Decentralization Of Services Research Articles

Patient pathways in primary health care – an interview study across various health care personnel in a Canadian and a Norwegian county

BackgroundDue to demographic changes in the Western world governments emphasize the need for viable solutions, e.g. through decentralization of specialist health care services and better coordination within and between health care services. Both Norway and Canada have been through health care reforms and initiatives aiming to improve continuity and coordination of services. Organizational change to primary care in both countries encompasses both team-based service delivery involving allied health professionals, and new blended payment models. The objective of this study was to explore patient pathways in primary healthcare from various health personnel’s perspectives, and across various primary care organizations in Norway and Canada.MethodsThe study had a qualitative design, including interviews with physicians, nurses and managers (n = 19) in primary care, from a county in Norway and a region in Canada. Data were analyzed with a thematic approach, in line with recommendations from Braun & Clarke.ResultsThree themes were identified: 1) Structural challenges, 2) Towards a more specialized primary health care and 3) Dedication could improve continuity. Findings indicate that coordinating health care services was assumed difficult due to different health care levels, funding systems, managements, electronic record systems and organizations. Hospitals were assumed more task oriented, while primary health care services were considered more care oriented, and this challenged the coordination across organizations. Primary care services were perceived to be more and more specialized, also representing a threat for coordination and continuity. Health care personnel in both countries perceived that dedicated personnel for each patient could improve information flow and continuity across services.ConclusionsAchieving continuity and coordination of health care services seems challenging. Integration strategies seem essential for reducing silo thinking and fragmentation of health care services.

A cross-comparative analysis of child poverty across sub-Saharan Africa: the case of Francophone and Anglophone African states

PurposeThe institutional structures established by French and British colonists continue to shape the socio-economic landscape of sub-Saharan Africa, potentially contributing to the unequal distribution of child poverty. This study, therefore, has significant relevance as it aims to estimate child poverty disparities within the context of colonial origins in Francophone and Anglophone African countries.Design/methodology/approachThis study utilised data from the Demographic and Health Surveys (DHS) conducted between 2000 and 2019 involving 22 sub-Saharan African states. A rights-based framework was applied based on the SDG-updated Gordon et al. (2003) methodology to measure child poverty. We then compared child poverty disparities between colonial origins using one-way ANOVA tests and risk ratios to quantify the magnitude of these differences.FindingsCritically high estimates of sanitation and housing poverty (above 70% prevalence) were observed in the two colonial settings. Children in Francophone states were 1.4 times (RR = 1.4; 95% CI: 1.1–1.8) more likely to experience higher risks of low medical access, almost twice as likely to experience low vaccine uptake (risk ratios-RR = 1.8; 95% CI: 1.2–2.8) or no formal education (RR = 1.7; 95% CI: 1.1–2.5). All other dimensions were equal between colonial origins.Research limitations/implicationsDue to its cross-comparative approach, this study is restricted in making conclusive inferences regarding the causal relationship between colonialism and health/education poverty. Also, given the limited number of countries, particularly Anglophone countries, our sample may not fully represent all French and British ex-colonies. As a follow-up to this study, we intend to repeat this analysis using the harmonised Multiple Indicator Cluster (MIC) surveys, providing a larger number of countries.Originality/valueDespite similar household poverty levels in both colonial settings, Francophone states had lower access to health and education services than Anglophone states. These findings indicate deeper systemic issues that may be rooted in the historical governance styles of centralisation. More effective decentralisation of healthcare and education services in Francophone countries and improved government commitment to addressing household poverty throughout sub-Saharan Africa are imperative.

The implementation process of decentralization of health services: a qualitative perspective from Sudan.

