast Asian countries. This review is beneficial by providing a detailed summary of the models of care adopted by these countries, and their impact on patient outcomes. It is hoped that the evidence will also generate momentum for continued conversation around palliative care development in Asia.

A multi-site, non-randomized study of the feasibility and acceptability of a family-led postnatal care model in the Ada District, Ethiopia

Background: Postnatal care is a critical intervention to reduce newborn and maternal mortality in high-mortality settings. However, it is underutilized in many countries. Family-led postnatal care (FPNC) is an innovative postnatal care service delivery model that leverages self-care principles to address key barriers identified in the Ethiopian context, including women’s preference to stay home in the first week after delivery and receive support from trusted family members. Utilizing an improved discharge process, coupled with user-friendly monitoring devices made available as a home care kit kept with preferred community custodians, this self-care model for postnatal care will be evaluated as a potential solution to very low coverage of postnatal care in the first week of life. Methods: The study will use mixed sequential methods: quantitative pre-intervention and post-intervention survey and phenomenological qualitative study. Four health centers in Ada Districtof Oromia, Ethiopia will be purposively selected. A pre-intervention survey will measure coverage and content of postnatal checks and care-seeking behavior. Health centers will then implement family led postnatal care. Once FPNC is initiated, post-intervention quantitative data will be collected. Approximately 218 postnatal women are to be included in the quantitative survey. Qualitative interviews with approximately 20 mothers, 20 partners, 20 families, eight health managers, 12 postnatal discharge counselors, 20 health extension workers, and eight home care kit custodians will be conducted. A quantitative measurement of sustainability six months after the endline will also be assessed. Conclusions: Optimally, the study will contribute evidence to inform decision makers locally and globally on whether FPNC is a feasible and acceptable service delivery model for postnatal care, and whether it improves women’s empowerment and/or increases men’s support and connection to women and newborns in the early postnatal period.

Mental Health Care Use Among Children and Adolescents With High Health Care Costs in Ontario, Canada

Research on patients with high health care costs has examined mainly adults, with little focus on mental health care use. To examine the characteristics and costs of children and adolescents with high health care costs who use mostly mental health care and whether and why they persist in the high-cost state. This population-based, retrospective cohort study used health care records from Ontario, Canada, on all children and adolescents (age 0-17 years) covered under a universal health care system from January 1, 2012, to December 31, 2019. All children and adolescents in and above the 90th percentile of the cost distribution in 2012 for whom costs related to mental health care accounted for 50% or more of their costs were defined as patients with high mental health care costs. Data were analyzed from August 2019 to December 2022. High health care costs. Patients with high mental health care costs were characterized in terms of their sociodemographic characteristics; chronic physical health, mental health, and behavioral conditions; and health care costs (in 2021 Canadian dollars) by health service and type of care (mental health care vs non-mental health care). Patients were followed up until 2019 to assess whether they persisted in the high-cost state and to examine factors associated with persisting in that state. In 2012, there were 273 490 children and adolescents with high health care costs (mean [SD] age, 6.43 [5.99] years; 55.8% male; mean cost, $7936.40; 95% CI, $7850.30-$8022.40). Of these, 20 463 (7.5%) were classified as having high mental health care costs (mean cost, $10 040.20; 95% CI, $9822.80-$10 257.50). Asthma (30.3%), attention-deficit/hyperactivity disorder (35.8%), and mood and/or anxiety disorders (94.9%) were the most common chronic physical, behavioral, or mental health conditions. Few patients with high mental health care costs persisted in the high-cost state beyond 3 years (19.0%). Mood and/or anxiety disorders (relative risk ratio [RRR], 6.17; 95% CI, 3.19-11.96) and schizophrenia spectrum disorders (RRR, 2.98; 95% CI, 2.14-4.14) were identified as the main factors associated with persistence in the high-cost state. In this cohort study of children and adolescents with high health care costs, some patients had high levels of mental health care use and high costs of care, but few of these persisted in the high-cost state for 3 or more years. These findings may help inform the development of care coordination interventions and service delivery models, such as youth integrated services, to reduce costs and improve outcomes for children and adolescents.

Improving safe post-abortion care practices: A study on interventions implemented by Ipas Pakistan.

