Delivery Of Critical Services Research Articles

Association of Federal COVID-19 Funding Distributions With Workforce and Capacity in Health Centers.

Using novel national data, we examined the association between 2020 federal COVID-related funding targeted to health centers (i.e., H8 funding) and health center workforce and operational capacity measures that may be important for preserving patient access to care and staff safety. We assigned health centers to quartiles based on federal funding distribution per patient and used adjusted linear probability models to estimate differences in workforce and operational capacity outcomes across quartiles from April 2020 to June 2022. We found a nearly 6-fold difference in 2020 H8 funding per patient when comparing health centers in the lowest versus highest quartiles. Despite this difference, health centers' outcomes improved similarly across quartiles over time, with the lowest-funded health centers having the greatest staffing and service capacity challenges. Our findings suggest that COVID-related health center funding may have contributed to stabilization of health centers' workforce and operations. Amid concerns about staff turnover, sustained investments targeted to supporting workforce retention at health centers can help to ensure ongoing delivery of critical services.

A Regeneration Model for Mitigation Against Attacks on HTTP Servers for Mobile Wireless Networks

The widespread expansion of the internet has fueled a global surge in the utilization of various online transactions, with a significant portion of such services operating on mobile web platforms. Simultaneously, the deployment of innovative Mobile Ad Hoc Network (MANET) technologies and mobile applications has grown as solutions for diverse tasks. Unfortunately, this progress has attracted the attention of hackers, who continually devise new strategies to exploit the vulnerabilities inherent in mobile networks. This study aims to address the escalating challenges posed by cyber threats in the era of widespread internet expansion, particularly focusing on securing mobile web platforms against sophisticated attacks such as Structured Query Language Injection (SQLi) for web-based database solutions and Denial of Service (DoS/DDoS) for various applications. In response to the identified vulnerabilities, this paper proposes an HTTP regeneration (HReg) model that not only detects various cyber-attacks but also ensures the uninterrupted provision of critical services during such incidents. The model introduces an innovative regeneration algorithm capable of scanning both the connection channel and web application to detect attacks, creating survivable connections within the underlying TCP engine to replace compromised ones during an ongoing attack. In simulated environments using OMNeT++, where the server is subjected to attacks, the experimental results demonstrate the efficacy of the model. The response and performance metrics, including throughput (73%), delivery ratio (68.8%), delay (3s), and network load, showcase the model's ability to detect and neutralize attacks. A comparison with state-of-the-art approaches highlights the superior performance of the regeneration model, attributed to its additional survivability layer. While the regeneration model proves robust in simulated environments, its real-world application may encounter limitations. Future research should explore these limitations to enhance the practical applicability of the proposed model. The proposed HReg model's resilient performance under attack conditions ensures the survivability of web-based applications. This innovative approach offers practical implications for securing mobile web platforms, providing continuous delivery of critical services even in the face of persistent and evolving cyber threats. This research addresses a significant gap in existing efforts by not only focusing on attack detection but also emphasizing the development of a survivable TCP connection for HTTP servers during attacks. The introduced regeneration model stands out for its unique ability to maintain service continuity, showcasing originality in the approach to cybersecurity in the context of web-based applications.

Securing Lifelines: Safe Delivery of Critical Services in Areas with Volatile Security Situation via a Stackelberg Game Approach

Vaccine delivery in under-resourced locations with security risks is not just challenging but also life threatening. The COVID pandemic and the need to vaccinate added even more urgency to this issue. Motivated by this problem, we propose a general framework to set-up limited temporary (vaccination) centers that balance physical security and desired (vaccine) service coverage with limited resources. We set-up the problem as a Stackelberg game between the centers operator (defender) and an adversary, where the set of centers is not fixed a priori but is part of the decision output. This results in a mixed combinatorial and continuous optimization problem. As part of our scalable approximation solution, we provide a fundamental contribution by identifying general duality conditions of switching max and min when both discrete and continuous variables are involved. Via detailed experiments, we show that the solution proposed is scalable in practice.