Health system reform initiatives have increasingly embraced decentralization as a key trend. The implementation process and its outcomes are influenced by a myriad of factors, including economic forces, political dynamics, and ideological factors. Comprehending and carefully examining the implementation phase of decentralization and its consequences to achieve desired outcomes is crucial. Notably, this phase is often considered the weakest aspect of policy reforms, especially in developing countries. Therefore, this study aimed to explore and analyze the implementation phase of decentralization and its implications as essentials for achieving intended goals. The study objectives evolved around examining the entire decentralization as a multifaceted social and political process in Khartoum State, Sudan, from its early stages of decision-making, policy formulation, and implementation process and the influencing contextual factors. This study was an exploratory qualitative study that employed in-depth interviews to gather perspectives of healthcare providers and policymakers, semi-structured observations, and thematic analysis. The study utilized Grindle's framework for analysis. This study revealed a political nature of decision-making, with a top-down approach to the implementation, which also lacked stakeholder involvement. It showed a lack of transparency, official documentation, and proper handover procedures from the Ministry of Health to the devolved hospitals during the implementation process. A conflict of interest between the federal and the state level was also reported. It is important to note that this process occurred within the context of structural adjustment program (SAP) schemes, which had already empowered the private sector in Sudan. This study documented the implementation process of decentralization of health services and its influencing factors. The study recommended reforming the decentralization policy through consultative stakeholder involvement and by implementing a concurrent responsibility paradigm that divides authority between the federal and state levels.

Decentralisation as a marketing strategy for archival services in Zimbabwe

Purpose Archival institutions must make their holdings and services known to the public to ensure increased usage. It is the obligation of archival institutions to adopt strategies to market their services to increase the usage of their holdings. Therefore, this study aims to assess the National Archives of Zimbabwe’s (NAZ) decentralisation drive as a strategy to market its archival services. Design/methodology/approach The multiple case study research design, which is interpretive and qualitative, was used for the study. The study used interviews, questionnaires and document review as data collection tools. The collected data were presented, analysed and discussed using the thematic data analysis approach. Findings Findings revealed that the NAZ decentralised provincial records centres were actively involved in the marketing of archival services offered by the NAZ. The study also established that the decentralised provincial records centres perform activities such as records surveys, training, oral history, issuance of brochures, guided tours and career guidance, which increase their interactions with communities they serve. The decentralised offices took advantage of these interactions to market archival services offered by the NAZ. Originality/value The study illustrated that decentralisation of archival institutions and services to the lower tiers of government is a powerful strategy for the marketing of archival services. Therefore, there is need for archival institutions to adopt or enhance the use of this strategy to increase the usage of archives.

Predictors of mortality among multidrug-resistant tuberculosis patients after decentralization of services in Tanzania from 2017 to 2019: retrospective cohort study

BackgroundMultidrug-resistant tuberculosis (MDR-TB) presents persistent global health challenges, characterized by low treatment success rates among patients enrolled for treatment. The World Health Organization recommends decentralization to improve outcomes. This study aims to assess predictors of mortality among MDR-TB patients after decentralization of services in Tanzania. This was a retrospective cohort study involving all MDR-TB patients enrolled in treatment in all 31 regions in Tanzania from 2017 to 2019. The overall mortality rate among MDR-TB patients was calculated using the incidence rate. Additionally, independent factors of MDR-TB mortality were determined using multivariable cox proportional hazards models.ResultsThe study followed 985 patients for a total of 12,929 months. During this time, it found that approximately 12 out of every 1000 patients died each month. Specifically, the death rates were about 18 out of 1000 patients at 6 months, 8 out of 1000 at 12 months, and 7 out of 1000 at 24 months. Patients who had both MDR-TB and HIV, as well as those who were malnourished, had a lower chance of surviving at 6, 12, and 24 months. Malnourished patients had almost three times the risk of dying [adjusted hazard ratio (aHR) 2.96, with a 95% confidence interval (CI) of 2.10–4.19], while those with HIV had nearly double the risk [aHR 1.91, with a 95% CI of 1.37–2.65].ConclusionIn summary, our study on MDR-TB patient outcomes in Tanzania between 2017 and 2019 reveals a pattern of high mortality rates within the first 6 months of treatment. Furthermore, malnutrition and HIV co-infection were found to be significant predictors of mortality. To decrease mortality, it is crucial to closely monitor patients during the initial 6 months of treatment, especially those who are malnourished or co-infected with HIV, and ensure they receive appropriate and timely care. Additionally, further investigation is needed to find out what may be contributing to possible rise in mortality rate.

Decentralisation and integration of paediatric tuberculosis services to primary healthcare facilities as an approach to optimise management in Cameroon and Kenya: a descriptive cohort study

IntroductionTuberculosis (TB) remains a major cause of morbidity and mortality for children less than 5 years. Diagnosis and treatment of children with active TB is often centralised in district hospital...

