Centralized Health System Research Articles

Health care prioritization process for the elderly in rural Tanzania under decentralized system: Prospects and challenges.

Beginning the early 1990s, many countries globally adopted the third-generation health sector reforms with a focus of strengthening the primary health care system through community participation. On the contrary, three decades later, primary health care systems in many Low- and Middle-Income countries (LMICs) including Tanzania have remained weak. Specifically, priority setting for the vulnerable groups including the elderly have been weak. We aimed to analyse the prospects and challenges of the priority setting process for the elderly health care services following the 1990s health sector reforms in Tanzania. We conducted an exploratory case study on priority setting process for the elderly healthcare services in Igunga and Nzega Tanzania. We carried out 24 Key Informant Interviews (KIIs) with the positions of District medical officers, social welfare, Medical Officers in-charge (MOI), planning officers and health system information focal person. Additionally, we carried out two focus group discussions (FGDs), one from each district with six participants from each group. Participants for the FGDs were MOI, health secretary, representative members of Health Facility Governing Committee (HFGC) and Council Health Management Team (CHMT). Data were analyzed using the qualitative content analysis. Two categories emerged from the analysis of the transcripts. These were the prospects and challenges in priority setting for the elderly population under the decentralized health sector in rural Tanzania. The prospects included; the capacity of the LGAs on priority setting; existence of strategies used by LGAs; availability of teamwork spirit and the existence of guidelines for priority setting at LGAs. The challenges included difficulties of elderly identification, insufficient resources to implement the planned activities at the LGAs, unintegrated digitalized government health information tools or programs at the LGAs, interference of LGAs by the Central Government and low interest of stakeholders on elderly health care. This study highlights the prospects and challenges facing priority setting for elderly care at the centralized health system in rural Tanzania. From the results the process is well organized but faces some challenges which if not addressed jeopardized and has potential to continue affecting the priority setting. Addressing the challenges highlighted requires joint efforts from both the elderly population in the community, healthcare providers and decision makers across all levels of the health system. This study serves as an eye-opener and calls for a bigger study to get a comprehensive picture of priority setting of the elderly health care in Tanzania.

Health data governance for research use in Alberta.

Alberta has rich clinical and health services data held under the custodianship of Alberta Health and Alberta Health Services (AHS), which is not only used for clinical and administrative purposes but also disease surveillance and epidemiological research. Alberta is the largest province in Canada with a single payer centralised health system, AHS, and a consolidated data and analytics team supporting researchers across the province. This paper describes Alberta's data custodians, data governance mechanisms, and streamlined processes followed for research data access. AHS has created a centralised data repository from multiple sources, including practitioner claims data, hospital discharge data, and medications dispensed, available for research use through the provincial Data and Research Services (DRS) team. The DRS team is integrated within AHS to support researchers across the province with their data extraction and linkage requests. Furthermore, streamlined processes have been established, including: 1) ethics approval from a research ethics board, 2) any necessary operational approvals from AHS, and 3) a tripartite legal agreement dictating terms and conditions for data use, disclosure, and retention. This allows researchers to gain timely access to data. To meet the evolving and ever-expanding big-data needs, the University of Calgary, in partnership with AHS, has built high-performance computing (HPC) infrastructure to facilitate storage and processing of large datasets. When releasing data to researchers, the analytics team ensures that Alberta's Health Information Act's guiding principles are followed. The principal investigator also ensures data retention and disposition are according to the plan specified in ethics and per the terms set out by funding agencies. Even though there are disparities and variations in the data protection laws across the different provinces in Canada, the streamlined processes for research data access in Alberta are highly efficient.

'Its many workers and subscribers feel that their services can still be of benefit': Hospital Leagues of Friends in the English West Midlands, c. 1948-1998.

Leagues of Friends are charities that provide 'personal service to patients' and 'supply hospitals with equipment not likely to come from the budgeting of authorities'. Hundreds continue to exist, and many trace their origins to before the NHS's foundation in 1948. Despite the rich and growing historiographies of voluntarism and the NHS, Leagues have received little attention. This article uses case studies of Leagues in the English West Midlands to show how 'friendship' symbolised the relationship between local NHS institutions and the communities they served. The cases show that voluntarism in British healthcare has not always been based around activism and consumerism, two areas that recent scholarship has rightly highlighted, especially from the 1960s. This allows historians to interrogate the regional and local differences within, ostensibly, a highly centralised national health system.