Protection and Maintenance of Healthcare Services for Civilians’ Well-Being in Conflict Affected Areas: Comparative Analysis of The African Situation

Purpsoe: Medical neutrality refers to a globally accepted principle derived from International humanitarian law (IHL), International Human Rights Law and Medical Ethics. It is based on the principles of non-interference with medical services in times of armed conflict and civil unrest. It promotes the freedom for physicians and aid personnel to care for the sick and wounded, and to receive care regardless of political affiliation. The purpose of this study was to examine comparatively, the extent in which humanitarian aid access, healthcare facilities and healthcare professionals are protected in conflict affected areas in Africa. The protection of health personnel, health services and humanitarian workers is no longer respected. This compromises the achievement of the United Nations Sustainable Development Goals 3 – towards health for all, and 16 – towards justice and peace.
 Methdology: The study was guided by Andersen’s Behavioral Model of health service of 1995. Methodological wise, the study was depended on desktop review of empirical research including the works of Ramadan (2020) on availability of primary healthcare services in conflict affected areas as well as the works of Altare et al (2020) on the experience of women, children and adolescents in conflicts affected areas among others.
 Findings: The findings show that, limited infrastructure, lack of skilled personnel, and shortages of essential medical supplies hinder access to healthcare services, creating a significant gap in humanitarian aid for civilians in these areas. The study also reveals the vulnerability of health facilities and healthcare workers to attacks during conflicts, emphasizing the need for enhanced protection measures. Destruction of communication infrastructure and disrupted transportation further impede the functioning of health facilities and the delivery of critical services. The study underscores the limited access to humanitarian aid, the need for greater protection of health facilities, and the challenges in safeguarding healthcare professionals in conflict affected areas in Africa.
 Recommendations: The study recommends prioritization of the protection of health facilities and healthcare professionals, enhanced security measures, advocacy for International Humanitarian Law (IHL), support for healthcare infrastructure, improved access to healthcare, facilitation of humanitarian aid, support for peacebuilding initiatives and strengthening of monitoring and accountability by African Nations.

Associations between sociodemographic factors and receiving "ask and advise" services from healthcare providers in India: analysis of the national GATS-2 dataset

BackgroundIndia is home to about 12% of the world's tobacco users, with about 1.35 million tobacco-related deaths each year. The morbidity and mortality rates are socially patterned based on gender, rural vs. urban residence, education, and other factors. Following the World Health Organization's guidance, it is critical to offer tobacco users support for cessation as a complement to policy and environmental changes. Such guidance is typically unavailable in low-resource systems, despite the potential for population-level impact. Additionally, service delivery for tobacco control tends to be patterned by sociodemographic factors. To understand current activity in this area, we assessed the percentage of daily tobacco users being asked about tobacco use and advised to quit by a healthcare provider. We also examined social patterning of receipt of services (related to by rural vs. urban residence, age, gender, education, caste, and wealth).MethodsWe analyzed cross-sectional data from India's 2016-2017 Global Adult Tobacco Survey (GATS-2), a nationally representative survey. Among 74,037 respondents, about 25% were daily users of smoked and/or smokeless tobacco. We examined rates of being asked and advised about tobacco use overall and based on rural vs. urban residence, age, gender, education, caste, and wealth. We also conducted multivariate logistic regression to assess the association of demographic and socioeconomic conditions with participants' receipt of “ask and advise” services.ResultsNationally, among daily tobacco users, we found low rates of individuals reporting being asked about tobacco use or advised to quit by a healthcare provider (22% and 19%, respectively). Being asked and advised about tobacco use was patterned by age, gender, education, caste, and wealth in our final regression model.ConclusionsThis study offers a helpful starting point in identifying opportunities to address a critical service delivery gap in India. Given the existing burden on the public health and health systems, scale-up will require innovative, resource-appropriate solutions. The findings also point to the need to center equity in the design and scale-up of tobacco cessation supports so that marginalized and underserved groups will have equitable access to these critical services.

An assertive, practical, and substantive agenda to catalyse meaningful change

The Lancet Global Health Commission on financing primary health care1 combines a shared vision with practical guidance on how to align health financing with overall reform strategies that place primary care service delivery at the core. The Commission reinforces key messages that WHO has put forward on health financing reforms to enable progress towards universal health coverage (UHC). It then extends these by application to primary care as a critical service delivery element for the progressive realisation of UHC.