The impact of extension delivery through private local service providers on production outcomes of small-scale aquaculture farmers in Bangladesh

ABSTRACT Purpose This study delves into the effectiveness of local service providers (LSP) in improving production outcomes of small-scale aquaculture farmers in Bangladesh. Design/methodology/approach To gauge the effectiveness of LSPs, the research employs a performance-based assessment approach, focusing on 1653 fish farming households distributed across four different participation levels. Essentially, it compared quantifiable variables like the number of species cultured, productivity, proportion of fish sold and revenue metrics of the LSP-trained farmers against a control group that has not received training from LSPs. Data analysis was conducted with Multivalued Treatment Effects (MTE) estimated using an augmented inverse-probability weighting method that allows for heterogeneous treatment effects. Findings Findings revealed that farmers who received the LSP extension training exhibited a significant increase in all outcomes compared to their counterparts. The LSP extension participating farmers are more likely to adopt better management practices like improved feeding routines, dike constructions, pond cleanliness, and fish growth monitoring. Practical implications LSP extension model with enhanced capacity can be a catalyst for improved production of small-scale aquaculture farmers. Theoretical implications This study contributes to a research agenda related to the efficiency of emerging pluralistic extension service systems that favors decentralization, privatization, and outsourcing of extension service, and their capability to enhance the production outcomes of small-scale farmers. Originality/value This study addresses an important research gap in the agricultural extension literature, which is the value-for-money of Local Service Providers, and their capability to enhance the production outcomes of small-scale farmers.

Analysis of the Gravimetric Composition of Urban Solid Waste from the Municipality of Belém/PA

This article aimed to evaluate, using statistical tools, the generation and composition of municipal solid waste (MSW) in the city of Belém, Pará, from nine urban collection sectors in the municipality and the average nominal income of the population. Approximately 900 kg of urban solid waste was collected from the municipality in the period from 2021 to 2022. Statistical tests were carried out on hypotheses with 5% significance in comparative evaluations and their respective average nominal incomes. The results indicated that the organic fraction corresponded to 55.57% of the waste generated in the municipality, 14.26% was inert waste (potentially contaminating), and 0.67% was miscellaneous waste. It was observed that the waste generated by families with high purchasing power tended to contain higher percentages of recyclables while in families with lower purchasing power, the highest percentages tended to be organic. Knowledge of the generation of MSW is fundamental for the choice and dimensioning of operations and processes involved in the management chain at the municipal level. The decentralization of services offered based on solid waste management would enable greater success in serving the population.

Health and Nutrition Promotion Programs in Papua New Guinea: A Scoping Review.

There is a rising prevalence of non-communicable diseases (NCDs) in Papua New Guinea (PNG), adding to the disease burden from communicable infectious diseases and thus increasing the burden on the healthcare system in a low-resource setting. The aim of this review was to identify health and nutrition promotion programs conducted in PNG and the enablers and barriers to these programs. Four electronic databases and grey literature were searched. Two reviewers completed screening and data extraction. This review included 23 papers evaluating 22 health and nutrition promotion programs, which focused on the Ottawa Charter action areas of developing personal skills (12 programs), reorienting health services (12 programs) and strengthening community action (6 programs). Nineteen programs targeted communicable diseases; two addressed NCDs, and one addressed health services. Enablers of health promotion programs in PNG included community involvement, cultural appropriateness, strong leadership, and the use of mobile health technologies for the decentralisation of health services. Barriers included limited resources and funding and a lack of central leadership to drive ongoing implementation. There is an urgent need for health and nutrition promotion programs targeting NCDs and their modifiable risk factors, as well as longitudinal study designs for the evaluation of long-term impact and program sustainability.

The impact of decentralization of health services at the municipal level on health outcomes: evidence from China.