An estimated 50 million induced abortions occur in developing countries annually, and an estimated 7 million women are treated for complications associated with unsafe abortions. According to a 2012 estimate, 15 per 1,000 women aged 15-49 years seek treatment for abortion-related health complications in both private and public sectors. A high unmet need for family planning in Pakistan and a low percentage of women adopting a contraceptive method in the post-partum period led to unwanted pregnancy becoming one of the reasons for unsafe abortion. Post-abortion care (PAC) is an integrated service delivery model that includes both maternal health and family planning interventions. The study aims to examine improvement in abortion-related practices through the implementation of the PAC model at all tiers of public health service delivery systems in the two most populous provinces-Punjab, Sindh, Khyber Pakhtunkhwa, and Islamabad Capital Territory (ICT) region-of Pakistan. The improvement model comprises clinical training of healthcare providers, community engagement, and counseling of community women on safe post-abortion practices. It was a descriptive study utilizing data of 27,616 PAC clients recorded and reported by the service providers on the logbooks from 104 selected public health facilities from March 2018 to December 2021 in ICT, Punjab, Sindh, and Khyber Pakhtunkhwa provinces of Pakistan. Women who received PAC services were older than 25 years, 22,652 (82%), with a mean age of 29 years. Most of these women were in their first trimester, 26,110 (95%), and the majority diagnosed with PAC (incomplete, missed, or threatened abortion), 26,838 (97%). The majority of women, 25,324 (92%), received safe methods for post-abortion care that included the use of misoprostol, 15,804 (58%), and manual vacuum aspiration, 8,898 (32%). In total, 17,105 (72%) of women opted for a contraceptive method that included long-acting reversible contraceptives, 2,313 (10%); short-term excluding condoms, 3,436 (27%); and condoms, 8,113 (34%). The key predictors identified for uptake of the post-abortion family planning method indicated that women more than 25 years of age, in the early second trimester, and who were counseled on post-abortion family planning were more likely to adopt the contraceptive method than others. Increased access to post-abortion care and family planning could potentially reduce the incidence of unsafe abortion, unintended pregnancies, and associated maternal mortality. The experience of Pakistan suggests that the integrated post-abortion care service delivery model can be effectively implemented across the public health systems.

Providers' Competencies and Management Practices for Traditional Palliative Cancer Care Service Delivery in Kenya.

Many people in developing countries are struggling with chronic diseases yet traditional health services remain under-utilized in the quest for universal health care. Thousands patronize these outlets for care yet little is known about provider's competence and how these competencies inform palliative care decisions and practices. The study documented traditional health practitioners (THPs) competencies and practices for traditional palliative cancer care service delivery in Kenya. This study utilized mixed-methods design and was undertaken in major towns across Kenya. A total of 201 Traditional health practitioners were purposely sampled, and interviewed. Five in-depth interviews and 6 focus group discussions were conducted. Quantitative data were analyzed using SPSSv22 while thematic and discourse analysis was carried out for qualitative data. Majority (92.7%) of the THPs provided general traditional health services. Nearly half of the respondents (47.7%, n = 92) stated that they had received their knowledge and abilities through divine gifting, 71 (36.8%) lineage, 61 (31.6%) apprenticeship, and 39 (20.2%) formal study. Palliative care was determined by patient state and followed consultation with caregivers for 165 (85.5%) of respondents. For 160 respondents (83%), management practices involved a mix of patient examination, conventional medical tests, herbal medicine administration, follow-up or referral. Positive feedback consisted of symptom reduction and function recovery. Core competencies identified include: knowledge acquisition and specialization, assessment, diagnosis and disclosure, decision making, treatment, follow-up, and referral. Traditional palliative care providers share common health-related beliefs, practices and abilities that influence how they approach and make decisions regarding the health management of their patients, despite marked ethnic diversity. The shared pathways offer a chance to develop a cogent traditional palliative care service delivery model and health policy framework to promote its integration within the health workforce. The leading unmet requirements are knowledge of intellectual property rights, disclosure frameworks, and ethical regulation principles.