An integrated cyber security risk management framework and risk predication for the critical infrastructure protection

Cyber security risk management plays an important role for today’s businesses due to the rapidly changing threat landscape and the existence of evolving sophisticated cyber attacks. It is necessary for organisations, of any size, but in particular those that are associated with a critical infrastructure, to understand the risks, so that suitable controls can be taken for the overall business continuity and critical service delivery. There are a number of works that aim to develop systematic processes for risk assessment and management. However, the existing works have limited input from threat intelligence properties and evolving attack trends, resulting in limited contextual information related to cyber security risks. This creates a challenge, especially in the context of critical infrastructures, since attacks have evolved from technical to socio-technical and protecting against them requires such contextual information. This research proposes a novel integrated cyber security risk management (i-CSRM) framework that responds to that challenge by supporting systematic identification of critical assets through the use of a decision support mechanism built on fuzzy set theory, by predicting risk types through machine learning techniques, and by assessing the effectiveness of existing controls. The framework is composed of a language, a process, and it is supported by an automated tool. The paper also reports on the evaluation of our work to a real case study of a critical infrastructure. The results reveal that using the fuzzy set theory in assessing assets' criticality, our work supports stakeholders towards an effective risk management by assessing each asset's criticality. Furthermore, the results have demonstrated the machine learning classifiers’ exemplary performance to predict different risk types including denial of service, cyber espionage and crimeware.

Community perception of ecosystem services from commercially managed forests in Bhutan

Given the direct dependence rural communities have on forests, understanding ecosystem services can empower communities and align stakeholders to define priorities and objectives for the sustainable management of forest resources. In this qualitative study on the forest ecosystem services in Bhutan, we assessed community awareness and perceptions of local forest ecosystem services, identified their top priorities, and evaluated how they have changed over time. The study focused on state reserve forest areas designated for commercial timber production, formally known as forest management units (FMU). We held focus group discussions separately with women and men associated with five FMUs in the central belt of the country. Participants identified 45 ecosystem services, with soil productivity, freshwater, timber, fresh air, construction stone, carbon sequestration, spiritual value, pollination, and local weather regulation comprising the most highly valued services critical to local livelihood and well-being. Participants felt that forest ecosystem services have been generally declining over the past decade in the FMUs and identified a need for forest restoration activities to improve their delivery. We recommend that state forest entities conduct an awareness campaign to empower communities with the conceptual framework and globally recognized concepts to advocate for their needs related to forests. We also recommend that biophysical and economic studies be conducted in these areas to seek evidence for causal linkages between natural resource use and the status of ecosystem services. This study contributes to a growing literature on ecosystem services in Bhutan and provides a basis for future studies to understand how management activities can impact the delivery of critical services.

Managing critical services through hybrid arrangements

Purpose Building on the literature of hybrids in the context of public organizations, this paper aims to discuss under which conditions hybrids can adequately provide “critical services”, a subset of public services characterized by their simultaneous exposure to externalities, socio-economic cohesion and legitimacy concerns. Design/methodology/approach The authors collect indications from two stylized examples, prisons and defense, to develop propositions as a step toward assessing the potential role of hybrids as alternatives to direct public provision or full privatization in the delivery of critical services. Findings This paper examines the conditions under which hybrid arrangements outperform the polar cases of public bureaus and full privatization in the delivery of a specific subset of public goods that the authors identify as “critical services”. Originality/value The authors suggest that there might be comparative advantages in relying on hybrid arrangements rather than the usual solutions of fully private or fully governmental provision. However, they also submit that these advantages are conditional to the capacity of hybrids to reconcile competing interests to achieve socio-economic cohesion, to combine capabilities dispersed among partners to benefit from positive externalities and to satisfy legitimacy concerns with respect to the role of government.

Reliable maximin–maxisum locations for maximum service availability on tree networks vulnerable to disruptions

In this era of ubiquitous networks that become increasingly vulnerable to disruptions, network reliability has emerged as a critical issue in their design and operation. Businesses and individuals become ever more dependent on networks and demand reliable delivery of critical services every time. This paper finds Pareto optimal locations for a single facility on an existing tree network that maximizes service availability to customers by considering both the average and the lowest level of service delivery with respect to all customers. Examples are the location of decision entities on information infrastructures, servers or databases on computer networks, control systems on telecommunication networks, critical information on social networks, supply centers on supply chain networks, and location of emergency response facilities to intentional or natural disasters. Model properties are identified in decision and objective space and used to develop an efficient algorithm for finding the efficient and the non-dominated sets. Numerical examples are provided to illustrate the algorithm and to show special conditions for the efficient and non-dominated sets to be continuous.

Primary Health Care That Works: The Costa Rican Experience.

Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.