Implementing a group-based multi-component early child development intervention through the government health system in rural Bangladesh: A feasibility study.

Children in low- and middle-income countries face an increased risk of impaired cognitive development due to contaminated environments, poor nutrition, and inadequate responsive stimulation from caregivers. Implementing multi-component, community-level interventions may reduce these risks; however, there is little evidence supporting implementation of these interventions at scale. We assessed the feasibility of implementing a group-based intervention that included responsive stimulation, maternal and child nutrition, water and sanitation, and childhood lead exposure prevention through the government health system in Chatmohar, Bangladesh. After implementation, we conducted 17 in-depth interviews with frontline health service providers and 12 key informant interviews with their supervisors and managers to explore the facilitators and difficulties implementing such a complex programme within the health system. Factors facilitating implementation included: high quality training and skill level of providers, support from community members, family, and supervisors, positive relationships between providers and participants, and provision of children's toys and books free of cost. Difficulties included increased workload of the providers, complicated group-based yet stage-specific delivery where providers had to manage a large group of mother-child dyads representing many different child age-groups at once, and logistics difficulties in providing toys and books through a centralised health system process. Key informants made suggestions to ensure effective government-level scale-up including engaging relevant NGOs as partners, identifying feasible ways to make toys available, and offering providers meaningful even if non-monetary rewards. These findings can be used to shape the design and delivery of multi-component child development interventions to be delivered through the health system.

Evaluation and comparison of knowledge translation patterns in selected countries with Iran: A comparative study.

One of the main issues related to the inefficiency of the health system is the lack of sufficient communication between researchers and health policymakers regarding the exchange of the latest findings and the use of inappropriate evidence to manage cases. The knowledge translation removes this disconnect. In this comparative study, to obtain appropriate data on the status of knowledge translation, refer to the databases of reputable centers and governments and the knowledge translation models were reviewed in the title of main articles, abstracts, guidelines, and reports of reputable international organizations between 2005 and 2020. The origin of the models was determined, then the countries with the largest number of models were selected and analyzed using Walt and Gilson's "Policy Triangle framework in four dimensions: context, content, process, and actors." All the three countries have politically, socially, and economically made knowledge translation one of their policy priorities. Iran's centralized health system is a major obstacle. The USA and Canada have clear strategies and coherent and practical infrastructures that implement the knowledge translation in the form of operational plans. In contrast, in Iran, it has been enough to establish the knowledge translation centers at the level of universities and knowledge translation websites. In Iran, the Ministry of Health and universities of medical sciences play a direct role, but in Canada, they also use knowledge broker to apply knowledge. Iran is building capacity in the field of knowledge translation. That the implementation of interventions with the cooperation of macro policymakers can strengthen it.

Digitalizing and Upgrading Severe Acute Respiratory Infections Surveillance in Malta: System Development.

In late 2020, the European Centre for Disease Prevention and Control and Epiconcept started implementing a surveillance system for severe acute respiratory infections (SARI) across Europe. We sought to describe the process of digitizing and upgrading SARI surveillance in Malta, an island country with a centralized health system, during the COVID-19 pandemic from February to November 2021. We described the characteristics of people included in the surveillance system and compared different SARI case definitions, including their advantages and disadvantages. This study also discusses the process, output, and future for SARI and other public health surveillance opportunities. Malta has one main public hospital where, on admission, patient data are entered into electronic records as free text. Symptoms and comorbidities are manually extracted from these records, whereas other data are collected from registers. Collected data are formatted to produce weekly and monthly reports to inform public health actions. From October 2020 to February 2021, we established an analogue incidence-based system for SARI surveillance. From February 2021 onward, we mapped key stakeholders and digitized most surveillance processes. By November 30, 2021, 903 SARI cases were reported, with 380 (42.1%) positive for SARS-CoV-2. Of all SARI hospitalizations, 69 (7.6%) were admitted to the intensive care unit, 769 (85.2%) were discharged, 27 (3%) are still being treated, and 107 (11.8%) died. Among the 107 patients who died, 96 (89.7%) had more than one underlying condition, the most common of which were hypertension (n=57, 53.3%) and chronic heart disease (n=49, 45.8%). The implementation of enhanced SARI surveillance in Malta was completed by the end of May 2021, allowing the monitoring of SARI incidence and patient characteristics. A future shift to register-based surveillance should improve SARI detection through automated processes.