Under the system of health decentralization, there are differences in the level of expenditure decentralization at different levels of government, and their impact on residents' health may also be different. This paper is one of the first to evaluate the effect of decentralization of health services at the municipal level from a multi-dimensional health perspective. This paper uses the data of expenditure decentralization of health services at the municipal level to match the panel data from the China Household Panel Survey (CFPS) from 2010 to 2018, and uses the logit model, ordered logit model and two-way fixed effects model to empirically analyze the impact of health decentralization at the municipal level on health outcomes. Based on the perspective of multi-dimensional health, from the three aspects of physical health, depression status and cognitive ability, the six sub-indicators of self-rated health, BMI standards, depression scores (summation method), depression scores (factor method), phrase test scores and mathematics test scores are discussed separately. The results show that the decentralization of health services at the municipal level has a significant promotion effect on the multi-dimensional health of residents. The decentralization of health services at the municipal level has important theoretical significance for promoting the reasonable division of medical and health powers and expenditure responsibilities between provincial and municipal governments, improving the efficiency of health expenditure funds, and establishing a fiscal system that matches financial resources.

WED-495 The impact of integration and decentralization of HBV services on enhancing the HBV care continuum: an interrupted time series

WED-495 The impact of integration and decentralization of HBV services on enhancing the HBV care continuum: an interrupted time series

Toward enhanced decentralized palliative care services in Neno District, Malawi: a qualitative study.

BackgroundPalliative care remains key in assisting patients who have life-threatening conditions. In most low- and middle-income countries, it is often offered through a centralized system with limitations, including Malawi. In 2014, the World Health Organization called for improving palliative care access through primary health care and community models. Malawi and Neno District subsequently decentralized palliative care delivery to local health centers. This qualitative study explored the decentralization of palliative care services in Neno District, Malawi.MethodsThe descriptive qualitative study was conducted between 2021 and 2022 in two conveniently selected health centers providing palliative care in the Neno District. Fourteen healthcare workers were purposefully selected to participate in two focus groups. Fifteen patients were conveniently selected and participated in three focus groups. Data was analyzed using deductive and inductive approaches. Focused group discussions were conducted in Chichewa (Malawi’s official local language), audio recorded, transcribed, translated into English, and analyzed thematically.ResultsFour main themes emerged from the focus groups. Patients described positive relationships with healthcare workers built on trust and holistic care over time. Accessing care included transport, social support, time constraints, and distance issues. Facilities effectively responded to needs through coordinated care and follow-up. Decentralization was perceived to benefit patients by reducing travel challenges and improving local access to efficient and inclusive palliative care services. However, challenges with resources, distance, and social support remained. Limitations in sampling and missing participant details necessitate further research with broader sampling.ConclusionOverall, the study provides empirical evidence that can optimize palliative care delivery in similar low-resource contexts by informing policies to address barriers through decentralized approaches.

Impact of medical innovations on quality of care in low income settings

Access to high-quality healthcare remains a challenge in low-income settings, primarily due to resource constraints and limited access to medical innovations. This systematic review examines the impact of medical innovations on the quality of care in low-income settings. Through a comprehensive analysis of relevant literature, this paper highlights the various medical innovations that have been implemented in low-income settings and evaluates their effectiveness in improving healthcare outcomes and patient satisfaction. The review identifies three broad categories of medical innovations: technological innovations, innovative healthcare delivery models, and novel treatment modalities. Technological innovations encompass a wide range of advancements, including telemedicine, mobile health (mHealth) applications, and point-of-care diagnostics. These innovations have shown promise in improving access to healthcare services, enhancing diagnostic accuracy, and facilitating remote monitoring and follow-up care in low-resource settings. Innovative healthcare delivery models, such as community health worker programs, task shifting, and mobile clinics, have also been implemented to overcome barriers to healthcare access in low-income settings. These models prioritize community engagement, decentralization of services, and task delegation to non-physician healthcare providers to expand coverage and reach underserved populations. Furthermore, novel treatment modalities, including affordable and portable medical devices, point-of-care testing kits, and low-cost medications, have been developed to address the specific healthcare needs of low-income populations. These innovations aim to improve treatment efficacy, reduce treatment costs, and minimize the burden of disease in resource-limited settings. The review synthesizes evidence from a diverse range of studies to assess the impact of these medical innovations on healthcare outcomes and patient satisfaction. Key findings suggest that while medical innovations hold promise in enhancing quality of care, several challenges including limited resources, infrastructure constraints, and training requirements need to be addressed to maximize their impact. The paper concludes by emphasizing the importance of tailored approaches and sustainable strategies for implementing medical innovations in low-income settings. By fostering partnerships, leveraging existing infrastructure, and investing in capacity building initiatives, stakeholders can effectively integrate medical innovations into healthcare delivery systems and improve access to high-quality care for underserved populations. This systematic review contributes to the growing body of literature on healthcare innovation and provides valuable insights for policymakers, healthcare providers, and researchers seeking to address the healthcare needs of low-income populations and achieve health equity on a global scale.