Improving HIV outcomes in resource-limited countries: the importance of quality indicators

BackgroundResource-limited countries increasingly depend on quality indicators to improve outcomes within HIV treatment programs, but indicators of program performance suitable for use at the local program level remain underdeveloped.MethodsUsing the existing literature as a guide, we applied standard quality improvement (QI) concepts to the continuum of HIV care from HIV diagnosis, to enrollment and retention in care, and highlighted critical service delivery process steps to identify opportunities for performance indicator development. We then identified existing indicators to measure program performance, citing examples used by pivotal donor agencies, and assessed their feasibility for use in surveying local program performance. Clinical delivery steps without existing performance measures were identified as opportunities for measure development. Using National Quality Forum (NQF) criteria as a guide, we developed measurement concepts suitable for use at the local program level that address existing gaps in program performance assessment.ResultsThis analysis of the HIV continuum of care identified seven critical process steps providing numerous opportunities for performance measurement. Analysis of care delivery process steps and the application of NQF criteria identified 24 new measure concepts that are potentially useful for improving operational performance in HIV care at the local level.ConclusionAn evidence-based set of program-level quality indicators is critical for the improvement of HIV care in resource-limited settings. These performance indicators should be utilized as treatment programs continue to grow.

Persistence of High Maternal Mortality in Koppal District, Karnataka, India: Observed Service Delivery Constraints

Rural women with obstetric complications access many health providers in Koppal, the poorest district in the state of Karnataka, south India. Yet they die. Based on insights derived from case studies of women seeking emergency obstetric care and participant-observation of government health services, this article highlights service delivery constraints that underlie the persistence of high levels of maternal mortality in Koppal. Weak information systems, discontinuity in care, unsupported health workers, haphazard referral systems and distorted accountability mechanisms are identified as critical service delivery problems. For example, maternal deaths are under-reported and not reviewed, antenatal care and institutional delivery are not linked to post-partum or emergency obstetric care, and health workers use inappropriate injections but don’t treat anaemia or sepsis. Families waste valuable time and resources accessing many providers but fail to get effective care, and blame is laid on lower-level health workers and women for not accessing institutional delivery. Lastly, the role of administrators and politicians in ensuring functioning health services is obscured. While important supply and demand-side reforms are being implemented, these do not constructively engage with informal providers nor address systemic service delivery constraints. Critical managerial change is required, without which new budgetary allocations will be squandered with little impact on saving women’s lives.RésuméÀ Koppal, le district le plus pauvre de l’État de Karnataka en Inde méridionale, les femmes rurales présentant des complications obstétricales ont accès à de nombreux prestataires de soins. Pourtant, beaucoup d’entre elles succombent. Utilisant les données d’études sur des femmes ayant demandé des soins obstétricaux d’urgence et les observations des participants sur les services de santé gouvernementaux, cet article dégage les facteurs de la persistance de taux élevés de mortalité maternelle à Koppal; faiblesse des systèmes d’information, discontinuité des soins, soutien insuffisant aux agents de santé, manque de rigueur des systèmes d’orientation des patientes et mécanismes biaisés de responsabilité. Par exemple, les décès maternels sont sous-notifiés et ne sont pas étudiés, les soins prénatals et les accouchements en milieu institutionnel ne sont pas liés aux soins post-partum ou obstétricaux d’urgence, et les agents de santé utilisent des injections contre-indiquées, sans vraiment traiter l’anémie ou la septicémie. Les familles perdent des ressources et un temps précieux pour consulter de nombreux prestataires, mais n’obtiennent pas de soins efficaces; elles en rendent responsables les agents de santé du niveau inférieur et les femmes pour n’avoir pas accouché dans un établissement de soins. Enfin, le rôle des administrateurs et des politiciens pour garantir des services de santé efficaces est dissimulé. Des réformes importantes de l’offre et de la demande sont mises en oeuvre mais elles n’associent pas constructivement les prestataires informels, pas plus qu’elles ne s’attaquent aux obstacles systémiques. Un profond changement administratif est nécessaire, faute de quoi de nouvelles allocations budgétaires seront gaspillées, sans parvenir à sauver la vie des femmes.ResumenA pesar de tener acceso a numerosos prestadores de servicios de salud en Koppal, el distrito más pobre del estado de Karnataka, en la India meridional, muchas mujeres rurales con complicaciones obstétricas continúan muriendo. Basado en estudios de casos de mujeres que buscan cuidados obstétricos de emergencia y en la observación participante en servicios de salud gubernamentales, este artículo destaca las limitaciones de la prestación de servicios implícitas en la persistencia de los altos índices de mortalidad materna en Koppal, por ejemplo: sistemas de información débiles, discontinuidad de los cuidados, trabajadores de salud sin apoyo, sistemas de referencia al azar y mecanismos distorsionados de responsabilidad. Por ejemplo, las muertes maternas son subreportadas y no revisadas, la atención antenatal y el parto institucional no son vinculados con los cuidados obstétricos posparto o de emergencia, y los trabajadores de salud utilizan inyecciones indebidas pero no tratan la anemia o sepsis. Las familias desperdician tiempo y recursos valiosos cuando acceden a muchos prestadores de servicios sin obtener cuidados eficaces, y la culpa recae en los trabajadores de salud de nivel inferior y en las mujeres por no tener un parto institucional. Por último, no queda clara la función de los administradores y políticos en garantizar servicios de salud en buen estado de funcionamiento. A pesar de que se están implementando importantes reformas relacionadas con la oferta y demanda, éstas ni implican constructivamente a los prestadores de servicios extraoficiales ni tratan las limitaciones sistémicas de la prestación de servicios. Se necesita un cambio administrativo fundamental, sin el cual nuevas distribuciones presupuestales serían derrochadas con poco impacto en los esfuerzos por salvar la vida de las mujeres.