In Centralized Health Systems, Much Is Left Out When Analyses of Local HiAP Strategies Are Limited to Public Administration Comment on "A Realist Explanatory Case Study Investigating How Common Goals, Leadership, and Committed Staff Facilitate Health in All Policies Implementation in the Municipality of Kuopio, Finland".

We argue that the lessons drawn by Guglielmin and colleagues, from the Health in All Policies (HiAP) approach in the municipality of Kuopio, are of limited use to centralised health systems. There is a need for research more attuned to the circumstances of local governments that have little power over the provision of health programmes; yet can address a range of determinants of population health. In these cases, adopting a state-centric perspective may fail to capture the role of other actors such as non-governmental organizations (NGOs) and local branches of state agencies. Evidence from France shows that centralised health systems can foster HiAP locally through political commitment and dedicated coordination staff whose role is to mobilise and support NGOs, inhabitants, and other local branches of regional and central governments. We highlight, as three important challenges, the issue of legitimacy, funding and positioning of the HiAP instrument in the local government structure.

Provision of Mental Health Services in the Veterans Health Administration: A Nationwide Comparison With Other Providers.

Public interest in developing a national health care system has grown in the United States, but so have concerns that a large system would provide poor care. The Veterans Health Administration (VHA) is the largest national U.S. health care system, and several of its performance measures have been compared with those of non-VHA organizations. However, few studies have compared VHA's overall provision of mental health care services, and this study aimed to fill this gap. Using 2018 National Mental Health Services Survey data, the authors examined the differences in provision of 45 treatment modalities, specialized services, and dedicated programs between self-identified VHA facilities (N=459), non-VHA facilities that serve only adults (N=3,671), and non-VHA facilities that serve all ages (N=6,378). Self-identified VHA facilities offered more services (including more treatment modalities, specialized services, and dedicated programs) (mean±SD=24.2±8.9 services) than both non-VHA adult-only facilities (15.4±6.8; Cohen's d=1.11, p<0.001) and non-VHA all-ages facilities (17.1±6.6; Cohen's d=0.90, p<0.001). Notably, VHA facilities were more likely to offer electroconvulsive therapy and telemedicine. VHA facilities were more likely to offer integrated primary care, chronic illness management, supportive housing, vocational rehabilitation, and psychiatric emergency services, among others. Last, VHA facilities were more likely to offer dedicated treatment programs for patients identifying as lesbian, gay, bisexual, or transgender, as well as for patients with posttraumatic stress disorder, traumatic brain injury, or dementia. VHA facilities offer no fewer and possibly more comprehensive mental health services per facility than do non-VHA facilities, possibly because VHA represents an integrated and centralized health system.

Explaining vaccine hesitancy: A COVID-19 study of the United States.

Using recent data on the unvaccinated population across US states, this paper focuses on the determinants of vaccine hesitancy related to the COVID‐19 pandemic. Findings show that more prosperous states and states with more elderly residents and more physicians have lower vaccine hesitancy. There was some evidence of the significance of race, but internet access and history of other contagious diseases failed to make a difference. States with centralized health systems and those with mask mandates generally had a lower percentage of unvaccinated populations. Finally, the presence of Democrats in state legislatures tended to lower vaccination hesitancies, ceteris paribus.

Centralization and innovation: Competing priorities for health systems?

Over the last 15 years, there has been a trend in Canada to centralise the provision of health services that were previously administratively and fiscally decentralised. Canadian policy rhetoric on centralisation often identifies improved innovation as an anticipated outcome. This paper challenges the assumed relationship between centralisation and innovation. We incorporate evidence from the management literature into the debate on the structure of health systems to explore the effects that centralisation is likely to have on innovation in health systems. The findings of this paper will be of interest to international policymakers, who are currently grappling with the prospect of maintaining a decentralised approach or adopting a more centralised health system structure in the future.

Impact of Hospital Characteristics and Governance Structure on the Adoption of Tracking Technologies for Clinical and Supply Chain Use: Longitudinal Study of US Hospitals.