Unpacking “the system”: Multi‐level governance gaps in the labour market integration of highly skilled refugees

AbstractA plethora of government‐ and non‐government actors are involved in the labour market integration of highly skilled refugees, forming a complex “system” that is difficult to navigate for integration actors and refugees. Based on interviews with 32 labour market integration actors in Sweden, this article examines multi‐level governance gaps in the wake of the simultaneous centralization and decentralization of labour market preparation services. It examines various “steps” in the labour market integration process to gain a more holistic perspective of “the system”, and identifies governance gaps in each step. The article finds that the devolution of services has opened up participatory spaces for non‐government actors, but narrowly defined mandates and short‐term funding mechanisms hamper cooperation within and between territorial levels of policy implementation.

Does the healthcare decentralization provide better public health security capacity and health services satisfaction? An analysis of OECD countries

PurposeDecentralization has profound implications for many health systems. This study investigates the effect of health system decentralization in Organization for Economic Co-operation and Development (OECD) countries on public health security capacity and health service satisfaction.Design/methodology/approachMultiple linear regression analyses were employed for variables related to the level of health security capacity and satisfaction with the healthcare system while controlling for all socio-demographic variables from the European Social Survey, including over 44,000 respondents from 25 OECD countries. The Health Systems in Transition series of countries were used for assessing the decentralization level.FindingsThe result of multiple linear regression analyses showed that the level of decentralization in health systems was significantly associated with higher health security capacity (ß-coefficient 3.722, 95% confidence interval (CI) [3.536 3.908]; p=<0.001) and health service satisfaction (ß-coefficient 1.463, 95% CI [1.389 1.536]; p=<0.001) in the study. Countries with a higher level of decentralization in health policy tasks and areas were significantly likely to have higher health services satisfaction, whereas this satisfaction had a significant negative relation with the lower level of decentralization status of secondary/tertiary care services in OECD countries (ß-coefficient −5.250, 95% CI [−5.757–4.743]; p = 0.001).Originality/valueThis study contributes to a better understanding of the extent to which decentralization of health services affects public health safety capacity and satisfaction with health services, whereas the level of decentralization in OECD countries varies considerably. Overall, the findings highlight the importance of public health security and satisfaction with health care delivery in assessing the effects of decentralization in health services.

Public health systems in Brazil and Portugal: challenges and opportunities in health promotion and access

The Brazilian and Portuguese healthcare systems differ in structure, financing and accessibility. They are similar in terms of decentralization of services, coexistence of public and private health providers and universality and comprehensiveness. The Unified Health System is financed by the federal, state, and municipal governments and is free for everyone. Given the territorial size and economic and social inequality in Brazil, the quality of care can vary greatly, with disparities in access to healthcare between its regions. In Portugal, the National Health Service offers universal and largely free tax-funded coverage and provides comprehensive care, but long waiting times can be a problem. Both systems face challenges such as an aging population and budget constraints. This study pointed out that in addition to appropriate financing and the reorganization of models, academic knowledge can assist in improvement actions and public policies.

Comparison on treatment outcomes of patients enrolled on anti-retroviral therapy at different levels of the health-care system in a high HIV/AIDS setting.

HIV/AIDS prevalence in Botswana is amongst the highest in the world and remains a significant public health problem. however, the introduction of anti-retroviral therapy (ART) lead to a significant reduction in morbidity and mortality. Decentralization of anti-retroviral therapy has improved access to treatment for people living with HIV. Treatment outcomes for patient initiated on treatment at different levels of care is unknown and this study seeks to compare treatment outcomes of patients enrolled on ART at different levels of the health care. This is a retrospective cross-sectional study that included review of data from January 2017 to December 2018. The study was conducted in 2 health districts in the country. Nine hundred and sixty (960) patient's record were included in analysis. More than half (63%) of patients were enrolled at primary care level while 37% were at tertiary level. Sixty one percent (n = 587) were female while 39% (n = 373) were males. There were no statistically significant differences in viral load suppression after 12 months of treatment between patients enrolled at tertiary level and primary care level, x2 = 0.75, p value = 0.56. Time to initiation was longer at tertiary (median = 126) compared to primary are level (median = 18), p < 0.001. We reccommend further decentralization of ART services to lower levels of the health care system to initiate PLWHIV early on treatment and improve their health outcomes and reduce transmission through treatment by prevention.