Mitigating inequalities in community care needs of older adults with dementia: a qualitative case study of an integrated model of community care operated under the proportionate universalism principle

BackgroundPopulation ageing and community care on older adults, as well as the marked social inequalities in health, have received growing concern by the government and the community. This study evaluated the medico-social integrated day care model of the Cadenza Hub for older adults with dementia. We also examined whether services subsidized by the publicly funded graded financial support of the Community Care Service Voucher for the Elderly (CCSV) could mitigate social inequalities in community care needs, from the perspective of the caregivers.MethodsIn this qualitative case study, we adopted purposeful sampling strategy to recruit 14 caregivers of active day care service users with dementia, with different socioeconomic background and duration of service use, for face-to-face semi-structured in-depth interviews between June and August 2021. The transcribed data were closely read to capture key themes using thematic analyses.ResultsCaregivers faced tremendous caregiving burden in the absence of community care support and struggled in choosing care services. Most informants benefited from the day care service, whereas the financial support of CCSV was crucial to ensure equitable access to community care. Non-governmental organizations and social workers were the key to bridging the information gap.ConclusionThe integrated day care of the Cadenza Hub appeared to have addressed the unmet needs of older adults with dementia and their caregivers, including the socioeconomically disadvantaged with the CCSV support. The community care service delivery model might be applicable to address other health inequalities problems.

Service delivery models for enhancing linkage to and retention in HIV care services for adolescent girls and young women and adolescent boys and young men: a protocol for an overview of systematic reviews

IntroductionRecent advances in the HIV care continuum have shown that an individual diagnosed with HIV should be initiated on antiretroviral therapy as soon as possible regardless of the CD4 count...

Rural mistrust of public health interventions in the United States: A call for taking the long view to improve adoption.

Rural mistrust of public health interventions in the United States: A call for taking the long view to improve adoption.

Policy programs and service delivery models for older adults and their caregivers: Comparing three provinces and two states.

Despite an increase in prevalence of complex chronic conditions and dementia, long-term care services are being continuously pushed out of institutional settings and into the home and community. The majority of people living with dementia in Canada and the United States (U.S.) live at home with support provided by family, friends or other unpaid caregivers. Ten dementia care policy programs and service delivery models across five different North American jurisdictions in Canada and the U.S. are compared deductively using a comparative policy framework originally developed by Richard Rose. One aim of this research was to understand how different jurisdictions have worked to reduce the fragmentation of dementia care. Another aim is to assess, relying on the theory of smart policy layering, the extent to which these policy efforts 'patch' health system structures or add to system redundancies. We find that these programs were introduced in a manner that did not fully consider how to patch current programs and services and thus risk creating further system redundancies. The implementation of these policy programs may have led to policy layers, and potentially to tension among different policies and unintended consequences. One approach to reducing these negative impacts is to implement evaluative efforts that assess 'goodness of fit'. The degree to which these programs have embedded these efforts into an existing policy infrastructure successfully is low, with the possible exception of one program in NY.

A Comparative Assessment of Long-Term Care Financing and Service Delivery Models

The face of public long term care (LTC) funded largely through the Medicaid program is changing rapidly in the U.S. Over the last decade, most states have moved to managed LTC programs in various forms, with a growing number transferring all their programs, home and community based (HCBS) and nursing home services, to a Medicaid (MLTC) model. The amount of rigorously conducted and reported evaluation results on these programs are still very limited. Enough information is available, however, from other sources for at least preliminary comparison of relative cost-effectiveness of MLTC vs. traditional, non-profit models of public LTC services delivery and financing, as discussed in this paper. This comparison will show that, at this point, the MLTC programs are not more cost-effective than the traditional model of LTC administration. In fact, these initial assessments seem to indicate that the traditional model may be superior to the corporate for-profit MLTC model.

Comparative Analysis of Dementia Care Programs and Delivery Models

Dementia has significant social and economic impacts for those living with dementia and their caregivers. Despite an increase in prevalence of complex chronic conditions and dementia, long-term care services are continuously pushed out of institutional settings and into the home and community. The majority of people living with dementia in Canada and the United States (U.S.) live at home with support provided by family, friends, or other unpaid caregivers. Ten dementia care programs and service delivery models across five different North American jurisdictions in Canada and the U.S. are compared using a deductive analytical approach using a comparative policy framework developed by Richard Rose. The policy efforts included in this research attempt to improve health system flow and access for vulnerable populations. One common theme among all jurisdictions are long-standing institutional barriers that can make change difficult. These barriers can prevent the ability for systems to be flexible and adapt to meet the changing needs of populations. Incrementalism is often considered an appropriate approach to health system reform. Yet, incremental change efforts lead to policy layers and these layers can lead to tension between different policy mixes and unintended consequences. These programs were introduced in a manner that did not fully consider how to patch current structures and risk creating further system redundancies. One approach to reduce this risk is to combine evaluative efforts that assess ‘goodness of fit’. The degree to which these programs have embedded these efforts successfully is low, with the possible exception of DSRIP from NY.