Building an Effective Research Partnership Between a University and a State Correctional Agency: Assessment of Drug Treatment in Pennsylvania Prisons

The purpose of this project was to develop a collaborative research partnership between Temple University’s Center for Public Policy and the Pennsylvania Department of Corrections (DOC), with a demonstration research project that included three main elements: (a) a descriptive assessment of drug and alcohol programming (through program surveys and a 1-day symposium with treatment staff members), including the identification of critical service delivery components and goals; (b) an intensive on-site process evaluation of representative programs at two institutions; and (c) the preparation of an outcome evaluation research design on the basis of analyses and discussion between Temple and the DOC. This article summarizes critical stages in the development of the partnership; reactions from Steering Committee members and drug treatment staff members; results from a survey of 118 drug treatment programs at 24 state prisons; major findings from process evaluation; and implications for drug treatment programming, policy, and evaluation.

Strengthening research to improve the practice and management of long-term care.

Past investments in long-term care (LTC) research have improved the quality of care and the quality of life for LTC recipients by conceptualizing the goals and measuring the outcomes of care, designing practical assessment tools, testing clinical interventions, and evaluating new service delivery programs and models. To build a balanced portfolio of LTC research that will yield and sustain increased dividends in quality and outcomes will require (1) increasing investment in both basic and applied LTC research to ensure that critical service delivery issues are addressed in a rigorous and timely fashion, (2) fostering better communication between researchers and users to ensure research salience and credibility, and (3) dedicating more resources to identifying and implementing successful methods for translating LTC research into practice.

Developing an overarching legal framework for critical service delivery in America’s cities: Three recommendations for enhancing security and reliability

State and Local governments must develop an overarching legal foundation to manage critical service delivery in an electronic environment. Prior to establishing a foundation, decision-makers must first adopt a philosophy that focuses and harnesses expressions of law and public policy. The research and development community must supports the nation’s efforts with programs designed to aid in the risk assessment process. These programs must focus on identifying better ways to quantify risk, understanding infrastructure interdependency, and measuring cascading damages flowing from service outages. Finally, State and Local leaders should adopt security guidelines for industry and government service providers. Guidelines involve ten well-defined process requirements, all of which must be implemented to provide services online and in a safe and secure manner.

Towards ITS Map Database Interoperability—Database Error and Rectification

One of the impediments to the implementation of ITS is the lack of map database interoperability. Centreline databases are available from a number of sources, but few were designed specifically for ITS. Consequently there are a variety of problems—coordinate inaccuracy, errors of omission and commission, missing or wrong street names, incorrect topology—that are compounded when communicating parties use databases from different vendors. Many ITS applications (e.g., emergency response, ATIS) rely on the exchange of messages in which location is a component. Map error and interoperability problems can result in a variety of practical difficulties, from inappropriate vehicle routing to delays in delivery of critical services. These problems can be addressed by (a) standards for map databases, (b) intelligent messaging, (c) national integration efforts to improve database quality in the long term. This paper examines the dimensions of the problem, and describes solutions currently under development.