Mental health is just an Addendum: Assessing stakeholder's perceptions on COVID-19 and mental health services provision in Malawi.

The World Health Organization declared COVID-19 as a pandemic in March 2020. COVID-19 has since caused a significant increase in mental health problems at national and global levels. This study assessed the views of key mental health stakeholders regarding the state of mental health service provision in Malawi and the pandemic's impact on the sector. The study utilised a qualitative approach through key informant interviews (KIIs) conducted using a semi-structured interview guide. The interviews were audio recorded in English language and were manually transcribed for thematic analysis by generating codes re-classified into themes, sub-themes and quotes. The results are categorised into five themes. Firstly, the availability of mental health services. All experts confirmed the lack of availability of the mental health services especially at the lower levels of care. Currently, only 0.3% of facilities offer mental health services in Malawi. Moreover, although mental health services are part of the essential health care package and, therefore, are supposed to be provided for free in public facilities at all levels, the services are centralised and only functional at a tertiary level of care in public facilities. Secondly, funding sources for mental health in public and private facilities. We learnt that public facilities depend on donor sources and there is lack of prioritisation in budget allocation for mental health services. Whereas private facilities, their major source of funding is user fees. Thirdly, government's response in the provision of mental health services during COVID-19. Almost all experts echoed that government took a proactive approach to address the mental health needs of its population during the pandemic. There was increased collaboration between the government and the private sector to provide psychosocial and counselling services to health workers working directly with COVID-19 patients in isolation centres. Furthermore, to increase awareness of the general population on where to seek counselling services. Lastly, challenges in the provision of mental health services were highlighted and how the pandemic acerbated the challenges including shortage in human resources for health and inadequate funding. This study underscores the urgency of addressing mental health challenges in Malawi. Policymakers must prioritize the decentralization of mental health services, explore funding opportunities, and build on the successful collaboration with the private sector. These measures will not only enhance the accessibility and quality of mental health services but also ensure that mental well-being is a central component of public health efforts in Malawi.

Dispositions of Health Facility In-charges Towards Decentralization and Integration of Mental Health Services into Primary Health Care: A Case of Lusaka District.

Introduction: Worldwide, the burden of mental illnesses poses serious public health challenges, with approximately 7.4% of the global burden attributed to mental disorders. However, many primary healthcare systems in countries around the world focus mainly on physical care and neglect to provide mental health care to their populations. In Zambia, the prevalence of mental disorders is approximately 20%, with common mental disorders including acute psychotic episodes, schizophrenia, alcohol-related problems, and organic brain syndromes. These are mainly seen in Chainama, the only mental institution in the country. The institution is highly stigmatized, and previous studies have shown that the general population does not access services at this facility as intended, leading to considerations of decentralizing these services to be integrated into primary health care. This study sought to understand the dispositions of primary health facility in-charges towards decentralization and the integration of mental health services into primary health care. Methods: This study was cross-sectional and employed both quantitative and qualitative techniques. A total of 76 primary health care facility in-charges from seven subdistricts of Lusaka district provided data through a questionnaire, and 56 participated in focus group discussions. Findings: The study found that in-charges had a positive disposition (52 in-charges: 68.3 percent) despite having inadequate knowledge (56 in-charges: 73.7 percent) of the subject matter and the decentralization process. While their current practices towards mental patients were found to be acceptable, the study also found that the majority (52.6 percent) of the in-charges foresaw more barriers to the integration of mental health, citing skilled staff, infrastructure, and drugs as main barriers. Conclusion: The study concludes that integration requires more investment and sensitization for its success.

Finding out the Relationship Between Financial Decentralization and Quality of Maternal Health Services in Uganda. Sheema Municipality, Sheema District.

Finding out the Relationship Between Financial Decentralization and Quality of Maternal Health Services in Uganda. Sheema Municipality, Sheema District.