Conventional and complementary health care use and out-of-pocket expenses among Australians with a self-reported mental health diagnosis: a cross-sectional survey

BackgroundMental health disorders are a global health concern. In Australia, numerous national reports have found that the current mental healthcare system does not adequately meet the needs of Australians with mental illness. Consequently, a greater understanding of how people with a mental health disorder are using the broader healthcare system is needed. The aim of this paper is to explore conventional and complementary health care use and expenditure among Australian adults reporting a mental health disorder diagnosis.MethodsA cross-sectional online survey of 2,019 Australian adults examined socio-demographic characteristics, complementary and conventional health care use and the health status of participants.Results32 % (n = 641) of the total sample (N = 2019) reported a mental health disorder in the previous 3 years. Of these, 96 % reported consulting a general practitioner, 90.6 % reported using prescription medicines, 42.4 % consulted a complementary medicine practitioner, 56.9 % used a complementary medicine product and 23 % used a complementary medicine practice. The estimated 12-month out-of-pocket health care expenditure among Australians with a mental health disorder was AUD$ 4,568,267,421 (US$ 3,398,293,672) for conventional health care practitioners and medicines, and AUD$ 1,183,752,486 (US$ 880,729,891) for complementary medicine practitioners, products and practices. Older people (50–59 and 60 and over) were less likely to consult a CM practitioner (OR = 0.538, 95% CI [0.373, 0.775]; OR = 0.398, 95% CI [0.273, 0.581] respectively) or a psychologist/counsellor (OR = 0.394, 95% CI [0.243, 0.639]; OR = 0.267, 95% CI [0.160, 0.447] respectively). People either looking for work or not in the workforce were less likely to visit a CM practitioner (OR = 0.298, 95% CI [0.194, 0.458]; OR = 0.476, 95% CI [0.353, 0.642], respectively).ConclusionsA substantial proportion of Australian adults living with a mental health disorder pay for both complementary and conventional health care directly out-of-pocket. This finding suggests improved coordination of healthcare services is needed for individuals living with a mental health disorder. Research examining the redesign of primary health care provision should also consider whether complementary medicine practitioners and/or integrative health care service delivery models could play a role in addressing risks associated with complementary medicine use and the unmet needs of people living with a mental health disorder.

Features of health care interventions associated with reduced services and spending.

This study examines 14 independent and diverse health care interventions funded under the second round of Health Care Innovation Awards by CMS to determine if any organizational, model, or implementation features were strongly associated with the programs' estimated impacts on total expenditures, hospitalizations, or emergency department visits. We estimated program impacts using awardee-specific difference-in-differences models based on Medicare and Medicaid enrollment and claims data for treatment and matched comparison groups from 2012 to 2018. We used 2 analytic approaches to identify program features associated with favorable impacts. The first method identified program characteristics that were common among programs that had estimated reductions in costs and service use and uncommon among those that did not. The second approach compared median impacts among awardees with a given distinguishing feature with median impacts among awardees that lacked the characteristic. Of the 23 program features examined, 7 were associated with favorable estimated impacts: 3 intervention components (behavioral health, telehealth, and health information technology) and 4 program design and organizational characteristics (having prior experience implementing similar programs, targeting patients with substantial nonmedical needs in addition to medical problems, being focused on individual patient care rather than transforming provider practice, and using nonclinical staff as frontline providers of the intervention). Innovative health care service delivery models with 2 or more of these 7 identified features were more likely than programs without them to reduce Medicare and Medicaid beneficiaries' needs for costly health care services.

Understanding community member and health care professional perspectives on gender-affirming care-A qualitative study.

Transgender and gender diverse (TGD) people experience significant barriers to accessing affirming health services. There is a paucity of literature examining how both community members and health care professionals (HCPs) understand potential causes and solutions for these barriers, particularly in non-urban settings. We present the first systematic examination of perspectives from community members and HCPs regarding barriers to and solutions for promoting access to gender-affirming health care. Study activities were conducted through the Plan and Act for Transgender Health (PATH) Project, a health needs assessment of TGD people. Community members in the catchment area were recruited to participate in focus group discussions about access to gender-affirming health care and optimal health service delivery models in March-October 2019. HCPs were recruited to participate in focus group discussions or in-depth interviews about experiences working with TGD clients. Data were analyzed using an inductive grounded theory approach. 25 rural counties in Massachusetts, New York, Connecticut, Vermont, and New Hampshire. Study participants included 61 adult TGD community members and 23 HCPs working in the catchment area. Both community members and HCPs spoke of the need for connectedness and linkages among disparate health system components for gender-affirming health care. Participants expressed this priority through calls for systems-level improvements within existing services (e.g., expanded data collection, expanded mental health services, inclusive and affirming health care environments, and TGD staff). They also expressed the need for expanded TGD community outreach and engagement (e.g., incorporation of a patient feedback process, TGD health navigators, and resource mapping). Findings specifically reflect the perspectives of community members and HCPs in the rural New England area. Furthermore, the study sample was predominantly White non-Hispanic. Interventions to achieve accessible gender-affirming health care must address the diverse perspectives and needs of both community members and HCPs.