BackgroundDespite the increasing adoption rate of tracking technologies in hospitals in the United States, few empirical studies have examined the factors involved in such adoption within different use contexts (eg, clinical and supply chain use contexts). To date, no study has systematically examined how governance structures impact technology adoption in different use contexts in hospitals. Given that the hospital governance structure fundamentally governs health care workflows and operations, understanding its critical role provides a solid foundation from which to explore factors involved in the adoption of tracking technologies in hospitals.ObjectiveThis study aims to compare critical factors associated with the adoption of tracking technologies for clinical and supply chain uses and examine how governance structure types affect the adoption of tracking technologies in hospitals.MethodsThis study was conducted based on a comprehensive and longitudinal national census data set comprising 3623 unique hospitals across 50 states in the United States from 2012 to 2015. Using mixed effects population logistic regression models to account for the effects within and between hospitals, we captured and examined the effects of hospital characteristics, locations, and governance structure on adjustments to the innate development of tracking technology over time.ResultsFrom 2012 to 2015, we discovered that the proportion of hospitals in which tracking technologies were fully implemented for clinical use increased from 36.34% (782/2152) to 54.63% (1316/2409), and that for supply chain use increased from 28.58% (615/2152) to 41.3% (995/2409). We also discovered that adoption factors impact the clinical and supply chain use contexts differently. In the clinical use context, compared with hospitals located in urban areas, hospitals in rural areas (odds ratio [OR] 0.68, 95% CI 0.56-0.80) are less likely to fully adopt tracking technologies. In the context of supply chain use, the type of governance structure influences tracking technology adoption. Compared with hospitals not affiliated with a health system, implementation rates increased as hospitals affiliated with a more centralized health system—1.9-fold increase (OR 1.87, 95% CI 1.60-2.13) for decentralized or independent hospitals, 2.4-fold increase (OR 2.40, 95% CI 2.07-2.80) for moderately centralized health systems, and 3.1-fold increase for centralized health systems (OR 3.07, 95% CI 2.67-3.53).ConclusionsAs the first of such type of studies, we provided a longitudinal overview of how hospital characteristics and governance structure jointly affect adoption rates of tracking technology in both clinical and supply chain use contexts, which is essential for developing intelligent infrastructure for smart hospital systems. This study informs researchers, health care providers, and policy makers that hospital characteristics, locations, and governance structures have different impacts on the adoption of tracking technologies for clinical and supply chain use and on health resource disparities among hospitals of different sizes, locations, and governance structures.

Development of a Centralized Antimicrobial Stewardship Program Across a Diverse Health System and Early Antimicrobial Usage Trends.

BackgroundExpanding antimicrobial stewardship to community hospitals is vital and now required by regulatory agencies. UPMC instituted the Centralized Health system Antimicrobial Stewardship Efforts (CHASE) Program to expand antimicrobial stewardship to all UPMC hospitals regardless of local resources. For hospitals with few local stewardship resources, we used a model integrating local non-Infectious Diseases (ID) trained pharmacists with centralized ID experts.MethodsThirteen hospitals were included. Eleven were classified as robust (4) or nonrobust (7) depending on local stewardship resources and fulfillment of Centers for Disease Control and Prevention core elements of hospital antimicrobial stewardship. In addition to general stewardship oversight at all UPMC hospitals, the centralized team interacted regularly with nonrobust hospitals for individual patient reviews and local projects. We compared inpatient antimicrobial usage rates at nonrobust versus robust hospitals and at 2 UPMC academic medical centers.ResultsThe CHASE Program expanded in scope between 2018 and 2020. During this period, antimicrobial usage at these 13 hospitals decreased by 16% with a monthly change of −4.7 days of therapy (DOT)/1000 patient days (PD) (95% confidence interval [CI], −5.5 to −3.9; P < .0001). Monthly decrease at nonrobust hospitals was −3.3 DOT/1000 PD per month (−4.5 to −2.0, P < .0001), similar to rates of decline at both robust hospitals (−3.3 DOT/1000 PD) and academic medical centers (−4.8 DOT/1000 PD) (P = .167).ConclusionsCoordinated antimicrobial stewardship can be implemented across a large and diverse health system. Our hybrid model incorporating a central team of experts with local community hospital pharmacists led to usage decreases over 3 years at a rate comparable to that seen in larger hospitals with more established stewardship programs.

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The requirements of developing programs for the management of non-communicable diseases in Iran based on the CIPP model: a qualitative study

PurposeOne of the priorities of the health system is community health promotion. In this regards, proper development of programs and plans is needed to create a responsive system which leads to health promotion. The aim of this study was to identify the requirements for developing non-communicable disease (NCDs) programs based on CIPP (context, input, process and product) model.Design/methodology/approachThis is a qualitative study. Data were collected through semi-structured interviews with 40 experienced informants in the field of NCDs. The interviewees were selected bases on pre-determined criteria which then were completed by snowball sampling. Analysis was carried out using a content analysis approach that led to identifying program development requirements in four dimensions of context, input, process and product.FindingsTwenty-nine requirements of developing program were categorized in four domains of context, input, process and product. These requirements comprised of pilot studies, the existence of appropriate needs assessment, evidence-based programs, promoting organizational culture, adequacy of resources, identification of stakeholders and comprehensive cooperation and existence of an appropriate evaluation system.Research limitations/implicationsSince this study was performed through a qualitative method, it is possible, some prerequisites of program development may not be encountered. But the extreme effort has been made to perceive diversity and different aspects.Originality/valueThe first study was in the field of appropriate requirements for program development in the context of a centralized health system in a developing country.

Ovarian Cancer in the Sudan - Identifying the Social and Clinical Factors that Prevent an Early Diagnosis

Ovarian cancer, because it often presents with vague symptoms, is a difficult disease to diagnose at the early stages, especially in developing countries. In Sudan, diagnosis is further complicated by additional factors and challenges. First, as in any developing country, access to treatment, facilities and medical staff is generally lacking. Secondly, Sudan is the second largest country in Africa: its very size presents difficulties for the implementation of a centralized health system. The two tertiary hospitals in or near the capital have long patient waiting lists. The lack of female education in sub-Saharan Africa, together with social and economic issues affecting women, is a further obstacle to disease diagnosis and management. Misdiagnosis, leading to inappropriate treatment, may result from the presence of comorbid diseases such as Tuberculosis (TB), which can mimic ovarian cancer and obstruct early detection. Most patients are identified at the later stages when the complications associated with invasive procedures and conventional chemotherapy make treatment much less effective. The early detection of biomarkers may prove to be a vital tool to indicate targets for immunotherapy treatment. Financial aid may help improve the outcomes for patients with ovarian cancer in the Sudan, assisting with diagnosing and management procedures including training medical staff. Research and development, documentation and updating the statistical register for the whole country are also important requirements for future improvements. Finally, there is a need to promote interdisciplinary work between surgeons and clinical oncologists to optimize international guidelines and protocols in accordance with the facilities available.

Scaling up public health interventions: case study of the polio immunization program in Indonesia

BackgroundThe scaling up of public health interventions has received greater attention in recent years; however, there remains paucity of systematic investigations of the scaling up processes. We aim to investigate the overall process, actors and contexts of polio immunization scaling up in Indonesia from 1988 until 2018.MethodsA mixed method study with sequential explanatory design was conducted. We carried out a quantitative survey of 323 actors involved in the polio program at national and sub-national levels, followed by Key Informant Interviews (KII)s. Document review was also carried out to construct a timeline of the polio eradication program with milestones. We carried out descriptive statistical analysis of quantitative data and thematic analysis of qualitative data.ResultsThe scaling up of polio immunization in Indonesia started as a vertical expansion approach led by the Ministry of Health within a centralized health system. The coverage of immunization increased dramatically from 5% in the earlier 80s to 67.5% in 1987; incremental increases followed until achieving Universal Child Immunization (UCI) in 1990 and subsequently 95% coverage in 1995. Engagement of stakeholders and funding made the scaling up of polio immunization a priority. There was also substantial multisector involvement, including institutions and communities. Local area monitoring (LAM) and integrated health posts (Posyandu) were key to the polio immunization implementation strategy. Challenges for scaling up during this centralized period included cold chain infrastructure and limited experience in carrying out mass campaigns. Scaling up during the decentralized era was slower due to expansion in the number of provinces and districts. Moreover, there were challenges such as the negative perception of immunization side-effects, staff turnover, and the unsmooth transition of centralization towards decentralization.ConclusionVertical scaling up of polio immunization program intervention was successful during the centralized era, with involvement of the president as a role model and the engine of multi sector actors. Posyandu (integrated health posts) played an important role, yet its revitalization after the reform-decentralization era has not been optimum.