Developing Competencies of Nurses in Wound Care: The Impact of a New Service Delivery Model Including Teleassistance.

The implementation of a new wound care model of service delivery, including training and teleassistance, provided us with the opportunity to study nursing competencies in a primary health care context. A mixed-methods study was chosen to address the complexity related to the development of competencies from two complementary perspectives. Nurses' self-perceived knowledge and skills improved immediately after training. Factors identified as influencing the development process were grouped into three themes: Acquired Skills and Knowledge, Personal Factors, and Work Organization Factors. Our study demonstrates that the skills and knowledge can be enhanced through integrated continuing education efforts, and brings a deeper understanding of factors that influence the competency development. Finally, the research team highlighted the potential of telehealth technologies. [J Contin Educ Nurs. 2020;51(12):547-555.].

Chronic care service delivery models for people living with type 1 diabetes in low- and lower-middle income countries: a scoping review protocol.

The objective of this scoping review is to map the published literature that describes the distribution and organization of chronic care service delivery models for people living with type 1 diabetes (PLWT1D) in low- and lower-middle-income countries (LLMICs). Type 1 diabetes is an autoimmune condition commonly diagnosed in childhood and early adolescence; it cannot be prevented and is deadly without daily insulin injections. Among PLWT1D, the islet cells in the pancreas produce insufficient amounts of the glucose-regulating hormone, insulin, resulting in the need for chronic insulin replacement therapy. Epidemiological information regarding type 1 diabetes (T1D) is limited in LLMICs. Improving survival for PLWT1D in LLMICs requires early diagnosis and greater access to high quality chronic care service delivery models for T1D. The identification and reporting of service delivery model typologies for PLWT1D will allow for more specific research questions regarding individual typologies in subsequent systematic reviews. The review will consider all types of literature on the organization and distribution of chronic care services for the management of PLWT1D provided out of facilities in LLMICs, published from 2000 to the present. The JBI methodology for conducting scoping reviews will be employed. The search will be implemented across PubMed, Embase, and Web of Science. Full texts of the publications selected will be reviewed and data will be extracted through a charting table. The findings will be charted to summarize the results.

Health Care System for Immigrants (Accessibility, Quality, Cost)

The aim of this study is to identify and describe within the existing literature the characteristics (Immigrant, accessibility, quality, cost.) of primary health care models of service delivery for Indigenous immigrant people. Our focus was on knowledge synthesis of maternity care among immigrants to Greece provided a coherent evidence base for (a) eliciting a better understanding of the factor that generate disparities in accessibility, acceptability, and outcomes during maternity care and (b) improving culturally-based competency in maternity care. Our synthesis also identified pertinent issues in multiple sectors that should be addressed to configure maternity services and programs appropriately. Effectiveness, safety, and patient experience are key components of healthcare quality, an important element of health systems performance.

Public-Private Innovation in Health and Social Care: The Implications of Transaction Costs

In response to the continual pressure on health and social services worldwide, there has been a demand for innovation in this sector. One area of interest has been collaboration between public and private actors in developing new solutions for service delivery. So far, knowledge of how such private-public innovation (PPI) processes emerge has been limited. We studied barriers to PPI, focusing on how transaction costs influence the innovation process.
 We conducted a single case study, following the collaborative efforts of a Norwegian municipality and a local fire and rescue company searching for new care service delivery models. The data consist of interviews with central stakeholders and documents from the PPI process. The findings add to the knowledge on barriers in public-private innovation by highlighting transaction costs as a factor influencing the PPI process. An increased awareness of transaction costs throughout the innovation process may be important in planning and resource allocation. Findings from this case study may be useful in the development and implementation of innovative ideas. Our case illustrates the need for organisational change in service innovation. A focus on transaction costs can provide a useful tool for analysing necessary structures and their consequences when beginning PPI initiatives.