Centralized Electronic Health Records System: A Step Towards an Optimized Health Care Delivery System Ahead of Possible Future Outbreaks

COVID-19, the very recent pandemic that brought the global world to its knees has costed the lives of millions, the economy of many nations crippled, a lot of lives distorted due to this unforeseen attack on the health security of the whole world. Outbreaks such as the COVID-19 thrive with increasing mobility all around the world as this novel disease found its way into almost all the nations of the world in less than 6 months. This increases the likelihood for another outbreak of similar nature to occur in the future except certain long-term measures are put in place to strengthen and optimize the health care delivery system and health security. Centralized Electronic Health record system is a core system emanating across developed countries to help improve health system and better health delivery. Apparently, its introduction is somewhat in very few parts of the world, howbeit its full potential is yet to be maximized due to the reluctance of many nations to consider it. In addition, this article highlights the cardinal role of Centralized Health System in surmounting ineffective health care system, highlighting challenges faced by countries faced with the least Human Development Index and discusses why the employment of this system is significant towards achieving an optimized health care system that will be equipped enough to numb the spread of any possible outbreak even before it begins.

Understanding how health systems facilitate primary care redesign.

To understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work. A purposive sample of 24 health systems in 4 states. Data were systematically reviewed to identify how system leaders define and implement initiatives to redesign primary care delivery and identify challenges. Researchers applied codes which were based on the theoretical PCR literature and created new codes to capture emerging themes. Investigators analyzed coded data then produced and applied a thematic analysis to examine how health systems facilitate PCR. Semi-structured telephone interviews with 162 system executives and physician organization leaders from 24 systems. Leaders at all 24 health systems described initiatives to redesign the delivery of primary care, but many were in the early stages. Respondents described the use of centralized health system resources to facilitate PCR initiatives, such as regionalized care coordinators, and integrated electronic health records. Team-based care, population management, and care coordination were the most commonly described initiatives to transform primary care delivery. Respondents most often cited improving efficiency and enhancing clinician job satisfaction, as motivating factors for team-based care. Changes in payment and risk assumption as well as community needs were commonly cited motivators for population health management and care coordination. Return on investment and the slower than anticipated rate in moving from fee-for-service to value-based payment were noted by multiple respondents as challenges health systems face in redesigning primary care. Given their expanding role in health care and the potential to leverage resources, health systems are promising entities to promote the advancement of PCR. Systems demonstrate interest and engagement in this work but face significant challenges in getting to scale until payment models are in alignment with these efforts.

The role of health system context in the design and implementation of performance-based financing: evidence from Cote d’Ivoire

Low quality of care is a significant problem for health systems in low-income and middle-income countries (LMICs). Policymakers are increasingly interested in using performance-based financing (PBF), a system-wide provider payment...

Restructuring Health Reform, Mexican Style

ABSTRACT Mexico’s health system is undergoing major restructuring by the administration of President Andrés Manuel López Obrador (known as AMLO) starting in December 2018. The government has eliminated the 2003 health reform (Seguro Popular) from national laws and government agencies and is returning Mexico to a centralized health system with integrated public financing and delivery and reduced private participation. This article looks at the political drivers of Mexico’s restructuring reform. Three main ethical principles are identified as the foundation for the government’s health system vision: universality, free services, and anti-corruption. The article then compares what existed under Seguro Popular with the new system under the Instituto de Salud para el Bienestar (INSABI), which began on 1 January 2020. The analysis uses the five policy levers that shape health system performance: financing, payment, organization, regulation, and persuasion. The article concludes with five lessons about the reform process in Mexico. First, undoing past reforms is much easier than implementing a new system. Second, the AMLO government’s restructuring emerged more from broad ethical principles than detailed technical analyses, with limited plans for evaluation. Third, the overarching values of the AMLO government reflect a pro-statist and anti-market bias, swimming against the global flow of health policy trends to include the private sector in reforming health systems. Fourth, the experiences in Mexico show that path dependence does not always work as expected in policy reform. Finally, the debate of Seguro Popular versus INSABI shows the influence of personality politics and polarization.